[Senate Report 105-36]
[From the U.S. Government Publishing Office]
105th Congress Rept. 105-36
SENATE
2d Session Volume 3
_______________________________________________________________________
DEVELOPMENTS IN AGING: 1996 - VOLUME 3
__________
A REPORT
of the
SPECIAL COMMITTEE ON AGING
UNITED STATES SENATE
pursuant to
S. RES. 73, SEC. 19(c), FEBRUARY 13, 1995
Resolution Authorizing a Study of the Problems of the Aged and Aging
April 30, 1998.--Ordered to be printed
105th Congress Rept. 105-36
SENATE
2d Session Volume 3
_______________________________________________________________________
DEVELOPMENTS IN AGING: 1996
VOLUME 3
__________
A REPORT
of the
SPECIAL COMMITTEE ON AGING
UNITED STATES SENATE
pursuant to
S. RES. 73, SEC. 19(c), FEBRUARY 13, 1995
Resolution Authorizing a Study of the Problems of the Aged and Aging
April 30, 1998.--Ordered to be printed
Developments in Aging: 1996
Volume 3
SPECIAL COMMITTEE ON AGING
CHARLES E. GRASSLEY, Iowa, Chairman
JAMES M. JEFFORDS, Vermont JOHN B. BREAUX, Louisiana
LARRY CRAIG, Idaho JOHN GLENN, Ohio
CONRAD BURNS, Montana HARRY REID, Nevada
RICHARD SHELBY, Alabama HERB KOHL, Wisconsin
RICK SANTORUM, Pennsylvania RUSSELL D. FEINGOLD, Wisconsin
JOHN WARNER, Virginia CAROL MOSELEY-BRAUN, Illinois
CHUCK HAGEL, Nebraska RON WYDEN, Oregon
SUSAN COLLINS, Maine JACK REED, Rhode Island
MIKE ENZI, Wyoming
Theodore L. Totman, Staff Director
Kenneth R. Cohen, Minority Staff Director
LETTER OF TRANSMITTAL
----------
U.S. Senate,
Special Committee on Aging,
Washington, DC, 1997.
Hon. Albert A. Gore, Jr.,
President, U.S. Senate,
Washington, DC.
Dear Mr. President: Under authority of Senate Resolution 73
agreed to February 13, 1995, I am submitting to you the annual
report of the U.S. Senate Special Committee on Aging,
Developments in Aging: 1996, volume 3.
Senate Resolution 4, the Committee Systems Reorganization
Amendments of 1997, 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 1995 and 1996 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,
Charles E. Grassley, Chairman.
ITEM 1--DEPARTMENT OF AGRICULTURE
----------
AGRICULTURAL RESEARCH SERVICE (ARS)
Title and purpose statement of each program or activity which affects
older Americans
Studies are conducted at the Jean Mayer USDA Human
Nutrition Research Center on Aging (HNRCA) at Tufts University,
Boston, Massachusetts, which address the following problems of
the aging:
1. What are nutrient requirements to ensure optimal
function and well being for a maturing population?
2. How does nutrition influence the progressive loss
of tissue function associated with aging?
3. What is the role of nutrition in the genesis of
major chronic, degenerative conditions associated with
the aging process?
In addition, studies are performed at the Beltsville Human
Nutrition Research Center (BHNRC), the Grand Forks Human
Nutrition Research Center (GFHNRC), and the Western Human
Nutrition Research Center (WHNRC) on the role of nutrition in
the maintenance of health and prevention of age-related
conditions, including cancer, coronary heart disease,
hypertension, diabetes, neurological disorders, osteoporosis,
and immunocompetence. Summaries of human nutrition research
progress and a list of projects related to nutrition and the
elderly are attached.
Brief description of accomplishments
Researchers at the Jean Mayer USDA Human Nutrition Research
Center on Aging (HNRCA) at Tufts University have made
significant strides toward improving the quality of life for
men and women as they age. These accomplishments show promise
in delaying the onset of many age-related diseases and
conditions.
Immune Function. The decline in immune function during
aging, which increases susceptibility to infection and risk of
certain cancers, is modulated by protein, vitamin, and mineral
intake. Recent research at HNRCA supports the role of vitamin E
in enhancing immune response:
Vitamin E supplementation enhanced T cell-mediated
immune function in healthy elderly; the optimal dose
was demonstrated to be 200 IU/day.
Vitamin E supplementation also significantly
protected against exercise-induced oxidative damage and
promotes acute phase immune responses in healthy older
men.
Bone Health. Osteoporosis occurs most frequently in
postmenopausal white women and in the elderly. Approximately 20
percent of American women suffer one or more fractures before
age 65 and as many as 40 percent sustain fractures later in
life. Almost 50 percent of these people will require long-term
care services. Inadequate calcium and vitamin D intake can lead
to bone loss and increased risk of osteoporosis. Research at
HNRCA has shown that:
Calcium absorption has a heritable component that is
apparent at low but not at high calcium intake levels,
illustrating an interaction between heredity and the nutrient
intake. The HNRCA identified age-related changes in vitamin D-
independent calcium transport as a major determinant of
intestinal calcium malabsorption during senescence.
Supplementation with calcium and vitamin D to recommended
levels reduced the rate of bone loss and the incidence of
symptomatic fractures in healthy men and women age 65 and
older.
The HNRCA identified a negative role of high dietary
calcium intakes on zinc homeostasis in the elderly.
Specifically, high calcium intake reduced zinc retention, a
finding of substantial relevance to consumers who self-
prescribe calcium supplements and may thereby put themselves at
risk of zinc deficiency.
Exercise, Body Composition, and Prevention of Frailty.
Sarcopenia, the loss of lean body mass as one ages, strongly
influences muscle strength and mobility and contributes to
falls and frailty. Studies in this area have shown that:
Home-based resistance exercise training improves
function and reduces Sarcopenia and frailty in the
elderly.
Total body potassium content, a measure of lean body
mass, assessed by total body potassium (K-40)
measurements, declined at roughly 0.5-percent in muscle
per year without exercise and nutrition intervention.
Percent body fat assessed by neutron inelastic
scattering increased with age for female volunteers
between the ages of 20 to 50 years and throughout adult
life for males.
Elderly persons find it difficult to maintain a
constant body weight (some gain too much, others lose
weight) due to an impaired ability to regulate food
intake.
Sarcopenia is associated with increased production of
several cytokines, but not with low growth hormone.
Prevention of Cardiovascular Disease and Stroke.
Cardiovascular disease is the leading cause of death in the
United States. Coronary heart disease (CHD) increases with age
and is responsible for approximately 24 percent of total U.S.
deaths. Dietary changes, particularly reducing total and
saturated fat and increasing soluble fiber intake is often the
first step to attempt to reduce elevated cholesterol levels.
Recently, the significant impact for vitamins C, E, and other
antioxidant phytochemicals, and folate and vitamins B6 and B12
has been investigated. Genetics are also a significant factor
in disease risk.
Additional ARS research results included:
The carbon to oxygen ratio in tissue, measured by neutron
inelastic scattering, is a measure of fat content. This method
was validated against hydro densitometry and used to study the
relationship between fat distribution patterns and risk for
cardiovascular disease. Certain body fat distribution patterns
are associated with increased risk for cardiovascular disease.
Researchers identified a genetic influence on the over-
consumption of high fat diets that may help to explain why some
individuals become obese.
Consumption of hydrogenated oils were found to adversely
impact plasma low density lipoprotein (LDL) cholesterol levels.
Diets were developed that were adequate in essential fatty
acids which reduce LDL cholesterol and promote weight loss.
Low plasma level of docosahexaenoic acid is a risk factor
for dementia, as is an apoE-IV genotype. Both apoE and apoA-IV
genotype determine responsiveness to LDL cholesterol lowering
from diets restricted in saturated fat and cholesterol.
Nutrient factors are the primary determinants of elevated
total plasma homocysteine concentrations, commonly found in
older Americans. Plasma homocysteine is inversely correlated to
status and intake of foliate, vitamin B12 and vitamin B6 and
directly proportional to the prevalence of carotid stenosis in
the elderly subjects in the Framingham Heart Study.
Cataract and Age-Related Visual Impairments. Visual
impairment is common among older adults. In the United States,
the prevalence of cataracts which impact vision is about 40
percent of people over 75 years. Age-related macular
degeneration is the primary cause of incurable blindness in the
United States. Approximately 25 percent of people 65 years and
older have signs of age-related maculopathy. There is a growing
body of evidence that the onset of cataract and age-related
macular degeneration can be retarded in many cases by behavior
and nutrition factors.
Clinical/epidermiologic studies suggest a protective effect
of dietary vitamin C against cataract formation. Use of vitamin
C supplements for 10 or more years was associated with an 80%
lower prevalence of age-related lens opacities in women aged
55-71 years. Use of supplements for less than 10 years was
without significant effect.
Cancer in the aging population. The total incidence of
cancer each year is increasing for both men and women in the
United States. It has been estimated that at least a third of
cancer mortality is related to dietary factors. Research in
this area has found that:
Folic acid supplementation in human subjects who
harbor colonic polyps leads to an improvement in a
purported intermediary marker of colon cancer, DNA
hypomethylation of the colonic mucosa.
The protection that fruits and vegetables provide
against disease, including cancer and cardiovascular
diseases and stroke has been attributed to their
antioxidant content. The total antioxidant capacity of
fruits and vegetables has been measured using the
automated oxygen radical absorbance capacity (ORAC)
assay. Adults who consumed of a meal containing 3400
mol Trolox equivalents of ORAC from spinach,
strawberries, red wine phenolics or vitamin C increased
serum ORAC by 10-15 percent indicating significant
absorption of antioxidant phytochemicals from these
food sources.
Food and Diet Studies. Eating foods which are rich in
vitamin K rapidly improves vitamin K status. Epidemiologic
studies are underway to examine the relationship between
vitamin K status and chronic diseases, such as cardiovascular
disease and osteoporosis. In order to adequately assess dietary
intake of the vitamin, scientists have developed and validated
a comprehensive vitamin K food composition database.
High prevalences of disability, diabetes, depression and
obesity were found among a representative group of Hispanic
elders in Massachusetts. Puerto Rican elders, had higher rates
of these conditions than did other Hispanics or non-Hispanic
whites. A food frequency questionnaire developed for this
population found that their diets tend to be high in refined
starchy foods and low in variety and micronutrients.
The Framingham Heart Study revealed that diet patterns of
subjects predicted blood folate, homocysteine, vitamin B12
concentrations and bone status. Studies also indicated that:
Fruits, vegetables and breakfast cereal appear to be
protective of folate and homocysteine status; vitamin
B12 supplements and fortified breakfast cereal appear
protective of vitamin B12 status; and potassium,
magnesium, and fruits and vegetables were significantly
associated with greater bone mineral density in elderly
men and women and with lower losses in bone mineral
density over time in elderly men.
Long-term feeding of rats with a defined diet containing
extracts of strawberries or spinach or high in vitamin E
retarded the onset of several parameters of aging including;
loss of brain cell receptor sensitivity, and cognitive
behavior.
Antioxidants Research Laboratory. The Antioxidants Research
Laboratory works to understand the role of dietary antioxidants
and factors such as drugs and exercise on free radical
reactions and changes in oxidative stress status during aging.
Oxygen free radicals generated during cellular metabolism
and by certain lifestyle factors appear to play a critical role
in the aging process and in the development of chronic diseases
common among the elderly. Diets characterized by high intakes
of foods rich in antioxidant vitamins and other phytochemicals
are associated with better maintenance of physiologic function
and a lower prevalence of many chronic diseases. An
understanding of how antioxidants reduce oxidative stress
status and impact the pathogenesis of chronic disease will
enable us to improve health promotion and the treatment of
chronic disease among other adults.
Body Composition Laboratory. The Body Composition
Laboratory evaluates the effect of nutrition on the dynamic
interactions between the body's protein, water, fat and bone
and studies the relationship of these changes to the aging
process. This laboratory works to understand the mechanisms
leading to loss of muscle mass with age, and develop
appropriate interventions that reverse this decline; develop
new techniques of measuring muscle mass accurately in vivo;
develop and validate methods for assessing body composition and
nutrition status of non-institutionalized elderly in
epidemiologic studies; and evaluate the efficacy of anti-
cachexia and anti-obesity treatments.
Calcium and Bone Metabolism Laboratory. The Calcium and
Bone Metabolism Laboratory conducts research to improve the
scientific basis for understanding and establishing the intake
requirements for calcium, vitamin D, and other nutrients that
influence bone health in adult men and women. This requires an
understanding of how demographic, endocrine, genetic, racial,
seasonal, and physical factors influence bone mass and affect
nutrient requirements. It also requires an understanding of the
absorption and metabolism of these nutrients. In this clinical
research laboratory, volunteers are recruited to participate in
both long-term, randomized, placebo-controlled intervention
trials as well as smaller, more intense, shorter metabolic
studies.
Energy Metabolism Laboratory. The Energy Metabolism
Laboratory examines how body weight is normally regulated and
why many people gain weight as they grow older. The importance
of genetic and environmental factors in determining body
composition and energy regulation, and quantifying optimal
dietary energy requirements are under investigation. Whole-body
physiology studies examine the importance of energy expenditure
and energy intake in determining body fat gain during adult
life. Hormonal and cellular investigations are also underway to
identify the underlying metabolic cause of individual
differences in body composition and energy regulation.
Gastrointestinal Nutrition Laboratory. A major focus of the
Gastrointestinal Nutrition Laboratory is to determine how aging
and associated factors, such as medication use, effect the
intestinal absorption and metabolism of micronutrients,
including carotenoids. Human volunteers, experimental animals,
and cell culture models are studied to investigate whether
changes in the requirements for vitamins A, B6, B12, and niacin
are warranted in aging. Research is conducted in elderly
subjects with atrophic gastritis or hypochlorhydria,
representing a sub-population of elderly at risk for impaired
nutrient absorption and metabolism.
The chemopreventive effects of carotenoids against cancer
are also explored. The biologic activity of carotenoid
metabolites in gene expression is examined as a mechanism to
explain both chemopreventive (when present in low
concentrations) and cancer promoting (when present in high
concentration) properties. The functions of carotenoids in
preventing light damage to the macula of the eye and in
promoting intestinal immunity are studied in collaboration with
other HNRC laboratories.
Genetics Laboratory. The Genetics Laboratory studies
reactive oxygen species produced by cellular metabolic
reactions that have been implicated in the pathogenesis of
numerous diseases including atherosclerosis, cancer and
Alzheimer's disease. The laboratory focuses on the molecular
mechanisms, by which reactive oxygen species are used as
signaling molecules in the regulation of cellular function and
gene expression. Interestingly, clinical and epidemiologic
studies have, in some cases, indicated that antioxidant
nutrients may be effective in disease prevention. Recently
molecular and cellular approaches have demonstrated that
reactive oxygen species and antioxidants can directly affect
the cellular signaling apparatus, and consequently the control
of gene expression. The new research provides the link between
reactive oxygen species and antioxidant chemistries, and the
mechanisms of disease processes and prevention.
Laboratory for Nutrition and Vision Research. The
Laboratory for Nutrition and Vision Research seeks to determine
the primary causes of eye lens cataract and degeneration of the
macula and to apply this knowledge to extend the useful life of
these organs. Current clinical/epidemiologic approaches and
laboratory tests aim to define adequate nutrient levels during
various life stages which will ultimately result in delayed
accumulation of damaged lens and retinal proteins and delayed
lens opacification and age-related maculopathy. Human and other
mammalian lens tissue, a variety of animal models, whole lenses
in culture, and cultured lens epithelia cells are studied.
Since the lens is primarily composed of protein, a significant
effort is being made to understand interrelationships between
aging, regulation of lens protein metalobism, protease function
and expression, and nutrition.
Lipid Metabolism Laboratory, Cardiovascular disease (CVD),
including coronary heart disease (CHD) and stroke, remain the
leading causes of death and disability in our society. In
addition to age and gender, significant CHD risk factors
include an elevated level of low-density lipoprotein
cholesterol, a decreased level of high-density lipoprotein
cholesterol, cigarette smoking, hypertension, and diabetes.
Hypertension and age are significant risk factors for stroke.
Dietary intake and exercise level have a significant impact on
cardiovascular risk, as do genetic factors. The Lipid
Metabolism Laboratory focuses on defining the
interrelationships between lipoprotein metabolism and
consumption of various dietary fatty acids, cholesterol another
dietary constituents, genetics, and aging. Other studies are
designed to identify lipid and lipoprotein abnormalities and
genetic mutations associated with CHD, stroke, and dementia
risk. Scientistsare developing nutritionally-adequate optimal
diets for fatty acids, cholesterol, and other dietary constituents in
the elderly to minimize the risk of CVD and dementia.
Mineral Bioavailability Laboratory. The Mineral
Bioavailability Laboratory examines the biochemical and
physiologic basis for changes in absorption and utilization of
minerals with aging and determines the effects of aging on
mineral requirements in the elderly. Research focuses
specifically on understanding calcium, zinc, and iron
metabolism in the elderly, and the effects of nutrient and
hormonal changes on the expression of genes that modulate
mineral metabolism.
Neuroscience Laboratory. Although the primary focus of a
great deal of research in neuronal aging is directed to
identifying the mechanisms involved in age-related
neurodegenerative disease, e.g., Alzheimer's disease and
Parkinson's disease, many of the neurologic deficits seen in
aging occur in the absence of neurodegenerative disease. In
fact, these diseases are superimposed upon an already declining
nervous system. These deficits may include decreases in both
motor and memory functions which could, in many cases result in
hospitalization and/or custodial care. Research has suggested
that both the changes that occur in Alzheimer's disease and
Parkinson's disease, as well as those in aging, may involve
increases in vulnerability to oxidative stress. Research in the
Neuroscience Laboratory is directed to toward identifying
factors that increase vulnerability to oxidative stress with a
view toward identifying nutrient antioxidant regimens to
restore these behaviors or prevent their decline.
Research in the Neuroscience Laboratory is directed toward
determining the membrane and neurotransmitter receptor
characteristics that increase vulnerability to oxidative
stress, alter calcium homestatis, and ultimately, cell
viability in neuronal aging. Studies examine the expression of
the behavioral deficits in aging using assessments of cognitive
and motor behavior. Other studies examine the effects of
dietary supplementation with fruits and vegetables high in
antioxidant activity, as well as other antioxidants on
retarding to age-related cellular, neuronal, and behavioral
deficits.
Nutritional Epidemiology Program. The Nutrition(al)
Epidemiology Program uses the epidemiologic approach and
methods to investigate the role of nutrition in healthy aging.
Epidemiology allows for the study of complex interactions
between genetic, behavioral, and environmental factors in a
community setting. It is also the bridge between basic science
and public policy. This program identifies nutrition related
factors that influence the progressive loss of physiologic
function and genesis of the major chronic, degenerative
conditions associated with aging, such as cardiovascular
disease and visual impairment. Studies assess the possible
modification of these nutritional relations by personal
behavioral, and genetic factors. This information is used to
assist in determining the nutrient requirements necessary to
obtain optimal function and well being for a maturing
population. The research focuses on identifying the
determinants of nutrition status and intake in the elderly,
relating nutrition status and intake to measures of health and
well-being, and improving methodology for research relating
nutrition and aging.
Nutritional Immunology Laboratory. The Nutrition(al)
Immunology Laboratory has demonstrated that increased
production of suppressive factors free radicals, and enzymatic
products of lipid peroxidation, such as PGE2, play an important
role in the dysregulation of the immune response in older
adults, which contributes to increased incidence of infectious,
inflammatory, and neoplastic diseases. Antioxidant and
prooxidant nutrients modulate immune and inflammatory
responses. This laboratory investigates the role of dietary
components (antioxidants and prooxidants in particular) and
their interactions with other environmental factors in age-
associated changes of the immune and inflammatory responses.
Research is designed to develop a means to reverse and/or delay
the onset of these immunological and age-related changes by
appropriate dietary modifications and to determine the
molecular mechansim(s) by which antioxidant and prooxidant
nutrients modulate immune cell functions. Methods are being
developed to use the immune response as a biologically
meaningful in determining specific dietary requirements.
Nutrition, Exercise Physiology, and Sarcopenia Laboratory.
The mission of the Nutrition, Exercise Physiology, and
Sarcopenia Laboratory is to understand the interaction of
nutrition, hormonal and immunological factors in sarcopemia
(the loss of muscle mass and function with aging) and to
develop new methods of reversing and preventing these losses.
Studies are conducted in healthy humans, in animals, and in
vitro experimental systems. Over the past decade this
laboratory has demonstrated the safety and effectiveness of
progressive resistance exercise training (strength training) in
reversing sarcopenia and frailty. Current projects are designed
to better understand the mechansims causing sarcopenia,
including changes in various hormones and in the immune system
with age, and how exercise and diet can improve or prevent
these changes.
Phytochemical Laboratory. The Phytochemical Laboratory
investigates the bioavailability, metabolism, and potential
health benefits of various phytochemicals with antioxidant
activity. Specific antioxidants currently under investigation
include vitamins C and E, and the flavoniod family of
compounds, including flavones, flavanones, anthocyanins, etc.
The Oxygen Radical Absorbance Capacity assay and various High
Performance Liquid Chromatography methods are used to
characterize these antioxidants. In vivo nutrition studies are
conducted in human volunteers to asses biological activity and
function.
Vitamin Metabolism Laboratory. The Vitamin Metabolism
Laboratory examines the relationship between aging and B
vitamin status with emphasis on requirements and long-term
effects of inadequate status. The relationship of plasma
homocysteine levels to intake and status of the vitamins folic
acid, B12, B6 and B2 and cardiovascular disease, thrombosis and
stroke, cognitive dysfunciton, certain cancers e.g., breast,
colorectal, prostate and cervical are studied. The polymorphic
mutations in the gene encoding enzyme of folate metabolism such
as the thermolabile methylenetetrahy-drofolate reductase
mutation are under investigation. The epidemiologic component
of this research is conducted with a variety of outside
collaborators including the National Cancer Institute, Johns
Hopkins School of Public Health, Harvard School of Public
Health, Hadasah Hospitals and the Farmingham Heart Study. Basic
laboratory research includes the development of new methods for
the study of small human specimens and animal model studies.
Human Nutrition Research Center on Aging--Research Projects Related to
Nutrition and the Elderly
Funding Level
fiscal year
dollars
Functional Capacity and Nutrient Needs of Aging--HNRC, 1/11/
95-1/10/00. Objective: To examine the effects of increased
physical activity, body composition and diet on the
following: (1) Peripheral insulin sensitivity and glucose
metabolism; (2) Functional capacity and nutrition status
of the frail elderly; (3) Whole body and skeletal muscle
protein metabolism; (4) Total energy expenditure and its
relationship to physical activity level and body
composition............................................... 940,560
Function and Metabolism of Vitamin K and Vitamin K Dependent
Proteins During Aging--HNRC, 1/11/95-1/10/00. Objective:
Molecular, biochemical and functional assays of vitamin K
nutritional status and dietary tools for the assessment of
vitamin K intakes will be developed and validated. In vivo
studies with rats will determine dietary sources of
vitamin K and requirements related to the synthesis of
matrix gla protein (MGP). The effects of aging and gender
on the expression of MGP will be studied in relationship
to dietary sources of vitamin K (phylloquinone or
menadione) and vitamin K antagonists...................... 904,769
Absorption & Metabolism of Phytochemicals: Enhancement of
Antioxidant Defense Mechanisms in Aging--HNRC, 10/1/96-9/
30/99. Objective: Determine (1) extent of absorption and
metabolism of flavonoids in fruits and vegetables high in
antioxidant activity, (2) usefulness of Oxygen Radical
Absorbing Capacity (ORAC) assay as an indicator of
antioxidant capacity of fruits and vegetables and status
in animal models exposed to increased oxidative stress,
and (3) possible health related outcomes.................. 370,184
Dietary Antioxidants, Aging, and Oxidative Stress--HNRC, 11/1/
94-10/31/99. Objective: To determine the effect of
enhancing antioxidant status on oxidative status, immune
responsiveness, and other physiologic functions;
interactions between vitamin E, other dietary antioxidants
and/or polyunsaturated fatty acids; the effect of dietary
antioxidants on the generation of eicosanoid and cytokine
products and oxidized lipid, protein, and nucleic acid
targets; the value of measures of antioxidants and
oxidative stress status as biomakers of aging and health.. 670,700
Regulation of Gene Expression in Nutrient Metabolism--HNRC, 1/
11/95-1/10/99. Objective: The major areas being explored
are aimed at defining the molecular mechanisms which
contribute to metabolic dysfunction in diabetes and
obesity. Specifically, we are examining the role of
oxidants in nutrient and hormonal signal transduction and
gene expression. Secondly, we are exploring how aging
influences nutrient and hormonal signalling and gene
expression................................................ 432,679
Mineral Bioavailability in the Elderly--HNRC, 1/11/95-1/10/00.
Objective: To define the dietary factors that influence
the bioavailability, requirements, and status of minerals,
especially Ca, Mg, Fe, and Zn in humans. To define the
relationship between restriction fragment length
polymorphisms in the vitamin D receptor gene and calcium
metabolism in humans. To define the mechanism of age-
associated intestinal calcium malabsorption............... 610,334
Bioavailability of Nutrition in the Elderly--HNRC, 1/11/95-1/
10/00. Objective: To study the bioavailability of water
soluble vitamins in the aging population and determine the
effect of aging on vitamin requirements. To examine the
basis for the absorption utilization and excretion of
water soluble vitamins from food in the maturing and
elderly population. To assess vitamin status and its
relationships to drug intake and chronic diseases. To
study the impact of subclinical vitamin deficiencies on
the integrity and function of body physiology............. 901,017
Dietary Assessment of Rural Older Persons--HNRC, 2/1/96-12/31/
00. Objective: (1) Test dietary assessment methodologies
(24-hr phone recalls and written food records) in a rural
population of older persons; (2) seek confirmation of
dietary findings using doubly-labeled water and indirect
calorimetric procedures; and (3) correlate dietary
findings with biomarkers of nutritional status (i.e.
measures of visceral protein, folate, B12, pyridoxine,
homocysteine and iron). Investigate nutrition knowledge
and practices (use of dietary supplements and reduced
calorie foods) of rural older persons..................... 186,857
Maintaining Bone Health in the Elderly--HNRC, 11/1/94-10/31/
99. Objective: We will define the intake of calcium and
vitamin D above which skeletal mineral is maximally
spared. This requires an understanding of how hereditary,
demographic, endocrine, and physical factors (e.g. race,
sex, age, years since menopause, weight, and activity
level) affect the absorption and utilization of these
nutrients. Race differences in bone metabolism will be
sought in an effort to understand why blacks have less
osteoporosis.............................................. 1,100,401
Dietary Effects on Neurological Function--HNRC, 10/1/96-9/30/
99. Objective: Identify selected food components that
affect neurological function and determine their
mechanisms of action...................................... 633,579
Lipoproteins, Nutrition and Aging--HNRC, 1/11/95-1/10/00.
Objective: Our objectives are to develop optimal diets in
terms of fat and cholesterol content which are effective
in reducing LDL cholesterol, as well as favorably
affecting other heart disease risk factors, to study
nutritional regulation of plasma lipoproteins in animals,
and to study the interrelationships between aging,
nutrition, genetics, and to examine ways to prevent diet-
induced atherosclerosis, lipoproteins, and heart disease
risk in populations....................................... 1,285,299
Effect of Nutrition and Aging on Eye Lens Proteins, Proteases,
and Cataract--HNRC, 1/11/95-1/10/00. Objective: One-half
of the eye lens cataract operations and savings of over $1
billion would be realized if we could delay cataract by
only 10 years. We are attempting to use enhancement of
dietary antioxidants, such as vitamin C, and other
nutrients, such as carotenoids or tocopherol, to delay
damage to lens-proteins and proteases and to maintain
visual functions in elderly populations. This should delay
cataract-like lesions in eye lens preparations, cataracts
in vivo, and age-related maculopathy...................... 958,286
Epidemiology Applied to Problems of Aging and Nutrition--HNRC,
1/11/95-1/10/00. Objective: To define diet and nutritional
needs of older Americans; to advance methods in
nutritional epidemiology; and to develop indices which
reflect nutrient intake and which predict health or
disease outcomes in aging populations..................... 1,316,167
Gastrointestinal Function and Metabolism in Aging--HNRC, 11/1/
94-10/31/99. Objective: To delineate the pathways of
intestinal carotene metabolism, and to determine if any
metabolic intermediate can transactivate nuclear
receptors; to determine if beta-carotene or cryptoxanthin
can prevent gastric cancer in the ferret/model; to
determine relative bioavailabilities of different
carotenoid compounds in the human. To determine niacin
requirements in elderly humans. To study the effect of
antioxidants in gut immunity in young and elderly adults.. 1,684,467
Nutrition, Aging and Immune Response--HNRC, 11/1/94-10/31/99.
Objective: Investigate the role of nutrients and their
interactions with other environmental factors in age-
associated changes of the immune response, to reverse and/
or delay the onset of these immunological changes by
dietary modification and to use the immune response as an
index in determining the specific dietary requirements for
older adults.............................................. 1,033,933
The Role of Aging in Energy and Substrate Regulation and Body
Composition--HNRC, 1/11/95-1/10/00. Objective: To examine
the extent and causes of changes in energy metabolism,
energy regulation and body composition with aging, and to
investigate optimal values for dietary energy intake and
expenditure in the aging population. In particular, to
determine the (1) roles of genetic inheritance and
environment factors in the determining body fat content,
(2) extent to which changes in body fat and protein with
aging are inevitable, and (3) molecular regulation of
proteins involved in fat metabolism in adipocytes......... 1,879,726
COOPERATIVE STATE RESEARCH, EDUCATION, & EXTENSION SERVICE (CSREES)
Programs and Accomplishments
Title and purpose statement of each program or activity which affects
older Americans
The Cooperative State Research, Education, and Extension
Service (CSREES) in its mission advances research, extension,
and higher education in the agricultural, environmental, and
human sciences to benefit people, communities, and the Nation.
As a major research and education arm of USDA, CSREES through
its Land-Grant institution network has conducted educational
and research programs that have benefited older persons, their
adult children, and caregivers. The vision is for older persons
to maintain and continue a quality lifestyle while aging; have
a greater opportunity to be financially secure; experience
positive human relations; and to have the knowledge necessary
to access health care options.
CSREES and its state partner institutions collaborate with
a variety of national, state, and local organizations and
agencies such as the American Association of Retired Persons,
the National Association for Family and Community Education,
the Administration on Aging, theArea Agencies on Aging,
American Society on Aging, American gerontological Society, and State/
local departments of human/family services and health. This
collaboration provides more well-coordinated programs for consumers and
extends the resources of each collaborator to better serve the
clientele.
As a component of the CSREES National Initiative on
Children, Youth, and Families at Risk, human and electronic
networks are addressing targeted issues identified by
professionals and user groups throughout the system. One of
those networks, the National Network for Family Resiliency
(NNFR), provides leadership for acquisition, development, and
analysis of resources that foster family resiliency. Family
resiliency is defined as the family's ability to cultivate
strengths to positively meet the challenges of life. The NNFR
brings together educators, researchers, agency personnel,
families, advocates for families, and practitioners who share
an interest in strengthening families that face multiple risks
to their resiliency. Collaborators from CSREES and 42 Land-
Grant institutions share leadership for maximizing expertise,
bringing research to bear on significant family issues, and
guiding research based on evaluation of programs and practices.
The network provides access to resources through multiple
avenues including electronic media, training and education, and
community development. Within the network, a special interest
group has formed to address intergenerational issues. The work
group is composed of 35 multi-state and multi-institutional
members. Currently their focus is on ``grandparents raising
grandchildren.'' An Internet web site is in development that
will highlight resources for grandparents as primary caregivers
and promotion of positive intergenerational relationships for
educators and the general public.
Through the Cooperative Extension System at Land-Grant
institutions, administrators and specialists in such fields as
aging/gerontology, housing, financial management, nutrition,
health, human development, family life, community development,
and the agricultural sciences; plus the county extension
educators serving 3,150 counties have designed, implemented,
and evaluated numerous programs in the field of aging/
gerontology. Below are highlights of these programs.
Brief description of accomplishments
georgia
The University of Georgia Cooperative Extension Service
produces a quarterly newsletter entitled, ``Senior Sense
Putting Knowledge to Work for Older Georgians.'' The newsletter
is distributed to 2,700 persons and is also available on the
College of Family and Consumer Sciences web page, where it is
accessed and read worldwide. Topics covered in the newsletters
include health issues, financial management, and care giving
tips.
idaho
In Idaho, the rapid growth in the numbers of elderly
citizens has produced the need for more people trained with an
understanding of aging development and a wide variety of
approaches to serving the elderly. an Idaho extension/research
specialist joined forces with a teaching/research colleague to
develop an interdisciplinary minor in aging in the School of
Family and Consumer Sciences at the University of Idaho. A team
of professionals from academic programs in psychology,
sociology, architecture, family and consumer sciences,
communications, and a representative from the library developed
a proposal and submitted it to the Idaho Board of Education.
The program has been approved. A minor in Aging will be an
important career complement to majors as the student develops
expertise in a subject matter support area like aging.
The University of Idaho Cooperative Extension Service (CES)
and vocational education staff identified a need for additional
trained home health aides by the year 2005. They discovered
that 890 people were employed as aides in 1994 but by the year
2005, 1244 would be needed to meet the demand. The CES and the
Idaho Department of Vocational Education collaborated to plan a
secondary and post-secondary program for Geriatric Home Care
Aides. They compiled a curriculum to be used to train home care
aides, piloted the program, established sites for student
clinical experience and internships, and established a system
for graduate placement. Upon completion of the program
including the internship, the student will be eligible to take
the examination for Certified Nurse Assistant certification. In
Idaho, these positions command approximately $8.00 per hour and
prepare people for a wide variety of career paths.
michigan
Michigan State University Cooperative Extension Service is
in a partnership with Blue Cross and Blue Shield of Michigan,
Kirtland Community College, Michigan Rural Aging Institute,
Office of Services to the Aging, Michigan Department of
Community Health, and the Michigan Family Independence Agency
to provide caregiver training that will prepare caregivers to
improve the care provided to older persons. Annually 4,000
caregivers of older adults are trained on such topics as
financial and legal issues of older adults, dementia,
understanding difficult behaviors, working with the frail
elderly, and financial abuse of the elderly. The training is
provided statewide using distance learning technology.
Caregivers obtain certification for completion of the training.
missouri
The Center on Aging Without Walls is a unique way to bring
information on age-related issues to the University Outreach
and Extension network, to the older adults of the State of
Missouri, and the many caregivers who provide care for older
citizens. The Center is a web site made possible through a
partnership between the Center on Aging Studies at the
University of Missouri-Kansas City and the University of
Missouri Outreach and Extension. Care giving issues have been
addressed in this initial phase of the web site. Topics covered
include burdens and rewards, care giver resources, ethics,
health concerns, family relations, and mental health. The web
address is .
new york
A Cornell University program that has young people and
senior citizens interacting in ongoing activities has become a
national model. A detailed handbook for group leaders who want
to replicate the program is available nationally. Geared for
children ages 9 to 13, but easily adaptable for other ages,
Project EASE--Exploring Aging through Shared Experiences--is
ideal for groups of scouts, 4-H groups, religious youth groups,
after-school programs and other youth organizations. It can
also be utilized in the classroom. The project is based on
current research on the effectiveness of intergenerational
programs to develop activities and projects that youth and
senior citizens can share for mutually satisfying, meaningful
and goal oriented interaction. Three years in development,
Project EASE has been field tested and evaluated by more than
70 4-H clubs in New York, involving about 600 participants. The
youth and seniors may plan a joint community service project in
which children and elders work together on an activity that the
community will value; shared group activity projects that both
groups enjoy but are not community service; and one-on-one
programs, in which each youth is paired with a senior in
activities such as arts and crafts, sharing oral histories,
grooming pets, playing board games, etc. This project is
supported in part with grants from the Charles Stewart Mott
Foundation, the Public Welfare Foundation, and the College of
Human Ecology at Cornell.
In another innovative program, Cornell University
researchers, Cooperative Extension Service faculty, and State/
local volunteers, and community agencies are addressing housing
options for senior citizens. Twenty counties in New York have
provided multi-faceted educational programs about community-
based housing options for the elderly for both professionals
and the public. Professionals, housing and human service agency
staff, municipal officials, and residents have new capacity to
respond to the housing needs of an increasing older population.
As a result of this project, they are knowledgeable about low-
cost community-based housing options such as shared housing,
accessory apartments, and elder cottages. As a result of
Cornell's research and extension outreach, state legislation
was passed to provide capital funding for the creation of these
new types of housing units. Municipal land-use and zoning
regulations have been changed to permit the development of this
housing in approximately 25 communities. Technical assistance
is provided to attorneys and community planners about zoning
and land-use regulations. There are now 12 shared living
residences in communities throughout the State. A not-for-
profit organization has received $375,000 from the State to
develop and operate an elder cottage lease program for low-
income elderly.
north carolina
The North Carolina Aging with Gusto program has been
adopted in more than half of North Carolina's 100 counties.
This program is believed to be unique nationally because it
focuses on the positive aspects of aging in how to achieve
optimum financial, physical, and mental well-being in later
years. Older adults learn how to prepare for and cope with
problems related to finances, legal issues, health, care
giving, housing and self-care. Recent figures suggest that the
program has reached more than 35,000 people directly.
North Carolina Cooperative Extension Service (CES) and the
North Carolina Division of Aging have collaborated to pilot a
new approach by distributing nutrition education materials with
the Meals on Wheels food deliveries. This is one way to reach
home-bound elderly that are especially difficult to reach and
who are at greater risk of malnutrition and chronic disease.
Sixteen different learn-at-home lessons have resulted in
positive changes in the stages of change for fruit and
vegetable consumption as evidenced in the pre- and post-test
from 177 participants in five counties.
To address another important issue for seniors, North
Carolina CES and the North Carolina State Attorney General's
Office worked together to educate older adults about consumer
scams. In one county, 785 seniors were reached with 80 percent
reporting they would be more cautious about telephone and mail
solicitations and 77 percent stated that the program motivated
them to change some of their consumer practices such as avoid
sharing credit card information on the telephone, making
financial donations to known charities and organizations, and
checking on offers that are ``too good to be true.''
Oregon
Oregon State Cooperative Extension Service (CES) has a
grant to study Behavioral Changes in Dementia Patients;
Relationships to Caregiver Well-Being. Currently data is being
collected on caregivers to Alzheimer's patients. The goal of
the research is to expand the understanding of later life care
giving to dementia patients and its consequences on caregivers'
mental and physical health. Extension curricula will be
developed as a result of this research.
Dissemination of research-based information is the hallmark
of the Cooperative Extension System. A network of professional
educators provide such information in community-based settings.
For example, Oregon State University is in a four university
consortium to provide geriatric education with a special
emphasis on reaching rural areas. A grant from the Geriatric
Education Center Training Grant, Department of Health and Human
Services, Public Health Services makes this program possible. A
special focus is on reaching rural health care professionals to
update and expand their knowledge of geriatric health issues.
Oregon CES has disseminated 13 health guidelines for consumers
relevant to older populations to 2,700 English and over 625
Spanish consumers. In addition, Extension sponsored four
teleconferences on a variety of women's health issues in later
life with satellite downlinks in 27 sites throughout the State.
Pennsylvania
Pennsylvania State University Cooperative Extension Service
(CES) has a preventive health program for people over age 75
and their family caregivers. The program provides independent
living through lifestyle changes, nutrition, and regular
exercise. Developed in rural Pennsylvania in Tioga, Bradford,
Sullivan, and Susquehanna counties, this program reaches an
extremely high-risk population. Ninety percent of the
participants had annual household incomes below $20,000, and 84
percent had only a high school or less education. High
percentages had nutrition risk, low levels of physical
activity, and losses in daily living activities. This program
will be expanded statewide.
Pennsylvania CES has also provided a program entitled
``Medicare Managed Care: What Does It Mean for You?'' More than
190 senior citizens and health care professionals in Centre
County, Pennsylvania, participated. The six sessions were
organized by Penn State's College of Agricultural Sciences and
the Pennsylvania Office of Rural Health, in collaboration with
Centre County CES, American Association of Retired Persons,
Centre County Office of Aging Apprise Program, and the
Brookline Village.
In Allegheny County the Extension Service assisted
residents of Carnegie Towers public housing in Pittsburgh to
organize and take leadership for a fledgling community.
Originally built for low income elderly citizens, a
predominantly young population now occupies the project. Most
of the households are headed by single, low-income females.
Intergenerational conflicts existed between elderly residents
and children, partly because the housing area did not include
recreational facilities for youth. After Extension leader
training workshops were completed, residents organized and
elected a tenant council of eight adults and one youth. Since
organizing, the council has sponsored a Community Day
Celebration, supported by various fund raising activities. They
have established a computer room with computer training
classes, an outdoor play area, Extension educational programs
related to 4-H youth development and nutrition, and a program
highlighting guest speakers who provide useful and practical
information.
South Carolina
Clemson University Cooperative Extension Service (CES)
specialist Katherine Carson has developed a program entitled,
Learning, Innovation, Networking, and Celebration (LINC)
nutrition program. LINC focuses on the elderly and preschool
children, as well as pregnant and parenting adolescents.
Changes in attitude, skills, knowledge, and behavior are
documented. LINC has reached 2,407 elderly South Carolinians.
LINC is a collaborative effort between the Clemson University
CES, the South Carolina Department of Social Services, and the
State Department of Health and Environmental Control Center for
Health Promotion. South Carolina Governor David Beasley has
recognized Carson for developing a nutrition program that
reaches senior citizens by presenting her with the Governor's
Health Promotion for Older South Carolinians Award. This
program will be expanded with the assistance of a $759,000
grant from USDA Food and Consumer Services. One phase of the
expansion will include a Nutrition Education and Resource
Center on the Internet for people who want information rapidly.
ECONOMIC RESEARCH SERVICE (ERS)
Title and purpose statement of each program or activity which affects
older Americans
The ERS identifies research and social policy issues
relevant to the elderly population from the perspective of
rural development. Ongoing research looks at demographic and
socioeconomic characteristics of the elderly by metro-nonmetro
residence. Current research examines the poverty status of the
elderly across the rural-urban continuum, and changes in the
concentration of the older population by residential area,
based on 1990 census data and Current Population Survey data.
We actively participate in the Interagency Forum on Aging-
Related Statistics at the National Institutes of Health, and
served on the Forum's work group on Population and Vital
Statistics.
Brief description of accomplishments
The following publications on the rural elderly have been
prepared by our staff in 1995 and 1996:
Beale, Calvin L., ``Nonmetro Population Rebound
Continues and Broadens,'' Rural Conditions and Trends,
Vol. 7, No. 3 (1996).
Beale, Calvin L., and Kenneth M. Johnson, ``Nonmetro
Population Continues Post-1990 Rebound,'' Rural
Conditions and Trends, Vol. 6, No. 3 (Spring 1996).
Fuguitt, Glenn V., Richard M. Gibson, Calvin L.
Beale, and Stephen J. Tordella, ``Recent Elderly
Population Change in Nonmetropolitan Areas,''
unpublished paper (1996).
Rogers, Carolyn C., ``Aging-Related Policy-Making;
Demographic Data Needs and Recommendations,'' a joint
report prepared as part of a working group of the
Interagency Forum on Aging-Related Statistics (February
1996).
Rogers, Carolyn C., ``Health Status Transitions of the
Elderly, by Residential Location,'' Family Economics
Review, Vol. 8, No. 4 (Fall 1995).
Rogers, Carolyn C., ``More Nonmetro Elderly Rate
Their Health as Fair to Poor'', Rural Development
Perspectives, Vol. 9, No. 3, June 1994 (released Fall
1995).
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 1996, $22 billion in food
stamps were provided to a monthly average of 25 million
persons.
Households with elderly members accounted for approximately
16 percent of the total food stamp caseload. However, since
these households were smaller on average and had relatively
higher net income, they received only 6 percent of all benefits
issued although 7 percent of participants are elderly.
Brief description of accomplishments
The 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. Approximately 10,000
SSI households in South Carolina receive food stamp benefits
through this project. An independent evaluation of SCCAP is
underway and is scheduled to be completed in 1999.
Title and purpose statement for each program or activity which affects
older Americans
The Commodity Supplemental Food Program (CSFP) provides
supplemental foods, in the form of commodities, and nutrition
education to infants and children up to age 6, pregnant,
postpartum or breast-feeding 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, legislation 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 1996, approximately $51 million was spent on the elderly
component.
Brief description of accomplishments
About 57 percent of total program spending provides
supplemental food to approximately 219,000 elderly participants
a month. Older Americans are served by 18 of 20 State agencies.
Title and purpose statement of each program or activity which affects
older Americans
The Food Distribution Program on Indian Reservations
(FDPIR) 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.
Brief description of accomplishments
This program serves approximately 46,000 households with
elderly participants per month.
Title and purpose statement of each program or activity which affects
older Americans
The Child and Adult Care Food Program (CACFP) 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
1996, $25 million was spent on the adult day care component.
Brief discussion of accomplishments
The adult day care component of CACFP served approximately
23 million meals and supplements to over 46,000 participants a
day in fiscal year 1996.
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 days 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 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.
Title and purpose of 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.
As estimated $16 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.
Title and purpose statement of each program or activity which affects
older Americans
The Nutrition Program for the Elderly (NPE) 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 $140 million worth of cash and commodities.
Brief description of accomplishments
In fiscal years 1995 and 1996, over 245 million meals were
reimbursed at a cost of almost $150 million. On an average day,
approximately 925,000 meals were provided.
FOOD SAFETY AND INSPECTION SERVICE (FSIS)
Title and purpose statement of each program or activity which affects
older Americans
FSIS is continuing a consumer education campaign targeted
to older Americans, one of several groups of people who face
special risks from food-borne illness. The goal is to reduce
the incidence of food-borne illness caused by consumer
mishandling of food. Food-borne illness can lead to serious
health problems and even death for someone who is chronically
ill or has a weakened immune system. The elderly, with more
than 35 million people in their ranks, are the largest group at
risk and are increasing in number because of longer life
expectancies.
Brief description of accomplishments
FSIS continues to distribute food safety information to
this group through direct mail of publications and liaison work
with the Administration on Aging.
FOREST SERVICE (FS)
Title and purpose statement for each program or activity which affects
older Americans
Senior Community Service Employment Program (SCSEP)--
Program Year 1996, July 1, 1996--June 30, 1997, the USDA Forest
Service's Senior Community Service Employment Program (SCSEP)
provided training and work experience in research, budget and
finance, clerical/administrative, computer, forestry, building/
recreational maintenance, visitor interpreters, and
communication.
Brief description of accomplishments
The FS Senior Community Service Employment Program provided
an opportunity for 5,055 participants, age 55 and above, to
upgrade their work skills by receiving training and part-time
employment opportunities while providing community service to
the general public.
Title and purpose statement for each program or activity which affects
older Americans
Volunteers in the National Forests--Volunteers continue to
contribute to the management of the Nation's natural resources
that are administered by the FS.
Brief description of accomplishments
During fiscal year 1997, 112,384 participants assisted in
the management of National Forest System lands including 13,392
participants are 55 years and above. Volunteers participated in
recreation, resource protection and management, cooperative/
international forestry, and research. Typical positions
included campground hosts, administrative, recreation,
wildlife, and fisheries assistants, fire lookouts, and
information specialists.
RURAL HOUSING SERVICE (RHS)
Title and purpose statement of each program or activity which affects
older Americans
Each person experiences the aging process differently. Some
people are able to maintain lifelong health and independence,
while others find that they face increasingly more difficult
challenges to their abilities to take care of themselves. The
difficulties that aging can bring are felt not only by elderly
people but also by their children and grandchildren, making the
question of how to address these difficulties one of
intergenerational importance. Adding urgency to this question
is the fact that America's elderly population is growing
rapidly: the US Census Bureau forecasts a growth in the
proportion of people ages 65 and older from 12.5 percent in
1990 to 17.7 percent in 2020, a 41.6 percent increase.
The Rural Housing Service (RHS) recognizes the importance
of providing rural seniors with a wide range of living options.
We invest heavily in programs that help elderly people live
with as much independence and dignity as possible. These
include the Section 504 loan and grant programs, which make
vital home repairs for very low-income seniors; the Section 515
Rural Rental Housing program, which provides affordable rental
housing to seniors and people with disabilities (as well as
families); the Section 521 Rental Assistance program, which
makes rents in the Section 515 program affordable to tenants
with very low incomes; and the Community Facilities program,
which among other things finances a variety of elder care
facilities. Following are descriptions of how each of these
programs serves elderly people.
Section 504 Loan and grant programs. The Section 504 loan
and grant programs allow elderly people with very low to
maintain their independence by remaining in their own homes.
The loan program is available to any rural person with a very
low income, but most program beneficiaries are elderly: incomes
the average age of borrowers between 1991-1996 was 58, and the
median age was 61, which means that half of all borrowers were
61 or older. The grant program is available exclusively to very
low-income rural seniors. Both programs provide funds to make
such major repairs of renovations as removing electrical and
fire hazards, replacing roofing, installing or improving water
and waste-water disposal systems, and installing
weatherization.
Brief description of accomplishments
In 1996, the Section 504 loan program lent a total of $35.1
million to 6,861 very low-income borrowers; in 1995, it lent
$29.5 million to 6,116 borrowers. In 1996, the Section 504
grant program provided $29.5 million to 6,179 very low-income
elderly people; in 1995, it provide $27.8 million to 6,964
people. The average income of Section 504 borrowers between
1991-1996 was $11,652; the median income was $8,055. Average
and median incomes for Section 504 grant recipients are not
available but are likely very similar.
Title and purpose statement of each program or activity which affects
older Americans
Section 515 Rural Rental Housing program and Section 521
Rental Assistance program. Many relatively independent rural
seniors find that they cannot keep up with the yard work and
structural maintenance that home ownership requires. Others
find that they need to live closer to vital services such as
doctors, pharmacies, and grocery stores. For these elderly
people, the Section 515 Rural Rental Housing program is an
attractive option. In addition to being virtually maintenance-
free, our apartments for elderly and disabled people are
equipped with special amenities such as strategically placed
handrails and emergency call buttons or lights with which to
signal for help. Many of them are wheelchair accessible.
Managers of these complexes often arrange services such as
transportation, grocery and pharmaceutical delivery, Meals on
Wheels, health screenings, and entertainment, and they make
sure that the community rooms stay in constant use. In
addition, a small percentage of our Section 515 complexes offer
congregate facilities in which seniors receive two cooked meals
per day.
Brief description of accomplishments
In 1997, we invested $45.4 million dollars (47 percent of
the total funds we lent) to build 49 complexes and
approximately 1,200 units for elderly people and people with
disabilities. In addition, we lent $6.9 million to make repairs
to 47 existing complexes. The previous figures are not
available for 1995 or 1996. In our existing portfolio of
approximately 18,000 complexes, 6,765 complexes (38 percent of
the portfolio) serve elderly or disabled people. Another 375
complexes (2 percent) serve ``mixed'' tenant populations of
both families and elderly people. You and apply these same
percentages to 1995 and 1996--the portfolio did not grow much
and it's safe to assume that the percentage did not change. In
1995 (the last year in which we conducted a complete nationwide
tenant survey), 41 percent of our tenants were elderly people,
and a majority of these were women. The average tenant adjusted
income was $7,280.
1995 letter from then 82-year-old Betty C. McAfee of
Belfast, Maine. Before moving (to Section 515 rural rental
housing) I lived alone in a 2-room cabin (with) no foundation,
no plumbing and (which was) heated by a small wood-burning
stove. I had a long walk to the rural mail box over a rough
dirt lane. If this (Section 515) complex did not exist, I would
still be living there. Many other low-income elderly people in
Maine are living under these conditions, or worse.
To make Section 515 housing available to tenants who cannot
afford market rents, RHS provides assistance through its
separately appropriated Section 521 Rental Assistance program,
which brings tenants' rent down to 30 percent of their adjusted
incomes and makes up the difference to the landlords. In 1996,
RHS provided more than $540 million worth of Rental Assistance
to approximately 47 percent of Section 515 households, while in
1995 it provided $523 million. While we lack demographic
information on beneficiaries of Rental Assistance, it is safe
to assume that at least 25 percent of the beneficiaries are
seniors and that in 1996 seniors received approximately $135
million in RHS Rental Assistance while in 1995 they received
approximately $131 million.
Title and purpose of each program or activity which affects older
Americans
Community Facilities Loan and Grant Program. Through our
Community Facilities loan and grant program, we finance a range
of service centers for elderly people, including nursing homes,
boarding care facilities and assisted care, adult day care, and
a few intergenerational care facilities which serve both
elderly people and children at the same time.
Brief description of accomplishments
From its inception in 1974 to the end of 1996, the
Community Facilities program has made 535 loans and guarantees
worth $547 million facilities that directly benefit seniors. In
1996, the Community Facilities program invested $44.4 million--
17 percent of its total funding for the year--to either build
or make improvements to 32 senior facilities. In 1995, the
program invested $32.4 million--14 percent of its funding--in
27 seniors facilities. In addition, the program invested
heavily in hospitals, clinics, and emergency services, which
benefit people in every generation.
ITEM 2--DEPARTMENT OF COMMERCE
----------
ORGANIZATION OF THIS REPORT
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, here and
abroad. All of the items included in this report were released
by the Census Bureau during calendar years 1995 and 1996.
The items mentioned are available to the public in a
variety of formats including print, electronic databases,
microcomputer diskettes, and CD-ROM. Many of these products can
also be found on the Intent at the Census Bureau's web site
(http://www.census.gov).
1. Population, Housing, and International Reports.--Three
of the Census Bureau's major reports series (Current Population
Reports, Current Housing Reports, 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 their income,
health insurance coverage, need for assistance with daily
living tasks, and housing situation. Additionally, data on
elderly around the world, including such facts as the
decreasing age of death among Russian adults, are also found in
this 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 (NIA), agencies of the United Nations (UN),
and the Organization for Economic Cooperation and Development.
Additionally, the Census Bureau's population projection
program and Special Studies Report series also contained
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 every ten years after each decennial census. Included
in this is information (total numbers and characteristics) on
people 65 years of age and older.
3. Database on Aging/National Institute on Aging
Products.--This database provides a summary of analytical
studies and other ongoing international aging projects. Reports
are based on compilations of data obtained from individual
country statistical offices, various international
organizations, and estimates and projections prepared at the
Census Bureau. This work is funded by the NIA.
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
I. POPULATION, HOUSING, AND INTERNATIONAL REPORTS
Population
Series P-20 (Population Characteristics):
Regularly recurring reports in this series contain data from
the CPS on 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 of age and older.
The Black Population in the United States; March 1994 and 1993 480
Geographical Mobility: March 1992 to March 1993............... 481
Household and Family Characteristics: March 1994.............. 483
Marital Status and Living Arrangements: March 1994............ 484
Geographical Mobility: March 1993 to March 1994............... 485
The Foreign-Born Population: 1994............................. 486
Household and Family Characteristics: March 1995.............. 488
Educational Attainment in the United States: March 1995....... 489
Marital Status and Living Arrangements: March 1995............ 491
Series P-23 (Special Studies):
Information pertaining to methods, concepts, or specialized
data is furnished in these publications. The reports in this
series contain data on mobility rates, home ownership rates,
and Hispanic population for the general population and the
older population. The report Sixty-Five Plus in the United
States focuses on analyses of demographic, social, and
economic trends among the older population. It is a revision
of a 1993 report. It expands the use of 1990 census data,
incorporates updated national and state population
projections, and utilizes new survey data and analytical
findings from Federal agencies and numerous researchers in
the aging studies field.
How We're Changing: Demographic State of the Nation; 1995..... 188
Population Profile of the United States: 1995................. 189
Sixty-Five Plus in the United States.......................... 190
How We're Changing: Demographic State of the Nation: 1996..... 191
Series P-25 (Population Estimates and Projections):
This series includes monthly estimates of the total U.S.
population; annual midyear estimates of the U.S. population
by age, sex, race, and Hispanic origin; state estimates by
age and sex; and projections for the United States and
states. This series also includes estimates of housing units
and households for states.
National and State Population Estimates: 1990 to 1994......... 1127
Projections of the Number of Households and Families in the
United States: 1995 to 2010................................. 1129
Population Projections of the United States by Age, Sex, Race,
and Hispanic Origin 1995 to 2050............................ 1130
Population Projections for States by Age, Sex, Race, and
Hispanic Origin: 1995 to 2025............................... 1131
Series PPL (Population Paper Listings):
This series of reports contains estimates of population and
projections of the population by age, sex, race, and origin.
Other topics appear as well, some of which address issues
related to aging.
Hispanic Tabulations from the Current Population Survey: March
1994........................................................ 26
The Foreign-Born Population: 1994............................. 31
The Asian and Pacific Islander Population: March 1994......... 32
Child Care Costs and Arrangements: Fall 1993.................. 34
U.S. Population Estimates by Age, Sex, Race, and Hispanic
origin: 1990 to 1995........................................ 41
Population of States by Broad Age Group and Sex: 1990 and 1995 44
The Black Population in the United States: March 1995......... 45
Household and Family Characteristics: March 1995.............. 46
Population Projections for States by Age, Sex, Race, and
Hispanic Origin: 1995 to 2025............................... 47
Educational Attainment in the United States: March 1995....... 48
Marital Status and Living Arrangements: March 1995............ 52
Technical Working Paper Series:
This series contains papers of a technical nature that have
been written by staff of the Population Division of the
Census Bureau. Topics covered are varied. 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.
``Estimation of the Annual Emigration of U.S. Born Persons by
Using Foreign Censuses and Selected Administrative Data:
Circa 1980,'' Edward W. Fernandez........................... 10
``Fertility of American Men,'' Amara Bachu.................... 14
``Comparisons of Selected Social and Economic Characteristics
Between Asians, Hawaiians, Pacific Islanders, and American
Indians (Including Alaskan Natives),'' Edward W. Fernandez.. 15
Series SB/CENTER (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.
Sixty-Five Plus in United States.............................. 95-8
How Much We Earn--Factors That Make a Difference.............. 95-17
Women in the United States: A Profile......................\1\ 95-19
Health Insurance Coverage--Who Had a Lapse Between 1991 and
1993?....................................................... 95-21
The Nation's Asian and Pacific Islander Population--1994...... 95-24
The Nation's Hispanic Population--1994........................ 95-25
What We're Worth--Asset Ownership of Households: 1993......... 95-26
Getting a Helping Hand--Long-Term Participants in Assistance
Programs.................................................... 95-27
Warmer, Older, More Diverse................................... 96-1
Election '96--Counting the American Electorate................ 96-2
Series PE (Population Electronic):
This series comprises microcomputer diskettes or computer
tapes covering a variety of topics in the population field.
The information on the diskettes is, for the most part,
available in printed format.
The Asian and Pacific Islander Population: March 1994......... 25
Population Estimates for States, Counties, MCDs and
Incorporated Places: April 1, 1990 to July 1, 1994.......... 28
Estimates of the Population of States by Age, Sex, Race, and
Hispanic Origin: 1990 to 1992............................... 29
Estimates of the Population of Counties by Age, Sex, and
Hispanic Origin: 1990 to 1992............................... 30
The Foreign-Born Population: March 1994....................... 32
Estimates of Population for Counties and Components of Change:
1990 to 1995................................................ 34
National Population Projections by Age, Sex, Race, and
Hispanic Origin: 1995 to 2050............................... 37
Population Estimates of States by Single Years of Age and Sex
for States: 1990 to 1995.................................... 38
Population Estimates of States by Selected Age Groups and Sex:
1970 to 1979................................................ 39
Population Estimates of States by Single Years of Age and Sex:
1980 to 1989................................................ 0
Projections of the Number of Households and Families: 1995 to
2010........................................................ 44
Educational Attainment: March 1995............................ 46
Estimates of the Population of States by Age, Sex, Race, and
Hispanic Origin: 1990-1994.................................. 47
Estimates of the Population of Counties by Age, Sex, Race, and
Hispanic Origin: 1990-1994.................................. 48
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.
Income, Poverty, and Valuation of Noncash Benefits: 1994...... 189
Health Insurance Coverage: 1994............................... 190
A Brief Look at Postwar U.S. Income Inequality................ 191
Money Income in the United States: 1995....................... 193
Poverty in the United States: 1995............................ 194
Health Insurance Coverage: 1995............................... 195
Series P-70 (Household Economic Studies):
These data are from the 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 of age and older.
Dynamics of Economic Well-Being: Health Insurance, 1991 to
1993........................................................ 43
The Effect of Health Insurance Coverage on Doctor and Hospital
Visits: 1990 to 1992........................................ 44
Dynamics of Economic Well-Being: Poverty: 1991 to 1993........ 45
Dynamics of Economic Well-Being: Program Participation, 1991
to 1993..................................................... 46
Household Economic Studies, Asset Ownership of Households,
1993........................................................ 47
Dynamics of Economic Well-Being: Income, 1991 to 1992......... 49
Beyond Poverty, Extended Measures of Well-Being, 1992.........\1\ 50
Health Insurance, 1992 to 1993. Who Loses Coverage and for How
Long?....................................................... 54
Poverty, 1992-1993. Who Stays Poor? Who Doesn't?.............. 55
Dynamics of Economic Well-Being: Labor Force, 1992 to 1993.... 57
Program Participation, 1992-1993. Who Gets Assistance?........ 58
Americans with Disabilities: 1994-1995........................ 61
\1\ Revised.
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Housing
Series H121 (Housing Characteristics):
These reports present data from the American Housing Survey.
Some characteristics shown in these reports include
socioeconomic status of household, physical condition of the
housing unit, and affordability of housing in relation to
income.
Current Housing Report: American Housing Survey, A Quality
Profile..................................................... 95-1
Current Housing Reports: Our Nation's Housing in 1993......... 95-2
Series H-150 (Housing Vacancy):
This book presents data on apartments; single-family homes;
vacant housing units; age, sex, and race of householders;
income; housing and neighborhood quality; housing costs;
equipment and fuels; and size of housing units. The book
also presents data on home-owner's repairs and mortgages,
rent control, rent subsidies, previous unit of recent mover,
and reasons for moving. A wall chart accompanies this
product.
American Housing Survey of the United States in 1993.......... 93
Series H-151 (Supplements to the American Housing Survey):
This series provides additional information on occupied
housing units. Family type, household and financial
characteristics, and housing quality is included.
Demographic information is available, including a separate
discussion and data on the elderly.
Supplement to the American Housing Survey for the United
States in 1993.............................................. 93
American Housing Survey: Components of Inventory Change: 1980
to 1991, United States and Regions.......................... 91-2
Series H-170 (American Housing Survey, Selected Metro Areas):
This book presents data for selected metropolitan statistical
areas for the same characteristics shown above in Series H-
150. Eleven metro areas per year are produced on a 4-year
rotation for a total of 44 metro areas.
American Housing Survey for Selected Metropolitan Statistical
Areas, 1994................................................. 94
International
Series P-95 (International Population Reports):
The reports in this series contain demographic and
socioeconomic data on the older population as estimated or
projected by the Census Bureau or published by various
statistical offices, several agencies of the UN, and the
Organization for Economic Cooperation and Development. Older
Workers, Retirement and Pensions: A Comparative
International Chart Book provides an overview of underlying
demographic and socioeconomic trends as it relates to the
elderly. Graphical presentations of comparable statistics on
the status of the world's older population are also
included. This work is supported by the Office of the
Demography on Aging, NIA.
Older Workers, Retirement and Pensions: A Comparative
International Chart Book.................................... 95-2
Series PPT/IB (International Briefs):
This series of summaries covers a variety of topics, some of
which relate to aging. Many of the reports present basic
demographic data on a number of countries. The series is now
known as International Briefs.
Population Trends: Tanzania 1995 (PPT)........................ 92-10
Population Trends: Philippines 1996 (PPT)..................\2\ 92-11
Old Age Security Reform in China.............................. 95-1
Population Trends: Ghana 1996................................. 96-1
World Population at a Glance: 1996 and Beyond................. 96-3
Series WP (World Profiles):
This series provides comprehensive demographic information for
all countries and regions of the world. The information is
maintained in a database and is regularly updated. In
addition, each edition of the series focuses on a specific
topic of interest related to the world's population.
World Population Profile: 1996................................ 96
Series WID (Women in Development):
This new series contains information on the world's women,
including elderly women. Demographic, educational,
employment, and political participation data are included.
Women in Poland............................................... 5
Series SP (Staff Papers):
A variety of economic and demographic studies are included in
this series of papers, some of which concern issues related
to the elderly population.
Pension Reform in china: Implications for Labor Markets....... 83
\2\ Revised.
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II. DECENNIAL PRODUCTS
1. Printed Reports
Series CPH-L (Population and Housing Data):
These listings give statistics for states, counties, and
places, some of which contain information on the elderly
population.
Social and Economic Characteristics of Selected Language
Groups for U.S. and States: 1990............................ 194
Series CP:
This report presents social, economic, and housing census data
on the Black population. It shows data on age in nine
categories, each category cross-classified by social,
economic and housing data.
Characteristics of the Black Population....................... 3-6
Series CH:
This report presents statistical summaries of data on
residences from the Residential Finance Survey conducted in
1991 as part of the 1990 census. The report covers owner
characteristics, one of which is age.
Residential Finance........................................... 4-1
2. Computer Tape Files/CD-ROM
Series SSTF (Subject Summary Tape Files):
This CD-ROM contains sample data from the 1990 Census of
Population and Housing on the older population. The file
contains statistics on persons 60 years of age and older and
on families with a householder 60 years of age and older.
The Older Population of the United States..................... 19
The compact disks contain sample data from the 1990 Census of
Population and Housing on the Black population of the United
States. There are cross-classifications by sex and detailed
age groups.
Characteristics of the Black Population of the United States.. 21
III. DATABASE ON AGING/NATIONAL INSTITUTE ON AGING PRODUCTS
The following papers are based on information contained in
the Database on Aging and other related holdings. This work is
carried out with the support of the NIA. The statistics shown
in the wall chart are intended to highlight the present and
future worldwide dimensions of aging and portray the diversity
among nations.
``Aging Trends: Turkey,'' Journal of Cross-Cultural
Gerontology, Kevin Kinsella, ed. 1995.
``Demographic Imperative,'' Kevin Kinsella, Cancer
Control, Vol. 2, No. 2, supplement, 1995.
``Aging and the Family: Present and Future Demographic
Issues,'' Kevin Kinsella. In Handbook on Aging and
the Family, Rosemary Blieszner and Victoria
Hilkevitch Bedford, eds. Greenwood Press, 1995.
Global Aging Into the 21st Century [Wall Chart], U.S. Bureau of
the Census, 1996.
``Demographic Aspects,'' Kevin Kinsella. In Epidemiology in Old
Age, Shah Ebrahim and Alex Kalache, eds, British
Medical Journal Publishing Group, 1996.
IV. THE FEDERAL INTERAGENCY FORUM ON AGING-RELATED STATISTICS SUMMARY
The Census Bureau is one of the lead agencies in the
Federal Interagency Forum on Aging-Related Statistics, a first-
of-its-kind effort. The Forum encourages cooperaton among
Federal agencies in the development, collection, analysis, and
dissemination of data pertaining to the older population.
Through cooperation and coordinated approaches, the Forum
extends the use of limited resources among agencies through
joint problem solving, identification of data gaps, and
improvement of the statistical information bases on the older
population, which are used to set the priorities of the work of
individual agencies. The work of the Forum is guided by the
Office of Demography at the NIA, the Population Projections and
Aging Studies Branches at the Census Bureau, and the Office of
the Coordinator of Data on Aging, National Center for Health
Statistics. Senior subject-matter specialists from the agencies
are also involved in the activities of the Forum.
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, the Census Bureau publishes a newsletter,
Data Base News in Aging, which includes recent 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 newsletter.
The Census Bureau released Federal Forum Report 1991-93
(May 1995). It reviews the activities of the Forum and its
member agencies during 1991-1993. Various sections of the
report summarize Forum work and accomplishments, cooperative
efforts of members, publications by member agencies, and
activities planned for the near future. An interagency
telephone contact list of specialists on subjects related to
aging is also included. During the 1991-1993 time period, the
Forum oversaw activities of three working groups formed to
address technical issues related to the elderly and disability,
rural residence, and minority status. The working groups were
composed of area-specific experts in the Federal Government who
regularly sought advice from experts outside the Federal
service. Four policy-related areas focused on were: health,
retirement, population projections, and database development.
V. OTHER PRODUCTS
American Housing Survey
Computer data tapes and CD-ROM are available for the 1995
and 1996 survey efforts. The survey is designed to provide
information on the housing situation in the United States.
Information is available by age.
CPS and SIPP Surveys
Data for both surveys are available in electronic media.
Statistical Abstract of the United States: 1995 and 1996
As the national data book, this annual product contains an
enormous collection of statistics on social and economic
conditions in the United States. Selected international data
are also included. The Abstract appears in both print and CD-
ROM versions.
International Database
The International Database is a computerized data bank
containing statistical tables of demographic and socioeconomic
data for all countries of the world. Most of the data are
obtained from censuses and surveys or from administrative
records and are regularly updated. Selected information from
the Database is highlighted in the International Briefs series
of reports. In addition, Series WP reports, World Population
Profiles, provide detailed data, which are taken from the
Database.
ITEM 3--DEPARTMENT OF DEFENSE
The Department of Defense has several ongoing initiatives
in support of older Americans. They are detailed below.
Eldercare Support
The Department's Family Centers reports that there is an
increasing demand for information about eldercare. The Centers
providing information workshops on eldercare issues describe
them as well-attended and very useful. In addition to workshops
and seminars on eldercare, the Centers access the national 1-
800 eldercare locator to assist family members with eldercare
support services in other parts of the country. The Centers
also have a number of useful pamphlets and handouts on
eldercare that 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 that draw thousands of military retirees and
their families. For these seminars, the staff brings in experts
to discuss 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.
The Department of Defense recognizes that eldercare is a
growing issue for military personnel and their family members
and will continue to be responsive to the needs of the active
duty and retired community in this regard.
Health Care
The Department of Defense has nearly completed
implementation of TRICARE, its new, regionally managed care
program for members of the uniformed services and their
families and survivors and retired members and their families.
Retirees and their families are finding that this new program
has increased their access to high-quality health care.
TRICARE gives beneficiaries three choices for their health
care delivery: TRICARE Standard, TRICARE Extra, and TRICARE
Prime. All active-duty members will be enrolled in TRICARE
Prime. Those CHAMPUS-eligible beneficiaries who elect not to
enroll in TRICARE Prime and Medicare-eligible DoD beneficiaries
will remain eligible for care in military medical facilities on
a space-available basis. The three options are described below:
TRICARE Standard--This option is the same as the
standard CHAMPUS program.
TRICARE Extra--In the TRICARE Extra program, when a
CHAMPUS-eligible beneficiary uses a preferred network
provider, he or she receives an out-of-pocket discount
and usually does not have to file any claim forms.
CHAMPUS beneficiaries do not enroll in TRICARE Extra
but may participate in Extra on a case-by-case basis
just by using the network providers.
TRICARE Prime--This voluntary enrollment option
offers patients the advantage of managed health care,
such as primary care management, assistance in making
specialty appointments, and having someone else to do
their claims filing. The Prime option offers the scope
of coverage available today under CHAMPUS, plus
additional preventive and primary care service. For
Prime enrollees, the new cost-sharing provisions do
away with the usual standard CHAMPUS cost sharing. Of
particular note, families of active duty personnel will
have no enrollment fees. CHAMPUS-eligible retirees who
enroll in Prime will pay an enrollment fee but will pay
only $11 per day for civilian inpatient care in
comparison to the $360 per day plus 25 percent of
professional fees charge faced by those retirees who
use TRICARE Standard. For Prime enrollees, there will
be copayments for care received from civilian
providers. These copayments are significantly less than
for the other two options. Enrollees in TRICARE Prime
obtain most of their care within the integrated
military and civilian network of TRICARE providers.
Additionally, under a new point of service option,
Prime enrollees may retain freedom of choice to use
non-network providers, but at significantly higher cost
sharing than in TRICARE Standard.
Military beneficiaries over the age of 65 have
traditionally relied on a combination of health care
entitlements, including (1) an earned entitlement to Medicare,
(2) space-available access to military hospitals, and (3) other
benefits gained through non-military employment. With the post-
Cold War drawdown in the military, space in military facilities
is less available. The Department of Defense is seeking ways to
enhance its services to its over-65 beneficiaries; one approach
will be tested in a three-year demonstration program authorized
in the Balanced Budget Act of 1997. The Department will enroll
military Medicare-eligible beneficiaries in ``TRICARE Senior
Prime'' and receive capitated payments from the Medicare Trust
Fund. The demonstration will be conducted at six sites and
includes a requirement for Defense to maintain its budgeted
level of effort for Medicare beneficiaries prior to receiving
payments from Medicare. An additional component of the
demonstration, Medicare Partners, will enable the Department to
receive reimbursement from Medicare+Choice plans for inpatient
and speciality services it renders to their military enrollees.
ITEM 4--DEPARTMENT OF DEFENSE
Postsecondary Education
The Office of Postsecondary Education administers programs
designed to encourage participation in higher education by
providing support services and financial assistance to
students.
In fiscal year 1997, an estimated $43 billion was made
available to students through the student financial assistance
programs authorized by Title IV of the Higher Education Act of
1965, as amended (HEA). There are no age restrictions for
participation in the Title IV programs. For example, the Pell
Grant Program, our largest grant program, made an estimated 3.6
million awards in award year 1995-1996 (the most recent year
for which this information is available). Approximately 6.2
percent of the awardees were over age 40.
The Federal TRIO programs fund postsecondary education
outreach and student support services that encourage
individuals from disadvantaged backgrounds to enter and
complete college. Because age is not an eligibility criterion
under most of these programs, data on the age of participants
are not available.
In addition to these programs, the Office of Postsecondary
Education's Fund for the Improvement of Postsecondary Education
(FIPSE) supports innovative projects, which include some
projects designed to meet the needs of older Americans. In
fiscal year 1997, FIPSE funded a Dissemination Project entitled
Enhanced Intergenerational Learning at Eckerd College in St.
Petersburg, Florida. In 1984 Eckard College initiated a program
that drew on the experience and wisdom of high-achieving
retired men and women who would serve as ``Living Library
Resources'' to supplement other educational resources available
to professors and students. Periodic evaluations by faculty and
students attest to the educational value of this program, and
today an Academy of Senior Professionals at Eckard College
includes some 200 high achieving individuals who offer their
knowledge, perspectives, and experiences to enhance the
learning experience. FIPSE is supporting Eckerd College to
serve as mentor to six adapter institutions throughout the
country to determine if this program can be replicated on other
campuses.
Because jobs in today's workplace require an increasingly
higher level of knowledge and skill, it is essential that all
Americans have the opportunity for further education. The
Administration is including two initiatives in its proposal to
reauthorize the HEA that would encourage and assist working
Americans improve their wages through lifelong learning.
(1) Learning Anytime Anyplace Partnerships: This
program has been designed to encourage and enable
working Americans to increase their levels of knowledge
and skills by taking advantage of the increasing
opportunities for distance education. It calls for a
more innovative and comprehensive approach to lifelong
learning by supporting regional or national
partnerships among education institutions, state and
local governments, community agencies, software and
other technology developers, learning assessment
specialists, and private industry to expand non-
traditional learning opportunities.
(2) College Awareness Program: This program has been
designed to provide better information on preparing for
college and on the sources of financial aid to middle
and high school students, and to adults who want to
continue learning over their lifetimes. In addition to
serving middle and junior high school students, their
parents, teachers, and school counselors, this program
would also address the interests of the increasing
number of adults of all ages who want to go back to
college.
Adult Education
In the past, the education of persons 60 years of age and
older may not have been considered an educational priority in
the United States. The 1990's may well be considered the decade
of growth in educational gerontology. Demographics have tended
to make this development inevitable. A recent study entitled,
Profiles of the Adult Education Target Population--Information
from the 1990 Census, prepared by the Center for Research in
Education, Research Triangle Institute, indicates that more
than 44 million adults, or nearly 27 percent of the adult
population of the United States, have not completed a high
school diploma or its equivalent. These individuals make up the
adult education target population. Of the 44 million adults in
the target population, more than 18 million or 41 percent are
60 or more years old. Over 53 percent of the adults age 60 and
over in the target population have completed fewer than 8 years
of schooling. The high rate of under-education indicates a need
for emphasizing effective basic skills and coping strategies in
programs for older adults.
The U.S. Department of Education is authorized under the
Adult Education Act (AEA), Public Law 100-297, as amended by
the National Literacy Act of 1991, (Public Law 102-73), to
provide funds to the State and outlying areas for educational
programs and related supporting services benefiting all
segments of the eligible adult population. The central program
established by the AEA is the State-administered Basic Grant
Program. The AEA has also provided funds for programs of
workplace and English Literacy. In addition, the 1991
amendments established four new programs:
State Literacy Resource Centers; National Workforce
Literacy Strategies; Functional Literacy for State and
Local Prisoners; and Life Skills Training for State and
Local Prisoners.
The above-mentioned programs are administered by the Office
of Vocational and Adult Education.
In addition, amendments to the AEA State-administered Basic
Grant Program include, in part:
The authorization for competitive 2-year ``Gateway
Grants'' by States to public housing authorities for
literacy programs for housing residents.
A requirement for States to develop a system of
indicators of program quality to be used to judge the
quality of State and local programs.
An increase in the State set-aside under Section 353
for innovative demonstration projects and teacher
training from 10 to 15 percent, with two-thirds of that
amount to be used for training of professional
teachers, volunteers, and administrators.
A requirement in allocating Federal funds to local
programs, that each State consider: past program
effectiveness (especially with respect to recruitment
retention and learning gains of program participants),
the degree of coordination with other community
literacy and social services, and the commitment to
serving those most in need of literacy services.
A requirement that each State educational agency
receiving financial assistance under this program
provide assurance that local educational agencies,
public or private nonprofit agencies, community-based
organizations, correctional education agencies,
postsecondary education institutions, institutions
which serve educationally disadvantaged adults and any
other institution that has the ability to provide
literacy services to adults and families will be
provided direct and equitable access to all Federal
funds provided under this program.
A requirement that States evaluate 20 percent of
grant recipients each year.
Generally, the purpose of the AEA is to encourage the
establishment of programs for adults lacking literacy skills
who are 16 years of age and older or who are beyond the age of
compulsory school attendance under State law. These programs
will:
(1) Enable adults to acquire the basic educational
skills necessary for literate functioning;
(2) Provide sufficient basic education to enable
these adults to benefit from job training and
retraining and to obtain productive employment; and
(3) Enable adults to continue their education to at
least high school completion.
In Program Year 1992-93, 3.9 million adult learners were
served through the AEA program nationwide. Of these learners,
597,543 were 45 years of age or older.
Many of the emerging workforce participants, including a
large number of older adults, lack the basic literacy skills
necessary to meet the increased demands of rapid change and new
technology. Thus, employers will have to make training and
retraining a priority in order to upgrade the labor force.
The adult education program addresses the needs of older
adults by emphasizing functional competency and grade level
progression, from the lowest literacy level, to providing
English as a second language instruction, through attaining the
General Education Developmental Certificate. States operate
special projects to expand programs and services for older
persons through individualized instruction, use of print and
audio-visual media, home-based instruction, and curricula
relating basic educational skills to coping with daily problems
in maintaining health, managing money, using community
resources, understanding government, and participating in civic
activities.
Equally significant is the expanding delivery system,
increased public awareness, as well as clearinghouses and
satellite centers designed to overcome barriers to
participation. Where needed, supportive services such as
transportation are provided as are outreach activities adapting
programs to the life situations and experiences of older
persons. Individual learning preferences are recognized and
assisted through the provision of information, guidance and
study materials. To reach more people in the targeted age
range, adult education programs often operate in conjunction
with senior citizens centers, nutrition programs, nursing
homes, and retirement and day care centers.
Increased cooperation and collaboration among
organizations, institutions and community groups are encouraged
at the national, State and local levels. In addition, sharing
of resources and services can help meet the literacy needs for
older Americans.
U.S. DEPARTMENT OF EDUCATION
Enforcement of the Age Discrimination Act of 1975
I. Status of the Department of Education's Implementing Regulation
The Department of Education's final regulation implementing
the Age Discrimination Act of 1975 was published on July 27,
1993. The effective date of implementation was August 26, 1993.
The Department's regulation prohibiting age discrimination
applies to all elementary and secondary schools, colleges and
universities, public libraries, and vocational rehabilitation
services. It covers age discrimination at these institutions
except age discrimination in employment.
The regulation describes the standards for determining age
discrimination; the responsibilities of recipients; and
procedures for enforcing the statute and regulation
II. Age Discrimination Act Implementation
The Department of Education's (ED) Office for Civil Rights
(OCR) is responsible for enforcement of the Age Discrimination
Act of 1975 (the Age Act), as it relates to discrimination on
the basis of age in federally funded education programs or
activities. The Age Act applies to discrimination at all age
levels. The Age Act contains certain exceptions that permit,
under limited circumstances, continued use of age distinctions
or factors other than age that may have a disproportionate
effect on the basis of age.
The Age Act excludes from its coverage most employment
practices, except in federally funded public service employment
programs under the Job Training Partnership Act (formerly the
Comprehensive Employment and Training Act of 1974). The Equal
Employment Opportunity Commission (EEOC) has jurisdiction under
the Age Discrimination in Employment Act of 1967 to investigate
complaints of employment discrimination on the basis of age.
OCR generally refers employment complaints alleging age
discrimination to the appropriate EEOC regional office.
However, the EEOC does not have jurisdiction over cases
alleging age discrimination against persons under 40 years of
age. Rather than referring such a case to the EEOC, OCR would
close the complaint and inform the complainant that neither OCR
nor the EEOC has jurisdiction over the complaint.
The Department of Health and Human Services (HHS) has
published a general government-wide regulation on age
discrimination. Each agency that provides Federal financial
assistance must publish a final agency-specific regulation. On
July 27, 1993, ED published in the Federal Register its final
regulation implementing the Age Act.
Under ED's final regulation, OCR forwards complaints
alleging age discrimination to the Federal Mediation and
Conciliation Service (FMCS) for attempted resolution through
mediation. FMCS has 60 days after a complaint is filed with OCR
in which to mediate the age-only complaints or the age portion
of multiple-based complaints. ED's regulation provides that
mediation ends if: (1) 60 days elapse from the time the
complaint is received; (2) prior to the end of the 60-day
period, an agreement is reached; or (3) prior to the end of the
60-day period, the mediator determines that agreement cannot be
reached.
If FMCS is successful in mediating an age-only complaint or
the age portion of a multiple-based complaint within 60 days,
OCR closes the case or the age portion of the complaint. If
mediation is unsuccessful, the mediator returns the unresolved
complaint to ED for further case processing.
OCR helps its working relationship with FMCS by designating
enforcement office contact persons who coordinate directly with
FMCS. OCR also accepts verbal or facsimile referrals from FMCS
after unsuccessful attempts at mediation, and may grant FMCS
extensions of up to 10 days beyond the 60 day mediation period
on a case-by-case basis when mediated agreements appear to be
forthcoming.
The other statutes which OCR enforces are Title VI of the
Civil Rights Act of 1964, which prohibits discrimination on the
basis of race, color, and national origin; Title IX of the
Education Amendments of 1972, which prohibits discrimination on
the basis of sex; and Section 504 of the Rehabilitation Act of
1973 and Title II of the Americans with Disabilities Act of
1990, which prohibit discrimination on the basis of disability.
iii. Complaints
(a) Receipts
OCR received 203 age complaints in FY 1997. Of these 55
were age-only complaints and 148 were multiple bases
complaints. As shown on Table 1, 125 of the 203 receipts were
processed in OCR and 78 were referred to other Federal agencies
for processing. The most frequently cited issues in the FY 1997
age-only complaint receipts were ``academic retention/
dismissal,'' ``harassment,'' and ``retaliation.'' These were
also the most frequently cited issues contained in multiple-
based complaint receipts.
Table 1: Fiscal year 1997 age-based complaint receipts
Processed by OCR.................................................. 125
Processed by FMCS................................................. 27
Processed by EEOC................................................. 42
Processed by Other Federal Agencies............................... 9
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________________________________________________
Total receipts.............................................. 203
(b) Resolutions
During FY 1997, OCR resolved 210 age-based complaints,
including 62 age-only complaints and 148 multiple-based age
complaints. The resolution of the complaints are shown in Table
2.
Table 2: Fiscal year 1997 age-based complaint resolutions
Inappropriate for OCR Action...................................... 146
OCR Facilitated Change............................................ 17
No Change Required................................................ 47
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________________________________________________
Total resolutions........................................... 210
Inappropriate for OCR action
Of the 210 complaint resolutions, 146 were resolved because
they were ``Inappropriate for OCR Action.'' These would include
a resolution achieved by (1) referral of a complaint to another
federal agency; (2) lack of jurisdiction over recipient or
allegation contained in a complaint; (3) complaint was not
filed in a timely manner; (4) complaint did not contain
sufficient information necessary to proceed; (5) complaint
contained similar allegations repeatedly determined by OCR to
be factually or legally insubstantial or were addressed in a
recently closed OCR complaint or compliance review; (6) subject
of a complaint was foreclosed by previous decisions by federal
courts, Secretary of Education, Civil Rights Reviewing
Authority, or OCR; (7) there was pending litigation raising the
same allegations contained in a complaint; (8) allegations were
being investigated by another federal or state agency or
through a recipient's internal grievance procedures; (9) OCR
treated complaint as a compliance review; (10) allegation(s)
was moot and there were no class implications; (11) complaint
could not be investigated because of death of the complainant
or injured party or their refusal to cooperate; and (12)
complaint was investigated by another agency and the resolution
met OCR standards.
OCR facilitated change
There were 17 complaints resolved because ``OCR Facilitated
Change.'' These would include a resolution achieved by (1) a
recipient resolving the allegations contained in the complaint;
(2) OCR facilitating resolution between the recipient and
complainant through Early Complaint Resolution; (3) OCR
negotiating a corrective agreement resolving a complainant's
allegations; and (4) settlement achieved after OCR issued a
letter of findings.
No change required
In 47 complaints, there was ``No Change Required.'' These
would include a resolution achieved by (1) complainant
withdrawing his or her complaint without benefit to the
complainant; (2) OCR determining insufficient factual basis in
support of complainant's allegations; (3) OCR determining
insufficient evidence to support a finding of a violation; and
(4) OCR issuing a no violation letter of findings.
Older Americans in the 1992 National Adult Literacy Survey
While for some the importance of literacy derives from the
increasing needs of business for literate workers, for others
the importance of literacy derives from the benefits of
literacy skills in the everyday life of adults. Older adults
need literacy skills to live independently, to manage their
health care and personal finances, and more generally, to
function in society. Knowing the nature and extent of the
literacy problem in the United States today is an important
early step in devising effective policies to ensure adequate
literacy skills for every adult and to meet our Nation's
literacy goal.
The Adult Education Amendments of 1988 required the U.S.
Department of Education to report to Congress on the definition
of literacy and to estimate the extent of adult literacy in the
nation. In response, the National Center for Education
Statistics (NCES) and the Office of Vocational and Adult
Education (OVAE) cooperated to fund a statistical survey that
would assess the literacy of the adult population of the United
States.
The 1992 National Adult Literacy Survey adopted this
definition of literacy: Using printed and written information
to function in society, to achieve one's goals, and to develop
one's knowledge and potential. This definition of literacy
differed from previous definitions in that it rejected such
arbitrary standards as signing one's name, completing some
number of years to school, or scoring above some grade level on
a test of reading achievement. Further, this definition went
beyond simply decoding words, to include varied uses of many
forms of information.
The 1992 results are based on personal interviews with
nearly 27,000 adults aged 16 and older--the oldest was 99 years
old--conducted in their homes using an area-based sample of
households located in 200 counties throughout the United
States. The sample includes 1,100 inmates of federal and state
prisons and 1,000 extra residents in each of thirteen states
that paid for sample supplements (CA, FL, IL, IN, IA, LA, KY,
NJ, NY, OH, PA, TX, and WA). The survey design provides
nationally representative results, and for participating
states, state-representative results. The literacy of adults
was assessed using simulations of three kinds of literacy tasks
adults would ordinarily encounter in daily life (prose
literacy, document literacy, and quantitative literacy).
Besides completing literacy tasks, participants answered
questions about their demographic characteristics, educational
backgrounds, reading practices, labor market experiences, and
more.
Results from the survey have so far been published in Adult
Literacy in America, in Behind Prison Walls, and in Literacy of
Older Adults in America, each available from NCES. State-
specific reports are available from the thirteen state offices
of adult literacy. Further reports are planned in several
areas: schooling and literacy; literacy in language minority
communities; literacy in the labor force; and reading habits,
voting and literacy.
Results for older adults were briefly covered in the
initial survey report, and more extensively presented in a
special report on literacy among older adults. The report
included chapters on the distribution of literacy skills among
older adults, comparisons of older adults with adults under 60
years old, economic issues, civic participation, and literacy
and patterns of mass media usage. The results of the survey
provide a factual basis for policy decisions affecting literacy
programs designed for older adults or for adults with limited
literacy skills.
The results of the 1992 National Adult Literacy Survey
indicate that low levels of prose, document, and quantitative
literacy are a significant problem for a large portion of the
older adult population in the United States.
Seventy-one percent of adults age 60 and older, or
approximately 29 million individuals nationwide,
demonstrated limited prose skills, performing in the
two lowest levels of prose literacy defined in the
survey. This is a larger proportion than the 41 percent
of adults under age 60 performing in two lowest levels.
Slightly more than two-thirds, or 68 percent, of
older adults appeared to have difficulty finding and
processing quantitative information in printed
materials. In population terms, this means that an
estimated 28 million persons age 60 and older across
the nation have limited quantitative literacy skills.
This is a larger proportion than the 42 percent of
adults under age 60 performing in the two lowest
levels.
The problem appears to be even more acute in the area
of document literacy, which is associated with
activities such as filling out forms, reading and
following directions, and using schedules. Four of
every five older adults (80 percent) demonstrated
limited document literacy skills in the assessment,
performing in the two lowest proficiency levels
defined. This is a larger proportion than the 44
percent of adults under age 60 performing in the two
lowest levels.
Notable differences in performance are also evident
within the older adult population. Those age 60 to 69
performed those age 70 to 79, who in turn outperformed
those age 80 and older.
Many older individuals with limited literacy skills
do not seem to behave that they have a problem. The
percentage of older Americans who said they perform
various types of literacy activities ``very well'' was
about the same as that of persons under 60. In
actuality, however, the average literacy proficiencies
of older adults were much lower than those of younger
persons.
Many older adults reported receiving help from family
or friends with literacy tasks such as filling out
forms, writing notes and letters, doing math, and
processing written information.
The cost of including older adults in the survey and
preparing a report on older adults came to about $870,000, or
about 8 percent of the federal share of the total costs of the
survey.
National Institute on Disability and Rehabilitation Research Projects
That Relate to Aging
The National Institute on Disability and Rehabilitation
Research (NIDRR) authorized by Title II of the Rehabilitation
Act, has specific responsibilities for promoting and
coordinating research that relates directly to the
rehabilitation of disabled persons. Grants and contracts are
made to public and private agencies and organizations,
including institutions of higher education, Indian Tribes and
tribal organizations, for the purpose of planning and
conducting research, demonstrations, and related activities
which focus directly on the development of methods, procedures
and devices which assist in the provision of rehabilitation
services.
The Institute is also responsible for facilitating the
dissemination of information concerning developments in
rehabilitation procedures, methods, and devices to
rehabilitation professionals and to disabled persons to assist
them in leading more independent lives.
The Institute accomplishes its mission through the
following programs:
Rehabilitation Research and Training Centers.
Rehabilitation Engineering and Research Centers.
Research and Demonstration Projects.
Field-Initiated Projects.
Dissemination and Utilization Projects.
Career Development Projects which include:
Fellowships; Research Training.
State Technology Assistance.
Small Business Innovative Research.
Rehabilitation research and training centers
The primary goals of these centers are: (1) To conduct
research targeted toward the production of new knowledge which
will improve rehabilitation methodology and service delivery
systems, alleviate or stabilize disabling conditions, and
promote maximum social and economic independence; (2) To
institute related teaching and training programs to disseminate
and promote the utilization of research findings, thereby
reducing the usual long intervening delay between the discovery
of new knowledge and its wide application in practice.
The three major activities, research, training, and
service, are expected to be mutually supportive. Specifically,
this synergy calls for research ideas to derive from service
delivery problems, for research findings to be disseminated via
training, and for new professionals to be attracted to research
and service via training.
1. Rehabilitation Research and Training Center on Aging with a
Disability, Rancho Los Amigos Medical Center, Downey, CA
This Center is a collaborative effort between the Rancho
Los Amigos Medical Center, the University of Southern
California School of Medicine and the Andrus Gerontology
Center.
In ever-increasing numbers, people who acquired a
disability in an earlier part of life are now reaching an
advanced age. As they age, many people are developing new
medical, functional, social, and psychological problems. Little
is known about the etiology, consequences, or treatment of
these problems. This RRTC investigates several of these
problems and conducts training to help reduce the impact of
these changes. Studies are under way that examine: (1) the
natural course of aging in people with postpolio, cerebral
palsy, rheumatoid arthritis, and stroke; (2) the physiological
demands of mobility; (3) the benefit of training aging
individuals in the use of in-home personal assistants; (4) the
feasibility of using residential care facilities for older
people who have a disability; (5) ways to maintain employment
through the use of job modification; and (6) how federal and
state policies need to change to facilitate access to assistive
devices as people age. The training programs focus on medical,
allied health, and social service personnel at all levels, from
student through practicing professional. The project provides
information to consumers through an extensive system of
linkages to consumer organizations and publication in consumer-
oriented periodicals.
2. Rehabilitation Research and Training Center on Aging With Mental
Retardation, The University of Illinois at Chicago, University
of Illinois UAP, 1640 West Roosevelt Road, Chicago, IL
The Illinois University Affiliated Program in Developmental
Disabilities (UAP), University of Illinois at Chicago (UIC) has
established the Rehabilitation Research and Training Center on
Aging with Mental Retardation. This center will build on the
strength and continuity of the current RRTC on Aging and
Developmental Disabilities and bring to it the resources of a
major university with considerable commitment, applied research
and clinical expertise in the fields of mental retardation and
aging. The RRTC will build on the continuity of their
collaboration over the last five years. The RRTC has developed
a greater understanding of aging and developmental disabilities
by capitalizing on large data bases, longitudinal
investigations, and multi-state sites.
Investigators from other universities in Minnesota, Ohio,
Indiana, Wisconsin, Kentucky, and Hawaii contribute strengths
to the RRTC in epidemiological and clinical research on age-
related changes, family future planning, self-determination,
cultural diversity, and public policy analysis. In addition,
the RRTC has assembled a network of national, state, and local
organizations to ensure that the RRTC programs are widely
disseminated, have practical applications, and will stimulate
public policy change.
The research is applied and examines individuals' lives in
their natural settings. It is focused on outcomes in the lives
of older persons with mental retardation. The main goal of the
research is to translate the knowledge gained into practice
through broad-based training; technical assistance; and
dissemination to persons with mental retardation, their
families,service providers, administrators and policy makers,
advocacy groups, and the general community.
3. Rehabilitation Research and Training Center on Enhancing Quality of
Life of Stroke Survivors, Rehabilitation Institute Research
Corporation, 345 East Superior, Chicago, IL
The project is developing methods to prevent the occurrence
and minimize the consequences of comorbid medical conditions to
stroke patients during rehabilitation. It is evaluating methods
of assessing, classifying, monitoring, and predicting some of
the clinical functioning. It is evaluating the efficacy of
procedures used to enhance social and community functioning,
and studying the natural history of impairment, disability,
quality of life after stroke, and the associations between each
of those characteristics. The Center trains rehabilitation
professionals in new approaches, innovations, and the
specialized principles and practices of rehabilitative care of
individuals with stroke. The RRTC also develops and studies the
effects of an ideal method or providing education to caregivers
of stroke patients, disseminates information of new
developments in the areas of stroke care and research to
individuals with stroke and their families. Ultimately, through
all these methods, the project enhances the quality of life of
individuals with stroke.
4. Rehabilitation Research and Training Center on Aging with Spinal
Cord Injury, Craig Hospital and the University of Colorado
Health Science Center, Research Department, 3425 South
Clarkson, Englewood, CO
This project is conducting longitudinal research to
document the natural consequences of aging with spinal cord
injury (SCI) and to identify risk factors associated with
increasing medical complications, functional limitations,
psychosocial concerns, and escalating costs. The project is
developing, implementing, and evaluating lifetime management
and intervention strategies that minimize, delay, or enable
people with SCI to cope better with the problems of aging with
SCI. The project disseminates management and intervention
strategies and insights gained from longitudinal research and
implementation strategies.
5. Rehabilitation Research and Training Center Aging with Spinal Cord
Injury and Aging, Rancho Los Amigos Medical Center, Downey, CA
The Rehabilitation Research and Training Center (RRTC) on
Aging with Spinal Cord Injury (SCI) is devoted to undertaking
the unique problems people with spinal cord injury experience
as they age. Topics of research include: the course of aging
with SCI, cardiovascular and pulmonary aspects of aging with
SCI, bone loss across ethnic groups, activities of daily
living, employment, depression, and formal and informal care
systems for people aging with SCI. The RRTC has several goals
for education, training, dissemination, and utilization: to
train current and future health, allied health, and
rehabilitation professionals about aging with SCI; to train and
develop rehabilitation research professionals in the area of
aging with SCI; to have health and rehabilitation professionals
adopt and use knowledge and treatment regimens developed in the
RRTC; to disseminate information about aging with SCI to people
with SCI and their families; and to train graduate students and
medical students in advanced knowledge and techniques from
studies about aging with SCI. Training and dissemination occurs
through advanced and continuing education courses, local and
national conferences, workshops, and the Internet.
6. Disability Statistics Rehabilitation Research and Training Center,
University of California, San Francisco, Institute for Health
and Aging, Box 0646, Laurel Heights, San Francisco, CA 94143-
0646
The center conducts research in the demography and
epidemiology fields of disability and disability policy,
including costs, employment statistics, health and long-term
care statistics, statistical indicators, and congregate living
statistics. Statistical information is disseminated through
published statistical reports and abstracts, journals,
professional presentations, and a publications mailing list.
Training activities and resources (such as a predoctoral
program) disseminate scientific methods, procedures, and
results to both new and established researchers, policymakers,
and other consumers, and assist them in interpreting
statistical information. A National Disability Statistics and
Policy Forum is conducted periodically to establish a national
dialogue between people with disabilities and representative
organizations, researchers, and policymakers.
7. Rehabilitation Research and Training Center in Secondary
Complications in Spinal Cord Injury, University of Alabama/
Birmingham, Department of Physical Medicine and Rehabilitation,
Birmingham, AL
The primary goal of this RRTC is to conduct high-quality
basic and applied research that improves existing methods of
care for people with spinal cord injury (SCI). Current RRTC
research areas include urology, pressure ulcer healing,
spasticity, psychosocial adjustment, obstetric/gynecologic
complications, costs of rehospitalization, and pulmonary
complications. The Center's training component disseminates
RRTC research results to rehabilitation professionals and
consumers with SCI in useable formats such as videotapes,
audiotapes, written materials, journal articles, and short-term
training programs.
8. Research and Training Center on Personal Assistance Services (PAS),
World Institute on Disability, Oakland, CA
Activities of this project are designed to further the
understanding that Personal Assistance Service (PAS) systems
design can better promote the economic self-sufficiency
independent living, and full integration of people of all ages
and disabilities into society. This is accomplished by
exploring the models, policies, access to, and outcomes of
personal assistance services, through (1) gathering
perspectives of consumers, program administrators, policy
makers, and personal assistants using a State of the States
survey and database development; (2) a policy study on the
impact of devolution; (3) a cost-effectiveness study; (4) a
study of workplace PAS; and (5) a study on the supply of
qualified PAS
9. Rehabilitation Research and Training Center on Blindness and Low
Vision, Mississippi State University
The Center is conducting a series of research, training and
dissemination projects using a multidisciplinary strategy. The
project works to investigate and document employment status,
identify barriers to employment and techniques and reasonable
accommodations to overcome these barriers, identify training
needs in the Business Enterprise Program, and develop and
deliver training programs. Training and dissemination
activities include an information and referral center, national
conferences, in-service training and technical assistance,
advanced training for practitioners, advanced training in
research, and publication and distribution of a variety of
materials in accessible media.
10. Missouri Arthritis Rehabilitation Research and Training Center,
University of Missouri/Columbia, Multipurpose Arthritis Center
This project conducts a coordinated and advanced
multidisciplinary program of arthritis rehabilitation research
in a clinical service setting. Disciplinary education and
training, including graduate training to physicians, health
professionals, and other potential rehabilitation personnel is
provided to help them provide effective rehabilitation services
to people with arthritis and musculoskeletal diseases. Research
projects include: (1) medication and physical therapy treatment
of primary fibromyalgia syndrome, (2) early interventions to
prevent disability in juvenile arthritis, (3) arthritis patient
disability and physical fitness levels before and after
conditioning exercise intervention, (4) a computerized exercise
performance support system for osteoarthritis rehabilitation,
(5) depression management as a strategy for reducing disability
in rheumatoid arthritis, and (6) a rehabilitation research
database in musculoskeletal disease. The Center enhances
education programs on arthritis care and rehabilitation and
builds awareness through Missouri's Regional Arthritis Center.
11. Rehabilitation Research and Training Center on Rural Rehabilitation
Services, University of Montana, Missoula, MT
This RRTC has the following objectives for improving rural
rehabilitation services: (1) identify the employment and
vocational rehabilitation service needs of people with
disabilities in rural areas; (2) develop interventions to
improve employment outcomes; (3) demonstrate rural
entrepreneurial models; (4) identify issues in rural
independent living and develop interventions to improve
transportation, health care, housing, and accessibility; (5)
coordinate with rural independent living centers to identify or
design and test alternative models of delivery of rural
rehabilitation services; (6) provide training in rural
rehabilitation research and practice; (7) conduct an annual
meeting on the state-of-the-art in rural employment and
disability; (8) conduct an annual interactive conference on
disability issues in rural America; and (9) disseminate
research findings to rehabilitation service-delivery personnel.
Rehabilitation Engineering and Research Centers
This program provides support for the Rehabilitation
Engineering Research Centers to conduct programs of advanced
research of an engineering or technical nature in order to
develop and test new engineering solutions to problems of
disability. Each center is affiliated with a rehabilitation
setting, which provides an environment for cooperative research
and the transfer of rehabilitation technologies into
rehabilitation practice. The centers' additional
responsibilities include developing systems for the exchange of
technical and engineering information and improving the
distribution of technological devices and equipment to
individuals with disabilities.
1. Rehabilitation Engineering Center: Assistance Technology and
Environmental Interventions for Older Persons with
Disabilities, New York University at Buffalo, Buffalo, NY
Activities of the RERC focus on research, assistance device
development, education, and information relating to assistive
technology for older people in the home and beyond the home.
The projects of the RERC fall into four major areas: (1)
research: ten projects address assessments in the home and
community, issues for minority elders, highly problematic
device categories, clinical trials of effectiveness, and
managed care work issues; (2) device development: six projects,
including devices addressing automobiles, obesity, mobility,
balance, stairs, and pubic seating; (3) education: four
projects, addressing professional students, graduate students,
and rehabilitation and aging service professionals; and (4)
information: ten project areas, including a ``Helpful
Products'' series of videos and booklets, training manuals,
resources for hotel and motel guests, product information,
national conferences, newsletter inserts, a World Wide Web
site, monograph series, resource sourcebook, and a resource
phone line.
2. Rehabilitation Engineering Research Center in Augmentative
Communication, Applied Science and Engineering Laboratories,
University of Delaware, Wilmington, DE 19899
Research in the field of augmentative communication is
divided into five themes: language, speech, interface, systems,
and information. Specific projects within each of the first
four themes are designed to enhance accessibility of
communication for individuals with communication disabilities.
The project serves as a dissemination service for information
on augmentative and alternative communication. All projects are
designed so that technology transfer can be implemented as
quickly and effectively as possible so that people with
disabilities can pursue their educational, vocational, and
independent living goals.
3. Rehabilitation Engineering Research Center on Universal
Telecommunications Access, Gallaudet University, Washington, DC
This RERC conducts research and engineering activities with
the overall goal of improving the accessibility of emerging
telecommunications systems and products. The Center moves
forward the available telecommunications knowledge base for
access issues confronting people with all types of
disabilities. The program areas of the RERC are: (1) systems
engineering analysis; (2)telecommunications access research,
focusing on needs assessment and development of design solutions; (3)
universal design specification and review, aimed at developers of
products and services; (4) development of telecommunications standards
that include accessible features; (5) telecommunications applications
for increased independence; and (6) knowledge utilization and
dissemination. The RERC combines expertise from Gallaudet University,
the Trace Research and Development Center at the University of
Wisconsin, and the World Institute on Disability (WID) with the
expertise of the telecommunications industry through active involvement
of two noted telecommunications consultants, Richard P. Brandt and Dale
Hatfield.
4. Rehabilitation Engineering Research Center on Prosthetics and
Orthotics, Northwestern University, Rehabilitation Engineering
Research Program and Prosthetics Research Laboratory, Chicago,
IL
Activities of the Center include material science studies
and applications in limb prosthesis and orthoses, biomechanical
characterizations and functional design of prostheses and
orthoses, state-of-the-art studies that delineate the status of
the field and help organize and plan for the advancement of
prosthetics and orthotics, and an information and education
resource service.
5. Rehabilitation Engineering Research Center on Accessible and
Universal Design and Housing, North Carolina State University
School of Design, Center for Universal Design, Raleigh, NC
The RERC's mission is to: (1) conduct research in
documenting problems in housing for people with disabilities;
(2) identify or generate and test solutions to documented
problems; (3) demonstrate the general utility of solutions to
documented problems; and (4) conduct training to address skill
acquisition, knowledge diffusion, and general awareness of
issues related to housing for people with disabilities. The
Center also provides information and referral services to
address identified needs through development and dissemination
of publications and other information materials and referral to
other organizations and agencies who can assist with specific
information requests. The Center's audience includes designers,
contractors, developers, financial providers, consumer
advocates, and users of residential environments.
6. Vermont Rehabilitation Engineering Research Center for Low Back
Pain, University of Vermont, Vermont Back Research Center,
Burlington, VT
The Vermont RERC improves the employability of people with
back disorders and back disability by developing and testing
assistive technology. Engineering projects include studies of
lifting, posture, seating, vibration, and materials handling in
connection with back pain and disability. Applied research
projects include the testing of rehabilitation engineering
products, evaluation of exercise programs, and the development
of a statewide model program to hasten return to work of people
with back injuries. The Center's Information Services Division
provides toll-free assistance in locating research and
rehabilitation programs, as well as bibliographic searching and
fact finding. The Center also maintains an Electronic
Discussion Group: BACKS-L (Send subscription request to
[email protected]; body of message should read: subscribe
backs-l __your name__).
7. Rehabilitation Engineering Research Center on Adaptive Computers and
Information Systems, University of Wisconsin/Madison, Trace
Research and Development Center, Waisman Center, Madison, WI
This REFC is focused on maximizing the number of people
with disabilities who are able to access directly and use the
next generation of electronic devices and information systems,
either with or preferably without assistive technologies. This
RERC makes all electronic products and systems more accessible
to individuals with the full range of type, degree, and
combination of disability, such as low vision, blindness,
hearing impairment, deafness, deaf-blindness, physical
disabilities, cognitive disabilities, and language
disabilities. Electronic products include dedicated products
(e.g., phones, faxes, ATMs, etc.), general purpose computers
and operating systems, and access to information systems (e.g.,
Internet, television set-top boxes, kiosks, electronic
directories, and information phones). The work of the Center
includes basic research into more flexible interfaces;
extensions to human interfaces of existing computers, operating
systems, and information systems; development of design
guidelines; development of prototype systems and simulations;
support of industry; development of consumer awareness and
education materials; training programs; and joint service-
delivery programs.
Field Initiated Research Program
This program is designed to encourage eligible applicants
to originate valuable ideas for research and demonstrations,
development, or knowledge dissemination activities in areas
which represent their own interests, yet are directly related
to the rehabilitation of people with disabilities.
1. Aging and Adjustment after Spinal Cord Injury: A 20-Year
Longitudinal Study, Shepherd Center for Spinal Injuries, Inc.,
2020 Peachtree Road, NW, Atlanta, GA
This fourth study phase will be the most extensive follow-
up yet performed and will use an expanded version of the same
questionnaire that was used in each of the three previous
follow-ups (1973, 1984, 1988). Three types of research designs
will be used for data analysis including: (1) traditional
longitudinal analysis of 1973 to 1992 data from the original
participant sample; (2) cross-sequential analysis of the
repeated measures data from 1984 to 1992 for samples one and
two; and (3) time-sequential analysis of time-lagged data
comparing the 1984 data for sample two with that of the new
third sample.
2. Perceived Direction and Speech Intelligibility in Sensorineural,
Hearing Loss and Blindness, Smith-Kettlewell Eye Research
Institute, 2232 Webster Street, San Francisco, CA 94115
Experiencing great difficulty processing speech in noise is
one of the most characteristic and devastating aspects of the
sensory deficit of hearing loss in aging (presbycusis).
Conventional binaural hearing aids do not satisfactorily solve
this problem. The digital four-channel hearing aid is
innovative because of its use of temporal as well as intensity
parameters, unlike any other binaural hearing aid on the
market. Since sensorineural hearing loss (SNHL) and blindness
may interfere with localization of potentially hazardous
situations, a second goal of this project is to explore and
develop the parameters for improved localization as well as
improved speech intelligibility (comprehension) utilizing a new
rational. According to our model, a binaural balance of
interaural intensity difference (IID) and interaural time delay
(ITD) across frequencies is required to restore optimum speech
intelligibility and localization ability by eliminating or
lessening exaggerated dominance consequent of asymmetric
hearing loss. Variations of either or both IID and ITD at
different frequencies would impair directional localization
and, therefore, intelligibility of one speaker in a group. This
new hearing aid may permit people with SNHL and blindness,
using acoustic cues, to locate and avoid a hazard. To
accomplish this, the project will adjust the physical inputs of
intensity and interaural delay time across frequencies to
compensate for perceptual imbalances (i.e., deviations from IID
and ITD) and to test for the consequent restoration of optimal
localization and speech intelligibility inherent in normally
balanced auditory systems.
3. Development of a Novel PC-Based Test to Aid the Rehabilitation of
People with Macular Vision Loss, Smith-Kettlewell Eye Research
Institute, San Francisco, CA
Patients with age-related macular degeneration (AMD) lose
the ability to read and recognize faces on television. They
must learn to perform these tasks using their less-detailed
peripheral vision as a substitute. Research has shown that
people with AMD can learn this, but a majority do so only with
goal-directed instructions and training that must be based on
each patient's individual vision status. For the purpose of
this assessment, a new computerized test was developed at this
laboratory on Amiga computers that are no longer commercially
available. The overwhelmingly positive response to this new
procedure warrants this special effort to transfer the test to
the most common small computer, the IMB PC and its compatibles.
The product of this research is an inexpensive and easy-to-run
computerized test that can be performed within minutes in the
eyecare specialist's office, without requiring special
expertise and on widely available equipment. The results of the
test can be used: (1) to help the eyecare specialist customize
instructions and training procedures in order to keep the
required adaptation time as short as possible, and (2) to help
AMD patients understand the nature of their impairment.
4. Remote Signage Development to Address Current and Emerging Access
Problems for Blind Individuals, Smith-Kettlewell Eye Research
Institute, San Francisco, CA
This project is developing new, practical enhancements of
remote signage technology to solve a range of specific current
and emerging accessibility problems faced by people who are
blind and who have other print-reading disabilities. For blind
users, access to any place or facility begins with the problem
of knowing it is there; then the problem of finding it must be
addressed. Specific solutions are being developed for safe
usage of light-controlled pedestrian crossings, identification
and onboard announcements of stops for buses, identifying route
number and destination of oncoming buses, locating and
accessing automated teller machines and other vending
information terminals, and access to signage by people with
cognitive impairments. These innovative solutions are being
developed from the infrared Talking Signs (R) system of
remotely readable signs for people who are blind that was
developed by Smith-Kettlewell. This system is currently gaining
increased acceptance as an aid to orientation and navigation
for those who cannot read the print signage that fully sighted
people take for granted in navigating and accessing the world.
5. Toward a Risk Adjustment Methodology for People with Disabilities,
Medlantic Research Institute, National Rehabilitation Hospital
Research Center, Washington, DC
The principle goal of this knowledge dissemination project
is to provide its primary audiences, health care policy-makers
and payers, with key information to advance the development of
a risk adjustment system for working- and retirement-age people
with disabilities. Risk adjustment reduces the incentive for
risk selection and promotes access to needed health services.
To achieve this goal, the project assembles a panel of leading
experts on risk adjustment and disability to guide the
development of a consensus report that: (1) details the state
of science in risk adjustment, (2) evaluates the
appropriateness of health care outcome indicators for people
with physical and mental disabilities, and (3) provides a set
of recommendations for modifying and implementing risk
adjustment methodologies that enhance access to health services
for people with disabilities enrolled in public and private
sector health plans.
6. Cash and Counseling Models for Americans with Disabilities, The
National Council on the Aging, Inc. (NCOA), Research and
Development Department, Washington, DC 20024
In the ``cash and counseling'' model, consumers with
disabilities control most elements of their service needs,
normally through cash payments that allow them to purchase
support services. Activities of this three-year study include:
(1) continuing in-depth field research and ongoing monitoring
of domestic and overseas programs that currently use cash and
counseling or a similar model; (2) conducting two surveys of
state administrators to identify existing cash and counseling
programs, determined their level of knowledge and interest in
employing cash and counseling approaches, and identify
opportunities and barriers to program implementation, as well
as technical assistance needs; (3) collaborating on the Cash-
and Counseling Demonstration and Evaluation Project at the
University of Maryland Center on Aging funded by the Robert
Wood Johnson Foundation and the U.S. Department of Health and
Human Services; (4) providing information and technical
assistance to state administrators and policy analysts
interested in advancing cash and counselingapproaches,
including the four states awarded cash and counseling demonstration and
evaluation grants; (5) developing a series of analyses concerning the
feasibility, design, and implementation issues of cash and counseling
approaches; and (6) disseminating new knowledge to policy makers,
administrators, and the aging and disability communities.
7. Aging; Spinal cord injuries; Ethnic groups; Women Physician Training
in the Major Health Issues of Women with Disabilities: Learning
to Act in Partnership, Health Resource Center for Women with
Disabilities, Rehabilitation Institute of Chicago, Chicago, IL
Women with disabilities report that their health needs are
often overlooked or poorly addressed by physicians, who
evidence unfamiliarity with, and negative attitudes toward,
people with disabilities. These subjective reports are
corroborated by studies that suggest women with disabilities
may find their health service options severely compromised when
physicians lack information about their special needs and
experience. This project designs and tests the efficacy of a
training module that introduces medical students to the health
issues of women with disabilities, in three phases: (1) fourth-
year medical students respond to a questionnaire to assess
their deficiencies in knowledge regarding the health needs and
experiences of women with disabilities, (2) a training module
is developed incorporating a video, a corresponding in-person
educational presentation led by women with disabilities, and a
handbook of supplementary readings, (3) the efficacy of the
module in improving attitudes and knowledge is tested in a
pretest/post-test design with a control group. Women with a
broad range of disabilities, ages, and ethnic/racial/cultural
backgrounds are participating in all aspects of the project,
from research direction through training development to
dissemination of results. Consequently, the project represents
a model of consumer-physician partnership that is endorsed by
women health activists with disabilities.
8. Illinois Joint Training Initiative on Disability and Abuse: Advocacy
and Empowerment Through Knowledge Dissemination, University of
Illinois/Chicago, Institute on Disability and Human
Development, Chicago, IL
This project provides information and skills to advocates,
consumers, family members, service providers, and others to
empower them to enforce the rights of adults with disabilities
who have been abused or neglected. It is largely a training
project, with the following objectives regarding abuse-neglect:
(1) develop interactive consumer-responsive materials that
train consumers, family members, and service providers to
recognize incidents; (2) make the social and legal system
respond to cases; (3) provide referral to resources available
for victims; (4) conduct state-wide training using the
materials; (5) provide each training participant with the
opportunity to become a local trainer on these issues; and (6)
provide technical assistance, materials, and resources to local
trainers hosting training events.
9. Knowledge Dissemination for Vision Screeners, University of Kansas,
Institute for Life Span Studies, Parsons, KS
This project is disseminating a CD-ROM to providers of
vision screening and evaluation services, in order to increase
the quantity and quality of vision services available
nationally to infants, toddlers, preschoolers, and older people
with disabilities. These populations are sometimes considered
difficult to test, and as a consequence, often do not receive
traditional vision screening services. The project addresses
the training needs of a variety of personnel by providing an
interactive CD-ROM program, modeled after the ``knowledge on
demand'' technology used in industry, that can be readily
delivered in a variety of settings. The program is providing a
model for using CD-ROM to disseminate ``knowledge on demand.''
10. Secondary Conditions, Assistance, and Health-Related Access Among
Independently Living Adults with Major Disabling Conditions,
Massachusetts Health Research Institute, Boston, MA
Participants in this study are affiliated with six
Massachusetts independent living centers (ILCs). The cross-
disability sample includes people with a range of significant
physical, mental, sensory, and developmental disabilities who
require assistance with activities of daily living. Primary
outcomes of interest are: (1) the frequency and severity of
secondary conditions, including skin problems, seizures,
chronic pain, spasms, falls, fatigue, respiratory tract
infections, and urinary tract infections; and (2) reactions to
medication, depression, anxiety, and injuries related to
medical equipment. Mediating variables include: adequacy of
personal assistance, assistive technology, access to health
promotion and health care services, environmental barriers,
transportation, employment, education, socioeconomic status,
smoking, use of substances, and compliance with prescribed
health care routines. The research study includes two annual
cross-sectional surveys, each of 300 randomly-selected ILC
consumers, to determine prevalence, distribution, frequency,
and severity of secondary conditions. Focus groups of ILC
consumers and others help interpret the data.
11. The Universal Bathroom, Research Foundation of State University of
New York, State University of New York (SUNY)/Buffalo, Amherst,
NY
While the greatest potential benefactors of a universal
bathroom are non-institutionalized people with disabilities who
are living independently, the new bathroom's design will be
created to be safe, accessible and usable by all people
regardless of their age, sex, and disabling conditions. Its
assumed modular, interchangeable components will include three
primary units, for bathing/showering, toileting, and grooming.
Since the bathroom of the user's choice can be custom built
from a large range of component units, this will be a
marketable, culturally responsive one with accepted layouts and
levels of privacy. Additionally, the ``lifespan perspective''
of the bathroom's design will allow able-bodied care-providers
such as parents of young children and those assisting older
individuals to make layout changes and product alterations
based on their current needs. Thus the bathroom's assistive
qualities will reduce temporary dependence on others and
increase safety by preventing accidents that lead to
disability. It will empower independent users, dependent users,
and care-providers equally--the young, the old, married
couples, people with children, and families with ``live-in''
grandparents.
12. Pressure Ulcer Prevention by Interactive Learning, MetroHealth
Center for Rehabilitation, Spinal Cord Injury Unit, 2500
MetroHealth Drive, Cleveland, OH
This project assembles a set of materials for teaching
pressure ulcer prevention, uses text, diagrams, animations,
sound, and video; links existing material where possible with
new resources where necessary; and converts the materials to
digital format. Teaching programs are then written to provide
access through a personal computer in a variety of interactive
sequences. These sequences are customized, not only during
design but also by interaction during use, for users with
different learning abilities and requirements. The initial
target group is people with disabilities at risk of developing
pressure ulcers. However, the technology is well suited for
customization for other uses such as training for nurses and
other health professionals. The project plans to make the
materials available to larger audiences and is producing a CD-
ROM containing a set of teaching programs for institutions to
train people with disabilities on how to prevent pressure
ulcers. The project expects to distribute the CD-ROM nationally
and to make selected portions available on computer networks.
13. Further Development of a Lower Limb Prosthetic Socket CAD System
Based on Ultrasound Measurement Wright State University,
Department of Biomedical and Human Factors Engineering, Dayton,
OH
This project has four objectives: (1) to improve the
performance of an ultrasound-based computer-aided socket design
(CASD) system developed by this research team; (2) to enhance
the utility of the system by developing and testing new devices
and procedures for limb measurements using the system; (3) to
conduct a clinical trial to evaluate the usefulness of the
ultrasound-based CASD system in improving daily prosthetic
socket design/fitting; and (4) to investigate applications of
ultrasound measurements in finite-element modeling for the
study of limb-prosthesis interaction.
14. Women's Personal Assistance Services (PAS) Abuse Research Project,
Oregon Health Sciences University/Portland, Child Development
and Rehabilitation Center, Portland, OR
The purpose of the project is to increase the
identification, assessment, and response to abuse by formal and
informal personal assistance service (PAS) providers of women
with physical and physical and cognitive disabilities living
independently in the community. The aims of the project: (1)
develop culturally sensitive screening approaches to identify
PAS abuse, (2) develop a culturally appropriate PAS abuse
assessment protocol, and (3) develop culturally appropriate
response strategies to prevent and manage PAS abuse. Culturally
diverse participants assist in the development of these three
aims. The study includes three phases, beginning with a focus
group study of culturally diverse women with physical and
cognitive disabilities. Phase II involves the use of findings
from Phase I to develop and disseminate a survey of 260
culturally diverse females with disabilities drawn from four
national organizations. Phase III involves the development and
field testing of the effectiveness of the screening,
assessment, and support protocols, the final product being a
comprehensive package of PAS abuse prevention materials. The
project plans to disseminate these materials on a national
basis.
15. A Pilot Study for the Clinical Evaluation of Pressure-Relieving
Seat Cushions for Elderly Stroke Patients, University of
Pittsburgh, Pittsburgh, PA
This project designs and tests the feasibility of a
randomized clinical trial to determine the efficacy of
pressure-relieving seat cushions for immobile, elderly stroke
patients. Older people with disabilities who are immobile and,
thus, spend their time either in bed or seated, are at risk for
developing pressure ulcers. Commercial seat cushions intended
to reduce the risk of sitting-induced pressure ulcers are
available. The elderly population, however, is not customarily
evaluated for seating and positioning needs or provided with
the benefits of this technology. Reimbursement is not
available, due in part to the fact that the effectiveness of
this intervention has not been sufficiently demonstrated for
this high-risk population, and these services and technology
are not available. If these cushions are a successful
intervention for increased comfort, improved quality of life,
and pressure ulcer incidence rate reduction, the project plans
to disseminate the findings and provide justification for third
party funding. If successful, the project plans to increase the
availability of seating and positioning services and products
to this deserving population.
16. Access Solutions, Vermont Center for Independent Living,
Montpelier, VT
The Vermont Center for Independent Living, in conjunction
with Bike Track, Inc., is developing and testing a new system
for building modular, reusable, and highly durable access ramps
using a newly developed, non-toxic material made from recycled
plastic. The ramp system's performance, material, and elements
are field tested in a variety of setting and in a wide range of
climatic conditions. The results of this project are: (1) the
development, testing, and evaluation of an innovative
technology for building access ramps; and (2) dissemination of
the findings of the project among builders, ADA compliance
experts, and consumers.
Research and Demonstration Projects
These projects address rehabilitation priorities identified
by NIDRR and published in the Federal Register. These
priorities address a variety of problems encountered by people
with disabilities. Projects are funded for up to 36 months.
1. Exercise and Recreation for Individuals with a Disability:
Assessment and Intervention, Rehabilitation Institute of
Chicago, Center for Health and Fitness, Chicago, IL
This project demonstrates that participation in exercise
and physical activities improves function, facilitates
community reintegration, and enhances the quality of life of
people with disabilities. The project: (1) investigates the
long-term effects of an exercise fitness program on the
physiology, metabolic performance, and quality of life of
people with spinal cord injury, stroke, and cerebral palsy; (2)
examines the role of self-efficacy in maintaining participation
in an exercise fitness program; (3) describes the types and
frequency of recreation and fitness activities among people who
have had a stroke, people with spinal cord injury, and people
with cerebral palsy; (4) examines the relationships between
participation in recreation and exercise programs and the
health status, life satisfaction,and depression in the above
populations; and (5) delineates barriers and deterrents to
participation in recreation and exercise programs that exist for a
variety of disability groups.
2. Research and Demonstration of a Model for Successfully Accommodating
Adults with Disabilities in Adult Education Programs,
University of Kansas Institute for Adult Studies and Kansas
State University Department of Special Education, Lawrence, KS
This project provides adult educators and adults with
disabilities with validated accommodations useful in
instruction and assessment. These accommodations help the
individuals meet their educational needs and successfully
function in employment and community settings. Also,
information about their legal rights and responsibilities is
made available, including handbooks on legal rights and
responsibilities for both adults with disabilities and adult
service providers, a ``Compendium of Materials and Resources,''
and a ``Procedural Guide.'' These materials are compiled
through: (1) a national survey of adult education programs, (2)
a state survey of enrollees with disabilities in adult
education, and (3) a case study of one local program in an
urban center with high unemployment and multicultural
diversity. This process is aided by information gained from two
symposia with adult educators and subject matter experts
(proceedings and videotapes of the first symposium are
available). An accommodations model that matches the functional
needs of adults with disabilities to the demands of adult
education programs is being developed; the accommodations model
and related products are being tested using a national sample
of adult educators.
3. Reducing Risk Factors for Abuse Among Low-Income Minority Women with
Disabilities, Baylor College of Medicine, Department of
Physical Medicine and Rehabilitation, Houston, TX
This project pursues strategies to reach women with
disabilities at all stages of change in resolving abusive
situations. To accomplish this purpose, the project has the
following objectives: (1) identify risk factors for emotional,
physical, and sexual abuse faced by women with disabilities;
(2) assess the ability of rehabilitation and independent living
counselors to identify women in abusive situations and refer
them to appropriate community resources; (3) develop and test
models for programs that reduce the risk of abuse for women
with disabilities, particularly among women with disabilities
from low-income, minority backgrounds where the incidence of
abuse is the highest; and (4) establish an agenda for future
research on women with disabilities using a national advisory
panel. The project works not only with programs that help
battered women, but also those that have contact with women
with disabilities in various community contexts.
4. Understanding and Increasing the Adoption of Universal Design in
Product Design, University of Wisconsin/Madison, Trace Research
and Development Center, Madison, WI 53705-2280
This project: (1) identifies the factors that cause
industry to practice, or not to practice, universal design of
products; and (2) identifies ways that people outside companies
can encourage and facilitate the practice of universal design
of products on a more widespread basis. The project brings
together experts who have been active in universal design from
across the technology spectrum to work with industry in
addressing these questions. Areas of expertise include housing
and architecture, computers and electronic products, media and
materials, telecommunications, and educational software.
Utilization Projects
This program supports activities that will ensure that
rehabilitation knowledge generated from projects and centers
funded by the Institute and other sources is fully utilized to
improve the lives of individuals with disabilities.
1. Improving Access to Disability Data, InfoUse, Berkeley, CA
InfoUse's Center on Access to Disability Data is the
central source for disability statistics data and related
technical reports in accessible, easy-to-understand, user-
friendly formats. The Center provides this information to
businesses, the media, urban planners and policymakers, and the
disability community. The first major product, the ``Chartbook
on Disability in the United States, 1996,'' provided updated
statistical information on a range of disability topics.
Material for the ``Chartbook'' series and related fact sheets
are available to the public in a variety of published and
electronic formats, including print and electronic media. The
Center's Web site serves as a source for electronic documents,
includes guidelines for accessible Web publishing, and provides
links to major national data sources including data sites
developed by other NIDRR grantees and by major national
disability data suppliers.
2. National Rehabilitation Information Center (NARIC), KRA Corporation,
Silver Spring, MD
The National Rehabilitation Information Center (NARIC)
maintains a research library of more than 51,000 documents and
responds to a wide range of information requests, providing
facts and referral, database searches, and document delivery.
Through telephone information referral and the Internet, NARIC
disseminates information gathered from NIDRR-funded projects,
other federal programs, and from journals, periodicals,
newsletters, films, and videotapes. NARIC maintains REHABDATA,
a bibliographic database on rehabilitation and disability
issues, both in-house and on the Internet. Users are served by
telephone, mail, electronic communications, or in person.
3. Abledata Database Program, Macro International, Inc., Silver Spring,
MD
The project maintains and expands the ABLEDATA database,
develops information and referral services that are responsive
to the special technology product needs of consumers and
professionals, and provides the data to major dissemination
points to ensure wide distribution and availability of the
information to all who need it. The ABLEDATA database contains
information on more than 23,000 assistive devices, both
commercially produced and custom made. Requests for information
are answered via telephone, mail, electronic communications, or
in person.
4. National Center for the Dissemination of Disability Research (NCDDR)
Southwest Education Development Laboratory, Austin, TX
This project provides information and technical assistance
to NIDRR grantees in identifying and improving dissemination
strategies designed to meet the needs of their target audience.
The project also analyzes and reports on dissemination trends
relevant to disability research. Task force and material
development activities address multicultural factors that
influence dissemination and utilization. This project conducts
ongoing informational network through a variety of approaches,
including an interactive World Wide Web site highlighting
events and other information about specific NIDRR grantees, the
production of quarterly issues of ``The Research Exchange,''
and in-person and online technical assistance support.
Fellowships
Fellowships, named for the late Mary E. Switzer, build
future research capacity. NIDRR makes awards on two levels:
Distinguished Fellowships go to individuals of doctorate or
comparable academic status who have had seven or more years of
experience relevant to rehabilitation research. Merit
Fellowships are given to persons in earlier stages of their
research careers.
1. Quality Indicators for Comparative Analysis of Stroke Outcome,
Bartlett, IL, Principal Investigator: Robin Turpin, PhD
The goal of this study is to develop a set of a quality
indicators to assess the impact of medical rehabilitation
services on the lives of stroke survivors. Development involves
the World Health Organization's ``International Classification
of Impairments, Disability, and Handicaps'' (ICIDH), as well as
quality of life literature. The indicators assess the impact of
rehabilitation services from health status of community
integration and quality of life. Such a set of quality
indicators would be useful and feasible for a wide variety of
care across settings and providers.
2. Telemedicine and Neuropsychological Services: Improving Access to
Care to Care for Rural Residents with Brain Injury, University
of Missouri/Columbia, Department of Physical Medicine and
Rehabilitation) Columbia, MO, Principal Investigator: Laura H.
Schopp, PhD
Objectives of this study include: assessing telemedicine
versus in-person care in consumer, family member, provider, and
rehabilitation counselor satisfaction; assessing costs,
psychological and neuropsychological status, and level of
community integration; and providing qualitative and (to the
extent possible) quantitative evaluation of racial/ethnic
differences in needs and attitudes toward telemedicine.
Research Training Grants
The purpose of this program is to expand capability in the
field of rehabilitation research by supporting projects that
provide advanced training in rehabilitation research. These
projects provide research training and experience at an
advanced level to individuals with doctoral or similar advanced
degrees who have management or basic science research, in
fields pertinent to rehabilitation, in order to quality those
individuals to conduct independent research on problems related
to disability and rehabilitation.
1. Doctoral Training in Physical Therapy University of Iowa, Physical
Therapy Graduate Program, Iowa City, IA
This project supports five physical therapist trainees for
three years and five other physical therapist trainees for the
first two years of their doctoral program of study at the
University of Iowa. the long-term goal is to increase the
supply of physical therapists who have both the clinical
experience and advanced skills required to conduct effective
rehabilitation research. Specifically, the student must: (1) be
able to perform original scholarship and research that advances
the understanding of physical therapy clinical practice; (2)
have comprehensive knowledge of theoretical and research
literature in areas of specialization; (3) be skilled in the
application of basic and advanced concepts in the area of
cardiopulmonary, ergonomic, musculoskeletal, or neuromuscular
physical therapy; and (4) be able to teach at the basic
professional, master's degree, and doctoral levels of physical
therapy education.
2. Rehabilitation Research Training in Physical Therapy, Texas Woman's
University, School of Physical Therapy, Houston, TX
The purpose of this training project is to produce
qualified individuals who are capable of conducting valid
scientific research in rehabilitation. Participants are
physical therapists who have well-defined interests in pursuing
research careers in physical therapy. Four predoctoral student
fellows are recruited for a three-year course of study leading
to a PhD degree with a major in physical therapy. Fellows are
selected on the basis of their interest in programmatic
research conducted in one of the laboratories within the School
of Physical Therapy. Those laboratories are actively engaged in
investigating neuromuscular and musculoskeletal aspects of
rehabilitation. In addition, each fellow is expected to
participate in external projects conducted in conjunction with
the laboratory. A plan of both process and outcome evaluation
ensures the excellence of this training program.
Small Business Innovative Research
New ideas and products useful to people with disabilities
and the rehabilitation field are encouraged with small business
innovative research grants. This three-phase program takes an
idea from development to market readiness.
1. Development of a Lightweight, Portable, Easily-Assembled Scooter
Lift-Carrier for Automobiles and Other Vehicles, ACCESS/
ABILITIES, Mill Valley, CA
ACCESS/ABILITIES, in collaboration with the Veterans
Administration Rehabilitation Research and Development Center,
is developing a portable, lightweight, easy-to-assemble lift/
carrier for 3-wheeled scooters that can be used with
automobiles. Design selection is based on technical
feasibility, commercialviability, physical practicality for
users, and cost efficiency, using technical data on scooter
specifications gathered from manufacturers. Three design approaches are
considered.
2. Hiking Trails Web Site with Universal Access Information, Beneficial
Designs, Inc., Santa Cruz, CA
Although many people with disabilities enjoy visiting
outdoor parks and recreational areas, obtaining information
about the accessibility of outdoor trails is currently
difficult. The goal of the Trails Web site is to provide
universal access information for trails throughout the United
States that is useful to all hikers, regardless of their
ability. The Universal Trails Assessment Process enables trail
managers to assess specific trails objectively with regard to
grade, cross slope, width, surface characteristics, and
obstacles. The collected trail data is processed to create
Trail Access Information in a format similar to the Nutritional
Facts food label. The objectives of Phase I are to develop the
Web site and trail access information database, to collect and
enter trail access information, and to evaluate its
effectiveness through online evaluations. The Web site allows
users to search for trails that meet their specific access
needs. The site also contains links to other Web sites with
related information. Trail access information obtained remotely
allows Web site users to plan appropriate outdoor travel by
being able to determine in advance where they can hike.
3. Alternative communication; Computer applications; Communication;
Hearing impairments; Deaf blindness; Sign language; The
Adaptive Device Locator System on the World Wide Web, Academic
Software, Inc., Lexington, KY
This project's goal is to save the Adaptive Device Locator
System (ADLS), a unique and valuable national resource, by
transforming the entire Locator System database content and
program code into a World Wide Web site on the Internet. The
planned state-of-the-art, multilevel format is universally
accessible to teachers, health professionals, and consumers
with disabilities. The site lists computer access products the
company provides; vendor links allow ADLS visitors to jump
directly to other commercial sites once appropriate assistive
technology devices are located. On the Web, ADLS will be an
export leader, focusing on international trade in this field.
ADLS on the WEB will feature monthly infomercials, new product
announcements, and other information of interest to consumers.
4. Broadcast Radio for Individuals Who Are Deaf: Gaining Equity
(BRIDGE), Associated Enterprises, Inc. (AEI), TeleSonic
Division, Annapolis, MD
Talk radio reaches large audiences of people and is a
significantly less expensive medium than television. Yet radio
broadcasts are inaccessible to deaf and certain hard of hearing
people. In project BRIDGE, TeleSonic's goal is to broadcast
information via the radio simultaneously in multiple
transmission forms to delivery both audio and visual
information. Users of TTYs, for example, receive ``closed
captioned'' broadcasts of radio programs. The Phase I
hypothesis is: it is feasible to transmit multimedia signals
over commercial radio to be received by special decoder
devices. Phase I includes: (1) defining technical trial test
approaches, (2) developing test transmitter/receiver devices,
(3) producing a brief radio talk show, (4) organizing focus
group feedback sessions, (5) conducting trials, (6) developing
preliminary product design specifications, and (7) documenting
results. Anticipated long-term results include development of a
commercially marketable radio transmission and receiving
device.
5. Miniature, Voice Output Independent Reading Device (IRA), Ascent
Technology Inc., Boulder, CO
This project is developing and testing an innovative
reading device that interprets and speaks along the printing
found in books, labels, and other everyday items, this device
enhances the abilities of people with visual impairments in
schooling, employment, and independent living. The unique
optical character recognition and voice synthesis device
requires only one hand for operation and can read food and
pharmacological packaging, including curved surfaces. The
simplicity of the device allows the user to acquire functional
reading capability after only a few minutes of training. In
addition to serving people with visual impairments, this
technology is applicable to the needs of people with cognitive
impairments, such as people who have had a stroke, and to the
needs of people who cannot read and non-native language
readers. The prototype is being tested using 15 people with
visual impairments aged 55 and older and four adults under the
age of 45 to determine its applicability to the tasks of
independent living.
state technology assistance programs
This program, funded under The Technology-Related
Assistance for Individuals with Disabilities Act of 1988, as
amended, supports consumer-driven, statewide, technology-
related assistance for individuals of all ages with
disabilities.
States and territories are eligible to apply for one 3-year
development grant, a first-extension grant for year 4 and 5,
and a second-extension grant for years 6-10. The purpose of
these grants is to establish a program of statewide,
comprehensive, technology-related assistance for individuals
with disabilities of all ages.
Independent Living Services for Older Individuals Who Are Blind,
Chapter 2 of Title VII
Section 752 of the Rehabilitation Act of 1973, as amended,
authorizes discretionary grants to State vocational
rehabilitation (VR) agencies for projects that provide
independent living services for persons who have severe visual
impairments and who are aged 55 and older. Each designated
State unit that is authorized to provide rehabilitation
services to blind individuals may either directly provide
independent living services or it may make subgrants to other
public agencies or private non-profit organizations to provide
these services.
The services most commonly provided are: (1) training for
activities of daily living, (2) the provision of adaptive aids
and appliances, (3) low vision services, (4) orientation and
mobility services, (5) training in communication skills, (6)
family and peer counseling, and (7) community integration,
which includes outreach and information and referral.
During FY 1996, the most recent year for which we have
analyzed data, 26,846 older individuals with significant visual
impairment or blindness received services. Of these consumers,
64.4 percent were at age 76 or older and 45 percent were age 81
or older. The individuals served by this program represent
approximately one-half of the individuals with significant
visual impairments or blindness who receive rehabilitation and
independent living services through public and private
rehabilitation programs as estimated by the Mississippi State
University and the New York Lighthouse for the Blind.
ITEM 5--DEPARTMENT OF ENERGY
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Introduction
The Department of Energy (DOE) is a major government
enterprise. If included among the Nation's Fortune 500 firms,
it would rank in the top 50. It funds the largest environmental
cleanup in history as well as research and development that
supports the Nation's defense and its energy and economic
security. The Department employs more than 11,000 Federal
workers and 100,000 contract employees. It owns and manages
over 50 major installations located on 2.4 million acres in 35
States and is the fourth largest Federal landowner in the
United States.
The Department of Energy is an energy policy, supply, and
technology enterprise. It invests in developing a secure,
clean, and sustainable energy system. It helps the Nation meet
its environmental challenges by administering the largest
pollution prevention and energy efficiency program in the
world, with partners from every sector of the economy. It
enhances the Nation's energy security by increasing the
diversity of energy sources and fuel choices: bringing
renewable energy sources into the market, strengthening
domestic production of oil and gas, maintaining the U.S.
nuclear energy option, and increasing the efficiency with which
we use energy and generate electricity. The Department also
maintains the Strategic Petroleum Reserve and operates Power
Marketing Administrations that sell and distribute over $3
billion of electric power generated at Federal hydroelectric
plants.
The Department of Energy is a national security enterprise.
It is a key player in the Administration's furtherance of the
Comprehensive Test Ban Treaty and its overall goal of reducing
the global danger from nuclear weapons. DOE ensures the safety
and reliability of the U.S. nuclear weapons stockpile without
underground testing. At the same time, it manages and safely
dismantles excess nuclear weapons, disposes of surplus fissile
nuclear materials, and ensures the security of vital
Departmental nuclear assets. It provides policy and technical
assistance to curb global proliferation of weapons of mass
destruction, emphasizing U.S. nonproliferation, arms control,
and nuclear safety objectives in the states of the former
Soviet Union and world-wide. Further, DOE develops and ensures
the safety and reliability of nuclear reactor plants to power
U.S. Navy warships.
The Department of Energy is an environmental remediation
enterprise. It cleans up the 50-year environmental legacy left
at the industrial complexes where nuclear weapons were designed
and manufactured. It manages the problems associated with the
large quantities of various types of radioactive wastes,
surplus nuclear materials, and spent nuclear fuels that remain
at the sites of the Nation's nuclear weapons facilities and at
nuclear energy research and development sites. In addition, DOE
must address the growing inventory of spent nuclear fuel from
commercial nuclear reactors that is awaiting disposal. These
wastes must be dealt with responsibly to ensure the safety and
health of the public.
The Department of Energy is a science and technology
enterprise. At the center of all we do are our 27 laboratories,
our additional scientific user facilities, and our researchers
at the Nation's universities. These form the backbone of U.S.
scientific leadership by conducting and facilitating
breakthrough research in energy sciences and technology, high
energy physics, global climate change, genomics,
superconducting materials, accelerator technologies,
environmental sciences, and supercomputing in support of DOE's
mission. The laboratories, described as the crown jewels of the
Nation's science establishment, and the Department's funding of
research at universities have resulted in 70 Nobel prize
winners. The Department is also an investor in the Nation's
most precious resource--its youth--by supporting science and
mathematics education in our schools through grants,
educational programs, and fellowships.
The Department of Energy is a global enterprise. The
outcome of our work is the technology that stimulates the
private market for the expansion of clean energy to meet
national and global energy requirements of almost 500
quadrillion Btu's by the year 2010--a staggering 36 percent
increase over 1995. Overseas energy market needs include coal,
nuclear power, oil and gas exploration, energy efficiency, and
renewable energy technologies that are available for export now
or that will soon be available for the international
marketplace. The Department of Energy supports the export of
U.S. energy services and technologies by assisting the nations
in Asia, South America, Eastern Europe, and Africa, and the
states of the former Soviet Union in developing private markets
for environmentally responsible, sustainable energy. These
alliances support U.S. competitiveness in a global economy of
growing energy infrastructure requirements and create jobs in
the United States at all skill levels.
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,
1996 about 4.5 million homes had been weatherized with Federal,
State, and utility funds; of these, an estimated 1.8 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. A low-
income household now saves approximately $193 per year, about
one-third of its space heating costs. Program benefits are
further described in Progress Report of the National
Weatherization Assistance Program that features 90 photo
illustrations of specific benefits. The report is available
through the National Technical Information Service, 703/487-
4650, 5285 Port Royal Rd., Springfield, VA 22161.
The program is implemented by states through community-
based organizations. The Department of Energy and its State and
community partners weatherize approximately 70,000 single- and
multi-family dwellings each year. The program awarded $214.9
million in Fiscal Year 1995 and $111.7 million in Fiscal Year
1996 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 FY
1995 $53 million was appropriated and $25.9 million was
appropriated in FY 1996. 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.
There have been some projects that specifically target the
elderly such as Louisiana's low-income/handicapped/elderly/
Native American outreach program that provided energy-related
assistance through a joint venture with utilities. The elderly
also benefit from programs that provide energy audits, hands-on
energy conservation workshops, and low-interest loans for
homeowners that can result in significant energy savings.
Energy efficiency improvements in local and state buildings and
services also benefit the elderly by freeing up state and local
government tax revenues for non-energy expenses. Energy
efficient schools can be less of a burden on property taxes.
An emerging issue is the restructuring of the electric
utility industry. The State Energy Program has supported
workshops with States and local communities to ensure that
homeowners and disadvantaged groups are not overlooked or
denied the economic benefits of lower-cost sources of energy
after deregulation. Utility deregulation workshops for public
officials have emphasized techniques and negotiating
strategies, e.g. franchising, to ensure that vulnerable
populations such as the elderly are not excluded from energy
pricing competition.
Information Collection and Distribution
The Energy Information Administration collects and
publishes comprehensive data on energy consumption in the
residential sector through two surveys: the Residential Energy
Consumption Survey (RECS) and the Residential Transportation
Energy Consumption Survey (RTECS). The RECS is now collected
every 4 years and the RTECS was discontinued after the 1994
survey. The Residential Energy Consumption Survey includes data
collected from individual households throughout the country,
along with the actual billing data from the households' fuel
suppliers for a 12-month period. The data include information
on energy consumption, expenditures for energy, costs by fuel
type, and related housing unit characteristics (such as size,
housing type, and major energy-consuming appliances). The
Transportation Survey collected information on characteristics
of household vehicles and annual miles traveled for a subsample
of the RECS respondents. Both surveys contain data pertaining
to older Americans.
The results of these surveys are analyzed and published by
the Energy Information Administration. The most recent
household survey for which reports have been published is the
1993 RECS. Results of the 1993 RECS are published in two
reports: Housing Characteristics 1993 (published in June, 1995)
and Household Energy Consumption and Expenditures 1993
(published in October, 1995). The data file for the 1993 RECS
is available on PC diskettes. The reports and data file are
also available on the Internet at http://www.eia.doe.gov/emeu/
recs/contents.html. The RECS file contains demographic
characteristics of the elderly such as age, employment status,
marital status and family income, as well as estimates of
consumption and expenditures for electricity, natural gas, fuel
oil, kerosene, and liquefied petroleum gas used in the elderly
households.
In the 1993 RECS, 27.8 million, or 29 percent of all U.S.
households, were headed by a person 60 years of age or older.
Of these elderly households, 42 percent were one-member
households (11.7 million people living alone) and 45 percent
contained 2 people. In the 2-member elderly households, 78
percent of the second persons were also at least 60 years old.
Analysis of the 1993 RECS data shows that consumption
patterns differed between the elderly and nonelderly for some
uses of energy. The elderly used more energy to heat their
homes, for example, 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 was $681. 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 61 percent of total energy consumption and
about 38 percent of total energy expenditures in
elderly households were for space heating.
The most recent triennial Residential Transportation Energy
Consumption Survey was conducted for the calendar year 1994 and
the results reported in Household Vehicles Energy Consumption
1994 (published August, 1997).
This report and the RTECS data files are also available on
the Internet at http://www.eia.doe.gov/emeu/rtecs/
contents.html. Data in this publication, vehicle miles
traveled, gallons of motor fuel consumed, expenditures for
motor fuel, and number of vehicles, are categorized by
household characteristics and type of vehicle. These data show
that for calendar year 1994, elderly households drove fewer
miles and used less fuel on average than did all households.
For example, elderly households with one adult and no children
drove an average of 8,600 miles and consumed an average of 435
gallons of motor fuel. Elderly households with 2 or more adults
and no children averaged 17,000 miles and 907 gallons of motor
fuel. These averages are below the corresponding averages for
all U.S. households, 21,100 miles and 1,067 gallons of motor
fuel. Elderly households may travel fewer vehicle miles because
they make relatively less use of their vehicles for commuting
to work or earning a living.
Research Related to Aging
In 1995 and 1996, the Office of Environment, Safety and
Health (EH) sponsored research to further an understanding of
the human health effects of radiation. As part of this research
program, the Department of Energy sponsored epidemiologic
studies concerned with understanding biological changes over
time. Lifetime studies of humans constitute a significant part
of EH's research; 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
and some basic research concerning 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
nonexposed 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 1995-1996.
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 followup 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
contractor 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.
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 1940s through
the 1960s. These 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, such as 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 Applications and Biophysical Research Division within
the Office of Biological and Environmental Research carries out
a Congressional mandate to develop beneficial applications of
nuclear and other energy related technologies including
research in aging affecting older Americans. The Aging Research
involves study of a brain chemical, dopamine (DA), and its
function in humans as they age. A significant decline in the
function of the brain DA system with age has long been a
recognized fact, 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 the age-related losses in brain DA activity in
cerebral function and to investigate mechanisms involved with
the loss of DA function with normal aging. The results of these
studies have already shown that in healthy volunteers with no
evidence of neurological dysfunction there is a decline in
parameters of DA function, which are associated with 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 dopamine
system in the elderly.
Cancer is a disease generally associated with aging. One of
the essential steps in the conversion of a normal cell to a
malignant cancer cell is a heritable loss of the cell's ability
to control its normal growth behavior. In addition, cancer
cells often escape from the normal cell aging process. Research
is funded on the role of cell aging (or senescence) in the
aging of the whole organism. This research received an award
from the Alliance for Aging Research, the nation's leading
citizen advocacy organization for promoting scientific research
in human aging and working to ensure healthy longevity for all
Americans.
Additional research has resulted in the creation of a new
scientific discipline known as biodemography, a melding of
biology and demography. This research is searching for
biological information, at all levels of biological
organization, that predicts and explains patterns of age-
related mortality observed in populations. In the long term,
biodemography provides a conceptual framework that helps policy
makers assess the impact that specific biomedical interventions
such as heart bypass surgery, renal dialysis, chemotherapy, or
gene therapy will have on population aging and, as a result, on
the fiscal solvency of government entitlement programs for
aging citizens.
The programmatic costs for aging research are estimated at
approximately $400K annually.
ITEM 6--DEPARTMENT OF HEALTH & HUMAN SERVICES
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THE ADMINISTRATION ON AGING AND THE OLDER AMERICANS ACT
Introduction
Today, 44 million, or one in six, Americans are 60 or
older. While most older Americans are active members of their
families and communities, others are at risk of losing their
independence. These include the 4 million Americans 85 or
older, those living alone without a caregiver, members of
minority groups, older persons with physical or mental
impairments, low-income older persons, and those who are
abused, neglected, or exploited.
To meet the diverse needs of the growing number of older
people, the Older Americans Act of 1965 (the Act), as Amended,
calls for programs that offer services and opportunities for
older Americans. The Act established the Administration on
Aging (AoA), an agency of the U.S. Department of Health and
Human Services, which is headed by the Assistant Secretary for
Aging.
Among its major responsibilities, the AoA administers
programs at the federal level, which help those elderly at risk
of premature or unnecessary institutionalization to remain in
their own homes by providing supportive and nutrition services.
This report summarizes the major activities of the AoA in
Fiscal Years 1995 and 1996.
the national aging network
The AoA is the federal focal point and advocacy agency for
older persons. In this role, the AoA works to heighten the
awareness of other federal agencies, organizations, and the
business and public sectors about older persons--their many
contributions to the nation, their resources, but also their
needs and concerns. The AoA also works with these various
groups to ensure that, whenever possible, their programs and
resources are targeted to the elderly and coordinated with
those of the aging network. The AoA works closely with the
nationwide network of State Units on Aging (SUA's), Area
Agencies on Aging (AAA's), and Indian Tribal Organizations
(ITO's) to plan, coordinate, and develop community-level
systems of services designed to meet the unique needs of older
persons and their caregivers. The AoA awards funds for
nutrition and supportive in-home and community services to the
57 SUA's which are located in every state and territory.
Additional funds are awarded to these state agencies for elder
rights programs, including the nursing home ombudsman program,
and elder abuse prevention efforts.
Funding for programs is allocated to each SUA, based on the
number of older persons in the state, to plan, develop, and
coordinate systems of supportive services. Most states are
divided into Planning and Service Areas (PSA's) so that
programs can be developed and targeted to meet the unique needs
of the elderly residing in that area.
Nationwide, approximately 655 AAA's receive funds from the
SUA to plan, develop, coordinate and arrange for services in
each PSA. The AAA's contract with public and private groups to
provide in-home and community-based services. Nationwide, there
are some 27,000 service provider agencies.
The AoA also awards funds to 222 tribes and native
organizations to assist older American Indians, Alaskan
Natives, and Native Hawaiians. Funds are allocated to ITO's
based on the number of older American Indians, Alaskan Natives
or Native Hawaiians to be served in their designated geographic
area. The ITO's provide home and community-based service in
keeping with the unique cultural heritage of these Native
Americans.
Volunteers are a vital component of the national aging
network. The AoA uses the talents of a half-million volunteers,
many of them older persons, to assist in service programs
supported under the Act. These volunteers work at the community
level to enhance the independence of the elderly. Additionally,
the rich talents of older Americans are being tapped. Through
intergenerational programming, they are helping families by
working with Head Start children and their parents, as
counselors to troubled youth, and by providing respite care for
disabled children. Appendix I includes an organizational chart
of the National Aging Network.
Discretionary grant programs
The discretionary grant programs authorized by Title IV of
the Older Americans Act constitute the major research,
demonstration, training, and information dissemination effort
of the AoA. These programs are aimed at expanding our
understanding of older persons, developing innovative model
programs, training personnel for service in the field of aging,
and providing technical assistance and information to the aging
network and to others who work with older persons.
Because of severe reductions in Title IV funding for fiscal
year 1996, there were only three demonstration project areas--
the Eldercare Locator, Family Friends, in which older
volunteers service children with disabilities and their
families, and Senior Legal Hotlines/Legal Assistance and
related elder rights projects.
The Act under Title II requires the establishment of
resource centers. The AoA has provided funds to educational
institutions to develop curricula and training programs for
professionals and paraprofessionals.
In the past, the AoA awarded funds to support national
resource centers on long-term care, housing, nutrition, Native
Americans, older women, and elder abuse.
The budgets for AoA in FY 1995 and FY 1996 are included in
Appendix II.
aging in the future
During FY 1995-1996, the AoA worked to shape an environment
where Americans will have the best opportunity to adopt
attitudes and lifestyles that enable them to remain independent
in their later years. Through consumer advocacy and outreach
and education, the AoA is seeking to enable older Americans,
and those nearing retirement, to make changes that help them to
enjoy a fulfilling future. The key is to plan and to adopt, for
their later years, lifestyles that include the goals of good
health, a satisfying quality of life and financial security.
Through these and many other programs supported by the AoA,
the mandate of the Act--to ensure the dignity and independence
of older Americans in their own homes and the opportunity to
contribute to their communities and our nation--is coming
closer to being fully realized for present and future
generations.
This report is organized and divided into five sections
summarizing the major activities during FY 1995-1996. Section I
discusses the activities focused on ``Improving Services for
Seniors and Their Families.'' Section II discusses the
activities related to ``Enhancing the Capacity of the
Network.'' Section III discusses those activities geared toward
``Planning for the Future.'' Section IV discusses those
activities focused on ``Addressing Diversity.'' Section V
contains those activities related to ``Expanding international
Partnerships.''
Section I--Improving Services for Seniors and Their Families
Preserving and strengthening the Older Americans Act
The AoA, in consultation with key partners in the aging
network, produced a reauthorization proposal for the Older
Americans Act (the Act) designed to strengthen its services and
maintain the integrity of its successful programs and titles,
while improving local flexibility, protecting the most
vulnerable, and preparing for a growing and diverse aging
population. The Act was not reauthorized by the 104th Congress
and continues to be discussed in the 105th Congress.
Protecting elders' rights
As a result of the five Bi-Regional Elder Rights Protection
meetings conducted in fiscal year 1995, a number of state elder
rights coalitions were established during fiscal year 1996 to
develop ways to resolve problems affecting large numbers of
vulnerable older persons and to assist elders secure the rights
and benefits to which they are entitled.
In FY 1995, the Institute of Medicine, National Academy of
Sciences completed its study to evaluate the State Long-Term
Care Ombudsman Programs concluding that the ombudsman program
serves a vital public purpose and merits continuation with its
present mandate. Through advocacy efforts at both the
individual resident and the system levels, paid and volunteer
ombudsmen uniquely contribute to the well-being of LTC
residents--complementing, but not duplicating, the
contributions of regulatory agencies, families, community-based
organizations, and providers. The summary report can be found
in Appendix III.
The Congressionally-mandated National Ombudsman Reporting
System (NORS), established to obtain detailed ombudsman
compliant and program information, was fully implemented. The
information received from this report will serve as a basis for
policy development and as a baseline against which to measure
program outcomes in future years. The Introduction and Summary
from the FY 1995 Long-Term Care Ombudsman Annual Report is
included in Appendix IV.
A special task force to develop outcome measures for the
work of ombudsmen resulted in a report entitled ``An Approach
to Measuring the Outcomes of the Long-Term Care Ombudsman
Program'' which was issued to states and other interested
parties.
The Congressionally-mandated National Long-Term Care
Ombudsman Resource Center continued to provide technical
assistance and training activities for state long-term care
ombudsmen in nursing homes and board and care facilities.
Preventing crime and violence
A Crime/Violence Prevention Initiative which focused on the
prevention of crimes and violence against older persons was
initiated.
The Congressionally-mandated National Center on Elder Abuse
continued to serve the information, knowledge and skills
development, and knowledge-building needs of organizations,
individuals, and professionals working within and outside the
nation's elder abuse/neglect prevention network.
The AoA, in collaboration with the Department of Health and
Human Services (HHS) Administration for Children and Families,
is supporting a National Elder Abuse Incidence Study designed
to examine the incidence of elder abuse, neglect, and financial
exploitation. The study also identifies the characteristics of
victims of domestic elder abuse, as well as those of the
perpetrators. The second year of the three-year study was
devoted to collecting data. The third year of the study will be
devoted to the analysis of the data and dissemination of a
final report upon completion.
An interagency agreement with the Department of Justice to
address the public safety and security needs of older Americans
resulted in the formation of local and state TRIAD programs
(efforts to increase cooperation between law enforcement and
aging and social services providers to reduce criminal
victimization).
Final products from AoA-funded projects to link, at the
state and local levels, domestic violence and aging networks
were completed. They include manuals and other resources that
are useful for developing programs for the protection of older
women against domestic violence.
Cracking down on fraud
The AoA worked in partnership with the Office of Inspector
General and the Health Care Financing Administration in
carrying out Operation Restore Trust--a Presidential initiative
to detect and prevent fraud and abuse in the Medicare and
Medicaid programs. This demonstration program began operating
in five states--New York, Florida, Illinois, Texas, and
California--and plans to expand nationally under the Health
Insurance Accountability Act (Kassebaum-Kennedy bill).
Through September 30, 1996, the program produced $57.5
million in criminal and civil restitutions, fines, settlements
and penalties.
The AoA joined the American Association of Retired Persons,
the National Association of Attorneys General, the Federal
Bureau of Investigation, the U.S. Postal Inspection Service,
the National Fraud Information Center, the Royal Canadian
Mounted Police, MCI and Federal Express in launching
``Operation Unload.'' This national effort, named after the
boiler room operations (phone centers) commonly used by
fraudulent telemarketers, warned elderly victims and potential
victims that their names appear on telephone lists used by
criminals and unscrupulous telemarketers for telemarketing
schemes. Alerting potential victims that their names were on
such lists, resulted in unloading their names from the lists.
This effort reached nearly 2,000 people across the United
States.
Increasing visibility of nutrition as key health component
An independent Congressionally-mandated evaluation of the
Elderly Nutrition Program (ENP) under Titles III and VI of the
Act was completed. The study determined the effectiveness of
the ENP in meeting the nutritional needs of older persons, as
well as in addressing unmet needs. It was the first national
evaluation of nutrition programs of the Act since 1983, and the
first-ever to evaluate Title VI nutrition programs. Key
findings include:
The ENP provides an average of one million meals per
day to older Americans;
People who receive ENP meals have higher daily
intakes of key nutrients than similar nonparticipants;
ENP meals provide approximately 40 to 50 percent of
participants' intakes of most nutrients;
Participants have more social contacts per month than
similar participants; and
A dollar of Title III congregate nutrition funding is
supplemented with $1.70 from other sources. The
leveraging rate for home-delivered meals is higher: a
dollar of Title III home-delivered nutrition funding is
supplemented with $3.35 from other sources.
The final report on the national evaluation of the Elderly
Nutrition Program is included in Appendix V.
Implementing expedited assistance for disasters
Because of the loss of Title IV discretionary funds in
fiscal year 1996, AoA could not reserve funds to give to states
for disaster assistance.
The AoA signed a Statement of Understanding with the
American Red Cross to make the delivery of relief efforts to
elderly victims of disasters more efficient through cooperative
efforts, including training, data collection, emergency meal
distribution and transition of services.
A training video distributed to the aging network which
addresses the impact of disasters on the elderly was produced
in both English and Spanish.
Improving customer service
The first-ever strategic plan for the AoA was developed.
The plan articulated the mission as well as goals and
objectives for the agency and the aging network.
A customer service plan for the AoA was included with HHS
Secretary Shalala's plan. The plan contains nine customer
service standards for the AoA employees in delivering services
to older persons and their families, to State and Area Agencies
on Aging, ITO's, as well as other agencies, organizations and
grantees.
The use of these standards was expanded by establishing a
comprehensive AoA Website (http://www.aoa.dhhs.gov) on the
Internet which provides current data and information on a
variety of matters of concern to older consumers and their
families.
The ``AoA Update,'' a monthly newsletter, was created for
distribution to the aging network, agency employees and other
interested individuals to keep them apprised of agency
activities/initiatives.
A National Symposium on Performance-Based Management
brought together representatives of the aging network to
address data and technology requirements for the future.
Section II--Enhancing the Capacity of the Network
Improving research, training and discretionary grants process
The AoA undertook a variety of efforts which resulted in an
improved discretionary grants process:
Utilized the research, training and discretionary
funding program to move forward priorities of the
agency including home and community-based long-term
care, older women, nutrition/malnutrition, crime/
violence prevention, and planning for the future.
Improved the peer review process in awarding grants.
Established field-initiated projects to encourage
creativity and innovation. Field-initiated projects
offer applicants an opportunity to propose and develop
innovative approaches which expand knowledge in any
policy, program, or related issue of importance to
older Americans without being confined by specific
priority areas.
Assessing cost sharing for services to older persons
In anticipation of changes in the Act relating to cost
sharing, the AoA commissioned the HHS Office of Inspector
General to survey states and territories. The purpose of this
activity was to describe current cost sharing activities within
states and discuss implementation issues concerning cost
sharing for services to older persons under Title III of the
Act. The review found that although 36 states currently make
use of cost sharing programs, states' specific experiences with
these practices will affect their readiness to implement Title
III cost sharing. This report is contained in Appendix VI.
Establishing a national aging data base information and resource center
A Congressionally-mandated National Aging Information
Center funded by AoA provided convenient access to a wide range
of resources for those interested in aging issues and
information. The Center served policymakers and Congress, the
aging network, educators, researchers, practitioners and the
public, and is the repository of documents and the final report
of the 1995 While House Conference on Aging.
Working to expand home and community-based long-term care
Four long-term care resource centers contributed to a long-
term care agenda aimed at the development of consumer-driven
home and community-based systems of care for older persons who
need services. Products included guidebooks, policy papers,
manuals, and research briefs on such diverse topics as
expanding consumer choices, addressing the needs of persons
with disabilities, overcoming barriers to long-term care
assistance in rural areas, examining managed care and frail
elders, highlighting home and community-based cared best
practices, evaluating housing for rural and African American
elders, analyzing assisted living alternatives, reducing the
cost of institutional care, improving transportation for the
elderly, and others.
Phase II of AoA's Health Care University (conference on
managed care) brought together 750 representatives of the aging
network to understand the concepts of managed care for the
elderly and individuals with disabilities and its relationship
to Medicare, Medicaid and the Act. The conference also provided
an opportunity to examine ways to assure consumer protection
and offer advocacy to those in managed care.
The National Long-Term Care Mentoring Program continued to
assist states to develop more extensive programs in home and
community-based care, profile model home and community-based
programs, and provide a corps of ``mentors'' with a wide range
of expertise.
The AoA continued support for the Neighborhood Senior Care
Program which resulted in innovative neighborhood-based efforts
which encourage health professionals and community volunteers
to provide home and community-based services.
A working partnership with the Department of Housing and
Urban Development (HUD) enhanced the availability and
accessibility of services for the elderly and persons with
disabilities who reside in federally-assisted housing
facilities. This collaboration with HUD also resulted in ``Best
Practice'' awards to the top-rated housing facilities
demonstrating successful coordination between the aging network
and government-assisted housing facilities.
Establishing linkages between aging and disability communities
The AoA joined as a participant in the National Coalition
on Disability and Aging. The Coalition, comprised of twenty-
eight national aging and disability organizations, seeks to
focus national attention on the common concerns of aging and
disability constituencies. As a result of this linkage,
collaboration was enhanced between the disability and aging
communities, particularly with respect to home and community-
based services. Examples of collaborative efforts included:
Funding projects to provide information and technical
assistance on consumer-directed services; building
model partnerships between communities; fostering
involvement of home and community-based consumers in
systems development; and coordinating with agencies
that serve persons with developmental disabilities;
Provided joint funding with the HHS Office of the
Assistant Secretary for Planning and Evaluation for the
National Institute on Consumer-Directed Home and
Community-Based Care Systems to foster increased
opportunities for consumer choice and direction in
systems and services for adults with disabilities;
Renewed an informal partnership with the National
Easter Seal Society designed to call greater attention
to the needs of individuals who suffer from post-polio
syndrome, the long-term impact of which mirrors an
accelerated aging process.
Documenting value of aging network in human terms
The approval of the National Aging Program Information
System State Program Report (SPR) by the Office of Management
and Budget represents a successful conclusion to over four
years of cooperative work between AoA and all levels of the
aging network. The Congressionally-mandated SPR is a
comprehensive and coordinated information and reporting system
designed to provide data primarily on clients, services and
costs of the programs provided to the elderly under the Act.
The new state reporting requirements will replace a report
having up to 30 categories of services with a report of no more
than 15 categories of services, while at the same time
providing more in-depth data on client characteristics. The
reporting system, which includes electronic submission of
reports to AoA, is an important step in enhancing the
capacities of the aging network at all levels to utilize the
data in support of policy development, program enhancement, and
advocacy. Note that Appendix VII includes Executive Summary of
the State Program Report for fiscal year 1995.
Section III--Planning for the Future
Preparing for the needs of a growing aging population
An Initiative on Redefining Retirement resulted in a
variety of efforts designed to lay the foundation for changing
behaviors, attitudes and choices about planning for the future.
This Initiative sought to educate and motivate baby boomers to
make thoughtful choices now so that they will be more likely to
be financially secure, productive, healthy and socially
involved in their later years. Some examples of these efforts
include:
Initiated the National Planning Objectives Project
which brought together for the first time various
leaders of the public and private sector to explore and
initiate a process for setting national planning
objectives for an aging society;
Established mechanisms for policy dialogue at the
national, state and local level by funding the National
Academy on Aging to serve as a resource for objective
information on broad policy issues;
Provided funding to the Council of Governor's Policy
Advisors to work with states to help them better
understand the implications of an aging population for
state policymaking;
Established partnerships with other federal agencies
such as the Social Security Administration and the
Department of Labor; and
Cosponsored a publication produced by the
Metropolitan Life Insurance Company which provides tips
on how to enjoy one's retirement.
Improving service delivery to Hispanic elders
The Assistant Secretary for Aging co-chaired the HHS
Working Group on Hispanic Issues which worked to improve the
delivery of services to Hispanic customers. The working group
prepared a final report and recommendations for the Secretary
on strategies for improving services to Hispanic Americans.
Through the Eldercare Locator, a nationwide information and
referral service funded by AoA, assistance is being made
available in Spanish and the Locator is beginning an outreach
campaign to inform the Hispanic community about this important
service. A Spanish language brochure and advertisements have
been developed.
Improving service delivery to American indians, Alaskan Natives, and
native Hawaiians
To understand and respond to the home and community-based
long-term care needs of American Indians and Alaskan Natives
better, a survey of home and community-based long-term care in
American Indian and Alaskan Native communities was completed.
The Executive Summary from the report appears in Appendix VIII.
The AoA convened the Fourth American Indian, Alaskan
Native, and Native Hawaiian Elders Roundtable in Washington,
D.C. The focus was on home and community-based long-term care
in Native American communities.
Grants totaling $16,057,000 were awarded to 221 ITO's and
one Native Hawaiian organization for providing nutrition and
supportive services to elders. A summary of the program
performance data is contained in Appendix IX.
The Third Annual National Title VI Training and Technical
Assistance Meeting was held in Denver, Colorado. The focus was
on ``Aging with Honor'' and included training on preventive
health care, elder rights and abuse, and coordination of
program resources.
The University of Colorado at Denver and the University of
North Dakota at Grand Forks were awarded cooperative agreements
by AoA totaling approximately $500,000 to establish National
Resource Centers for Older Indians, Alaskan Natives and Native
Hawaiians. The primary focus of both centers is health,
community-based long-term care and related issues. The Centers
are the focal points for the development and sharing of
technical information and expertise to ITO's, Title VI
grantees, Native American communities, educational
institutions, and professionals and paraprofessionals in the
field.
The Federal Interagency Task Force on Older Indians which
facilitates coordination among federally-funded programs to
improve services to older Indians focused on three areas of
concern to older Indians during fiscal year 1996: health,
transportation, and data. The Task Force will make
recommendations to further interagency collaboration and
enhance services to older Indians, and highlight problems,
issues and/or barriers that prevent or diminish collaboration.
Working to improve the quality of life for older women
The AoA participated in a variety of collaborative efforts
designed to improve the quality of life for older women:
Launching the ``Pensions Not Posies Campaign''--a
public education effort developed by the Pension Policy
Consortium to inform women about the importance of
pensions and future planning;
Convening a roundtable entitled ``Grass Roots
Innovations for Older Women's Employment'' in
collaboration with the Pension Rights Center. The forum
highlighted innovative mechanisms at the state and
local level for assisting women to overcome barriers to
employment in areas of job training, caregiving and
pensions; and
Working with HHS Secretary Donna Shalala's work group
to prepare for the 39th Session of the United Nations'
Commission on the Status of Women; the Beijing Task
Force which focused on implementation of
recommendations adopted by the 4th World Conference on
Women; and the National Action Plan on Breast Cancer
Federal Coordinating Committee.
The National Policy and Resource Center on Women and Aging,
established by AoA to provide a national focal point for
coordinating efforts to educate older women at a grassroots/
local level, convened a National Conference on Women and Aging
in conjunction with the Office of Women's Health in HHS. The
Center published a monthly newsletter focused on critical
issues impacting older women, as well as numerous pamphlets and
reports on topics of interest to women including hormone
replacement therapy, caregiving, housing, health care and
economic security.
Section V--Expanding International Partnerships
Established cooperative efforts with Mexico and China
The AoA worked to establish stronger partnerships between
Mexico, China and the United States in preparing for the
growing numbers of older persons in their honored countries and
to elevate aging matters as a priority issue of mutual concern.
The Assistant Secretary for Aging was a keynote speaker at
the International Symposium of Geriatrics and Gerontology, held
in Guadalajara, Mexico.
Provided briefings for foreign officials
In fiscal year 1996, the AoA held a number of briefings for
visiting officials, including those from China, Japan, France,
Mexico, Uruguary, Latvia, Korea, Taiwan, Turkey, Argentina and
the Slovak Republic.
Provided international training and technical assistance
A Memorandum of Understanding between AoA and Sister Cities
International resulted in joining aging professionals and
volunteers in the United States with their counterparts in
other countries to provide technical assistance in meeting the
needs of an aging population.
With the cooperation of the U.S. Information Agency's
Individual Visitor Program and the National Personnel Authority
in Japan, the AoA also mentored two officials from the Japanese
Ministry of Health and Welfare who studied health care reform
and aging in the U.S.
Section I--The National Aging Service Network
Section II--FY 1995 and FY 1996 Budget Tables and Charts
Section III--Summary Report of the Institute of Medicine's ``Real
People, Real Problems: An Evaluation of the Long-Term Care Ombudsman
Programs of the Older Americans Act''
Section IV--Long-Term Care Ombudsman Annual Report Fiscal Year 1995
(Executive Summary Introduction and Summary)
Section V--``Serving Elders At Risk,'' the National Evaluation of the
Elderly Nutrition Program (Executive Summary)
Section VI--Office of Inspector General
Section VII--State Program Report (Executive Summary), Fiscal Year 1995
Section VIII--Home and Community-Based Long-Term Care in American
Indian and Alaska Native Communities (Executive Summary)
Section IX--Native American Elders Report, Covering 1991-1995
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.
Under the SSBG, Federal funds are available without a
matching requirement. In fiscal year 1995, a total of $2.8
billion was allotted to States. $2.381 billion was appropriated
for these activities in fiscal year 1996. 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, chore 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 1995, the list below indicates
the number of States providing certain types of services to the
aged under the SSBG.
Number of States \1\
Services:
Home-Based Services \2\....................................... 45
Adult Protective Services..................................... 35
Transportation Services....................................... 29
Adult Day Care................................................ 29
Health Related Services....................................... 21
Information and Referral...................................... 27
Home Delivered/Congregate Meals............................... 22
Adult Foster Care............................................. 15
Housing....................................................... 12
\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. Based on the FY 95 data, 35 States provided 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 also 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
one of six block grant programs administered within the
Department of Health and Human Services (HHS). LIHEAP is
administered by the Office of Community Services (OCS) in the
Administration for Children and Families.
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
Augustus F. Hawkins Human Services Reauthorization Act of 1990,
the NIH Revitalization Act of 1993 (P.L. 103-43), and the Human
Services Amendments of 1994 (P.L. 103-252). In fiscal year
1989, Congress appropriated $1.383 billion for the program.
Congress appropriated $1.443 billion for LIHEAP in fiscal year
1990, which included $50 million in supplemental
appropriations. In fiscal year 1991, Congress appropriated
$1.415 billion plus a contingency fund of $195 million, which
went into effect when fuel oil prices went above a certain
level. For FY 1992, $1.5 billion was appropriated, plus a
contingency fund of $300 million that would have been triggered
if the President had declared an emergency and had requested
the funds from Congress. Congress appropriated funding of
$1,346,029,877 for FY 1993, plus a contingency fund of
$595,200,000 that would have been triggered if the President
had declared an emergency and had requested the funds from
Congress. For FY 1994, Congress appropriated $1,437,408,000, of
which $141,950,240 could be used by grantees to reimburse
themselves for FY 1993 expenses. In addition, Congress
rescinded some funds and appropriated energy emergency
contingency funds of $300,000,000, which were released when the
President declared an emergency and requested the funds from
Congress, thus providing a total of $1,737,392,360 for FY 1994.
The FY 1994 appropriations act provided advance FY 1995 funds
of $1.475 billion. The FY 1995 HHS appropriations act rescinded
part of the advance FY 1995 appropriations included in the FY
1994 appropriations law, leaving funding of $1,319,202,479 for
FY 1995. In addition, Congress appropriated energy emergency
contingency funds of $300,000,000, of which $100 million were
released when the President declared an emergency and requested
the funds from Congress, thus providing a total of
$1,419,202,479 for FY 1995. The FY 1995 HHS appropriations law
also provided for advance FY 1996 funding of $1,319,204,000.
Congress rescinded part of the advance funding for FY 1996 in
the FY 1995 supplemental appropriations law and in the FY 1996
appropriations law, leaving funding of $899,997,500. In
addition, Congress appropriated energy emergency contingency
funds of $300,000,000, of which $180 million were released when
the President declared an emergency and requested the funds
from Congress, thus providing a total of $1,079,997,500 for FY
1996. Congress did not appropriate in advance for FY 1997.
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.\1\ Most households in which one or more persons
are receiving Aid to Families with Dependent Children,
Supplemental Security Income, Food Stamps or need-tested
veterans' benefits may be regarded as categorically eligible
for LIHEAP.
---------------------------------------------------------------------------
\1\ 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 1995, about 34 percent of households
receiving assistance with heating costs included at least one
person age 60 or over, as estimated by the March 1995 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.
No major program and policy changes for the elderly
occurred in the 1990 or 1993 reauthorization legislation. The
1994 reauthorization legislation specifically allows grantees
to target funds to vulnerable populations, mentioning by name
``frail older individuals'' and ``individuals with
disabilities''. No new initiatives commenced in 1995 or 1996
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 (Subtitle B, Public Law 97-35 as amended) is
authorized through fiscal year 1998. 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 1995 and 1996--The Office of Community Services
made no major changes in program or policy related to the CSBG
program in 1995 or 1996. 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 1994 requires local community action agencies to include a
description of how linkages will be developed to fill
identified gaps in services through information, referral, case
management, and followup 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 $389.6 million in fiscal year 1995. For fiscal year 1996,
$389.5975 million was appropriated.
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: 7/1/90-6/30/96, FY '90-$90,000, FY '91-
$90,000, FY '92-$90,000, FY '93-$90,000, FY '94-$90,000, FY
'95-$99,000, FY '96-$72,364.
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: 7/1/90-6/30/96, FY '90-$90,000, FY '91-
$90,000, FY '92-$90,000, FY '93-$90,000, FY '94-$90,000, FY
'95-$99,000, FY '96-$72,364.
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: 7/1/90-6/30/96, FY '91-$90,000, FY '92-
$90,000, FY '93-$90,000, FY '94-$90,000, FY '95-$99,000, FY
'96-$72,364.
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.
training models for rural areas
Grantee: Montana University Affiliated Rural Institute on
Disabilities, Missoula, MT.
Project Director: Philip Wittekiend, M.S., (406) 243-5467;
Fax (406) 243-2349.
Project Period: 7/1/90-6/30/96, FY '90-$90,000, FY '91-
$90,000, FY '92-$90,000, FY '93-$90,000, FY '94-$90,000, FY
'95-$99,000, FY '96-$72,364.
Montana's focus is on linking exiting networks and
expertise to meet the unique needs of a rural area with sparse
populations and limited professional resources. The project
will develop audio conference packages with simultaneous long
distance training for remote areas and involve nontraditional
networks such as churches and senior groups.
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: 7/1/90-6/30/96, FY '90-$90,000, FY '91-
$90,000, FY '92-$90,000, FY '93-$90,000, FY '94-$90,000, FY
'95-$99,000, FY '96-$72,364.
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.
aging and developmental disabilities clinical assessment, training and
service
Grantee: Waisman Center UAP, University of Wisconsin-
Madison.
Project Director: Gary B. Seltzer, Ph.D. (608) 263-1472;
Fax (608) 263-0529.
Project Period: 7/1/90-6/30/96, FY '90-$90,000, FY '91-
$90,000, FY '92-$90,000, FY '93-$90,000, FY '94-$90,000, FY
'95-$99,000, FY '96-$72,364.
Waisman Center operates an interdisciplinary clinic,
provides training to health care and other professionals, and
disseminates information and technical assistance to director
care networks. Materials include a functional assessment
instrument and curricula for medical students, geriatric
fellows and physician assistants.
interdisciplinary training models (idt)
Grantee: UAP, College of Family and Consumer and Consumer
Sciences.
Project Director: Zolinda Stoneman, Ph.D., (404) 542-4827;
Fax (404) 542-4815.
Project Period: 7/1/90-6/30/96, FY '91-$90,000, FY '92-
$90,000, FY '93-$90,000, FY '94-$90,000, FY '95-$99,000, FY
'96-$72,364.
This project is using IDT models for graduate and
undergraduate training, developing community-based internship
and practicum sites; collecting audiovisual materials for
dissemination; and providing information to the UAP regional
information and referral service. Products will include
training videotapes and modules, course materials, and radio
program recordings.
training initiative in aging and developmental disabilities
Grantee: Institute for the Study of Developmental
Disabilities, University of Illinois at Chicago.
Project Director: David Braddock, Ph.D., (312)-413-1647.
Project Period: 7/1/93-6/30/96, FY '93-$90,000, FY '94-
$90,000, FY '95-$99,000, FY '96-$72,364.
The project addresses three priority areas emerging from
the UAP's research activities and clinical programs: (1)
advocacy and futures planning for older adults with
developmental disabilities and their families; (2) to maintain
functioning and promote community inclusion for aging persons
with cerebral palsy; and (3) to enhance the psychosocial well-
being of aging persons with Down Syndrome and bolster older
families' caregiving efforts.
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: 7/1/92-6/30/96, FY '92-$89,999, FY '93-
$89,999, FY '94-$89,999, FY '95-$99,000, FY '96-$72,364.
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.
a collaborative interdisciplinary training approach to improve services
to aging persons with developmental disabilities
Grantee: Institute for Disability, University of Southern
Mississippi.
Project Director: Valerie M. De Coux, (601) 266-5163.
Project Period: 7/1/93-6/30/96, FY '93-$90,000, FY '94-
$90,000, FY '95-$99,000, FY '96-$72,364.
The project develops a collaborative interdisciplinary
training approach to meet pre-service, in-service, and consumer
needs. Training of professionals and paraprofessionals occurs
at both the pre-service and in-service levels and focuses on
cross-network training in best practices which ensures an
optimal quality of life for older persons with developmental
disabilities.
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: 7/1/93-6/30/96, FY '93-$90,000, FY '94-
$90,000, FY '95-$99,000, FY '96-$72,364.
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 consumer 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. 11453, (809) 754-4377.
Project Period: 8/2/94-6/30/97, FY '94-$90,000, FY '95-
$90,000, FY '96-$72,364, FY '97-$90,000.
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.
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 1995 and 1996, ASPE undertook or participated in the
following analytic and research activities which had a major
focus on the elderly.
1. policy development--aging
Task force and Alzheimer's disease
As a member of the DHHS Council on Alzheimer's Disease,
ASPE helps prepare the annual report to Congress on selected
aspects of caring for persons with Alzheimer's Disease. The
report focuses on the Department's current and planned services
and research initiatives on the disease.
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.
Departmental Data Planning and Analysis Work Group
The Data Planning and Analysis Work Group chaired by ASPE
analyzes Departmental data requirements and develops plans for
fostering the full utilization of such data. The Group
identifies needs for data within DHHS, evaluates the capacity
of current systems to meet these needs and prepares
recommendations for the effective performance of DHHS data
systems.
Long-term care microsimulation model
During 1995 and 1996, ASPE continued to use extensively the
Long-Term Care Financing Model developed by ICF and the
Brookings Institution. The model simulates the use and
financing of nursing home and home care services by a
nationally representative sample of elderly persons. It gives
the Department the capacity to simulate the effects of various
financing and organizational reform options on public and
private expenditures for long-term care services.
2. Research and Demonstration Projects
Panel Study of Income Dynamics
University of Michigan, Institute for Social Research--Principal
investigators: Sandra Hofferth, Frank Stafford
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 fathered 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--$200,000;
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--$300,000; FY96--$300,000;
FY97--$300,000.
End date: Ongoing.
Assets and health dynamics (AHEAD) of the oldest old
University of Michigan, Survey Research Center--Principal
investigators: Regula Herzog, U. Michigan, Beth Soldo,
Georgetown Univ.
Beginning in 1992 the Health and Retirement Survey, which
is funded principally by the National Institute in Aging, began
to follow a cohort of men and women aged 51 to 61 to track
various aspects of health status, retirement patterns and use
of health and other services.
The AHEAD survey is a companion to the HRS. It surveys a
nationally representative community sample of persons aged 70
and over. It was first fielded in 1993 and is administered
every two years longitudinally. AHEAD focuses on a variety of
key aging-related issues, such as health and functional status,
family structure and transfers, income and wealth; health
insurance; and work activities. In 1994, ASPE funded an Early
Results Workshop at the University of Michigan, at which a
number of papers were presented using AHEAD data. The workshop
papers subsequently became the basis for a Special Issue of the
Journal of Gerontology: Psychological and Social Sciences (May
1997) on AHEAD.
Funding: FY94--$30,000 (for Early Results Workshop).
End date: September 1994.
Analysis of State Board and Care Regulations and Their Effects on the
Quality of Care
Research Triangle Institute--Principal investigator: Catherine Hawes
As the nation's long-term care system evolves, more
emphasis is being placed on home and community-based care as an
alternative to institutional care. Community-based living
arrangements for dependent populations (disabled elderly,
mentally ill, persons with mental retardation/developmental
disabilities) play a major role in the continuum of long-term
care and disability-related services. Prominent among these
arrangements are board and care homes. There is a widespread
perception in the Congress and elsewhere that too often board
and care home residents are the victims of unsafe and
unsanitary living conditions, abuse and neglect by operators,
and fraud.
This project analyzed the impact of State regulations on
the quality of care in board and care homes in ten States and
documented the characteristics of board and care facilities,
their owners and operators, and collect information on the
health status, level of dependency, program participation and
service needs of residents. Key findings were the B&C residents
are significantly older and more frail than was true a decade
ago. Appropriate regulation and licensure requirements result
in homes that are better prepared to meet the needs of the
resident population. Thee include: (1) greater availability of
supportive services (2) lower use of psychotropic drugs and
medications and (3) more operator training in the care of the
frail elderly and other persons with disabilities.
Funding: FY 1989--$350,000; FY 1990--$300,000; FY 1991--
$400,000.
End date: September 1995.
Evaluation of the Elderly Nutrition Program
Mathematica Policy Research--Principal investigator: Michael Ponza
At the request of Congress (Section 206 of the 1992 Older
Americans Act Amendments), the Department of Health and Human
Services in conducting an evaluation of the Elderly Nutrition
Program. The evaluation, which is co-sponsored by ASPE and the
Administration on Aging, provided estimates of the impact of
the program's nutritional components on the nutrition, health,
functioning, and social well being of participants. It
described how the program is administered, operated and funded,
and the effectiveness of those components. The study also
described and compared the characteristics of congregate and
home-delivered meal participants, and assessed how well the
program reached special populations, such as low-income and
minority elderly. The study covered 57 State Units on Aging,
250 Area Agencies on Aging, 100 Indian Tribal Organizations and
200 Nutrition Projects. The key findings were that people who
participated in the Elderly Nutrition Program have higher daily
intake of key nutrients than similar nonparticipants, that
participants have more social contacts per month than similar
nonparticipants and that most participant are satisfied with
ENP services.
Funding: FY 1993--$1,200,000; FY 1994--$1,245,000.
End date: September 1995.
A national study of assisted living for the frail elderly
Research Triangle Institute--Principal investigator: Catherine Hawes
ASPE has commissioned a national study of assisted living.
Assisted living refers to residential settings that combine
housing, personal assistance and other supportive service
arrangements for persons with disabilities. These settings are
thought to offer greater autonomy and control to consumers over
their living and service arrangements than is typically
provided by more traditional residential settings, such as
nursing homes or board and care homes. The study will focus on
such issues as (a) trends the supply of assisted living
facilities, (b) barriers to development (c) the existing
regulatory structure, (d) the extent to which assisted living
embodies in reality the principles of consumer autonomy and
choice in a supportive residential setting, and (e) the effect
of such features (or their absence) on persons who live and
work in assisted living facilities. The study will include data
from owner/operators, staff and residents from a national
sample of 690 assisted living facilities.
Funding: FY94-$200,000; FY 96-$200,000.
End date: July 1999.
Creating a multistate database for dual eligibles
Mathematica Policy Research (MPR)--Principal investigator: Sue Dodds
There has been growing interest in the service utilization
and expenditure patterns of individuals enrolled in both
Medicare and Medicaid (i.e., dual eligibles). In order to
provide important data on these populations, two ASPE offices
(HP and DALTCP) collaborate with HCFA to fund a project that
will link Medicare and Medicaid data in 10-12 states. This is
an effort to develop a uniform database that can be utilized by
both States and the Federal Government to improve the
efficiency and effectiveness of both acute and long-term care
services provided to these populations. More specifically, the
project strengthens the ability of HHS and States to develop
effective risk-adjusted payment methods for dual eligibles, and
further understanding of how interactions between the Medicare
and Medicaid programs affect the access, costs and quality of
services received by dually eligible beneficiaries.
Funding information: FY 97--$1,024,000 (ASPS funds--
$350,000)
End date: Fall 2000
Impact of Medicare HMO Enrollment on health care costs in California
RAND--Principal investigator: Glenn Melnick
This work is an extension of previous APSE--funded work.
The contractor performs three major activities including: (1)
updating the earlier analysis of competition and selective
contracting in California to the most recent year available;
(2) analyzing the effects of Medicare managed care penetration
on hospital Medicare Costs and Utilization at the county level;
and (3) analyzing the effects on beneficiary utilization and
costs of joining managed care plans. In addition, the
feasibility of conducting a fourth analysis will be assessed;
namely to replicate analysis number three for beneficiaries who
have withdrawn from Medicare managed care plans in the recent
past to try to see if such beneficiaries are different from
those who remain in managed care. The contractor will put out a
public use file with documentation of the materials gathered
since 1980 with ASPE support beginning in 1987.
The project builds upon previous ASPE-funded work. It
compares pre-managed care enrollment characteristics, service
utilization, and costs among demographically-matched
individuals in standard Medicare and Medicare HMOs. In
addition, the project includes comparisons with a third group
of persons who disenrolled from Medicare HMOs. This data will
then be used to build prediction models for subsequent years.
Funding: FY 94--$531,000; FY 97--$160,000.
End date: Fall 1998.
SENATE SPECIAL COMMITTEE ON AGING'S ANNUAL REPORT--CDC UPDATE FOR 1995
AND 1996
(1) National Center for Chronic Disease Prevention and Health Promotion
(NCCDPHP)
In the paragraph regarding Quality-of-Life, page 175,
please change ``1993'' to ``1993-1996'' (with respect to
BRFSS).
There are about three paragraphs of program-specific
language at the end of the report, regarding Diabetes and
Breast and Cervical Cancer.
(2) National Center for Environmental Health
The following programs should be added to update the
information for 1995-1996:
The National Center For Environmental Health (NCEH) has
collaborated in a study of 180 women to determine risk factors
for osteoporosis, including vitamin D receptor polymorphisms.
NCEH has spearheaded the establishment of the Cholesterol
Reference Method Laboratory Network (CRMLN) that helps assure
the quality of total cholesterol and HDL cholesterol
measurements in clinical laboratories in the United States.
High quality cholesterol measurements assure correct diagnosis
and treatment of elevated cholesterol levels.
The Office on Disability and Health (ODH) at NCEH is
collaborating with the NCCDPHP in two activities that relate to
the process of aging. First, ODH is partnering with the Health
Care and Aging Branch in the Johnston County Osteoarthritis
Longitudinal Study to describe the epidemiology of secondary
conditions in persons with hip and knee osteoarthritis that
result in functional limitation and disability.
Second, ODH provides technical assistance to disability
related activities within the University of Washington Center
for Health Promotion in Older Adults, A NCCDPHP Prevention
Research Center. Aims of this prevention center related to
disabilities include (a) implementing community-wide elderly
chronic disease and disability reduction efforts under the
auspices of a public health department; (b) design and evaluate
strategies for recruiting people with disabilities to
participate in health promotion interventions; (c) develop
measures of attitudes, behaviors, performance, and health
related quality of life for persons with disabilities; and (d)
develop a method to evaluate prevention effectiveness for
interventions on disability.
(3) National Center for Health Statistics
The following changes and additions should be made for
1995-1996 (The Section for NCHS begins on p. 177):
International Collaborative Effort on Measuring the Health
and Health Care of the Aging
Page 178 top of the page--
Strike ``Health Promotion and Disease Prevention Among the
Aged: USA and the Netherlands,'' and add ``and'' to the end of
the last phrase on p. 177.
1st full paragraph on p. 178, 2nd sentence should read: A
third and final international symposium was held in 1996 to
present final research results and address issues of
implementation. Proceedings will be published.
3rd sentence fine. Add to publications:
LTC In Five Nations, Canadian Journal on Aging, Vol.
15, Suppl. 1, 1996. The journal issue contains
individual articles about LTC in Australia, Canada, The
Netherlands, Norway, and the U.S. Articles on LTC in
the U.S. include one on institutional care by J. Van
Nostrand and another on home care by R. Clark.
E. Bacon, S. Maggi, A Looker, et al, International
Comparisons of Hip Fracture Rates in 1988-89,
Osteoporosis International, Vol. 6, pp. 69-75, 1996
Last paragraph, last sentence, strike ``NCHS Coordinator of
Data on Aging'' replace with: Project Director, ICE on Aging, *
* * Room 1100, * * * 20782 * * * (301) 436-7062.
Federal Interagency Forum on Aging-Related Statistics
Second paragraph, strike to end of section and replace
with:
In 1995-96, the Forum produced the following publications:
Trends in the Health of Older Americans: United
States, 1994 Vital Health Statistics 3(30), 1995.
a bibliography, Health of an Aging America: 1994
Bibliography, guide to Reports About Older Americans
from the National Center for Health Statistics.
Policy for Aging over the Next Decade: Priority Data
Needs for Health and Long Term Care
Summary of Data Sources on Alzheimer's Disease and
Related Dementia from the National Center for Health
Statistics
Measuring Cognitive Impairment in Population-Based Surveys
Replace with the following:
A Work Group has been established by the Federal
Interagency Forum on Aging-Related Statistics with the task of
strengthening the measurement of cognitive impairment in
national, population-based surveys. This activity builds on the
previous work of the Forum in developing research
recommendations for strengthening assessment of cognitive
impairment. Specific activities for 1995-96 were to: (1)
identify the state-of-the-art in measuring cognitive impairment
of the elderly in national surveys, and (2) implement a
research agenda for strengthening its measurement in national
surveys. Results of the research activity include:
B. Gurland, D. Wilder, et al, A flexible system of
detection for Alzheimer's Disease and related
dementias, Aging: Clinical and Experimental Research,
Vol. 7, No. 3, pp. 165-172, 1995.
R. Herzog, ``Approaches to Measuring Cognitive
Functioning in Large Scale Surveys: Review of the
Literature and Analysis of Data form the Assets and
Health Dynamics Among the Oldest-Old Survey, Occasional
Paper of the Forum.
National Mortality Followback Survey: 1986 and 1993
Replace paragraph 4 with:
The 1993 Survey is comprised of a nationally
representative sample of approximately 23,000 decedents
15 years of age or over who died in 1993, with over-
sampling of some groups including black decedents,
females, persons under 35 years, and centenarians. The
design parallels that of the 1986 survey, with
additional emphasis on deaths due to external causes,
that is, accidents, homicides, and suicides, as well as
disability in the last year of life. Hospital records
are not included in the 1993 survey, but medical
examiner/coroner records are included. A preliminary
file is planned for release to the public in February
1998, and a final file containing the medical examiner/
coroner information will be released later in 1998.
National Health Interview (NHIS): Special Topics
Insert the word ``Survey'' after Interview in the section
title above.
Paragraph 1--after 1st sentence revise to read: Data
collection has been completed for the special health topics on
disabilities. The disability topic had two phases. The first
phase questionnaire identified persons with disabilities. The
second phase collected detailed * * *.
Change the beginning of the next 2 paragraphs to read:
Disability Phase 1 included questions on: sensory, *
* *
Disability Phase 2 included questions on: housing * *
*
Add to the end of the last paragraph: The first year of the
Phase I Disability file was released in 1996. The remainder of
the Disability files will be released in 1998.
Note: Reverse the order of the next 2 sections placing the
SOA II writeup after the LSOA writeup.
Longitudinal Study of Aging
Replace the entire section with the following:
The Longitudinal Study of Aging (LSOA) is a
collaborative effort of the National Center for Health
Statistics and the National Institute on Aging. The
baseline information for the LSOA came from the
Supplemental on Aging (SOA), a supplemental to the 1984
National Health Interview Survey (NHIS).
The SOA is comprised of a nationally representative
sample of 16,148 civilians 55 years of age and over
living in the community at the time of the 1984 NIHS.
The Supplement obtained data on the health of older
Americans, information on housing, including barriers
and ownership; social and familial support, including
number and proximity of children and recent contacts in
the community; retirement, including reasons for
retirement and sources of retirement income; and
physical functioning measures, including activities of
daily living, instrumental activities of daily living,
and work-related activities.
The sample for the LSOA is comprised of the 7,527
persons who were 70 years of age and over at the time
of the SOA. The survey was designed to measure changes
in functional status and living arrangements, including
institutionalization, as persons moved into and through
the oldest ages. The baseline SOA interviews were
conducted in-person. Follow up reinterviews, conducted
in 1986, 1988 and 1990, were conducted by telephone
using Computer Assisted Telephone Interviewing (CATI).
In addition to the interview data, permission was
obtained from sample persons or their proxies to match
interview data with other records maintained by the
Department of Health and Human Services.
The fourth version of the LSOA public-use data was
released in October, 1991. The Version 4 files are
available on magnetic tape and include the following
information: all four waves of interview data (1984,
1986, 1988, 1990), National Death Index data (1984-
1989), and Medicare records data (1984-1989. A diskette
containing detailed multiple cause-of-death data for
the LSOA sample is available. The fifth version of the
LSOA public-use data, released in September, 1993, is
available on CD-ROM. This version includes all
interview data available in Version 4 and updates the
administrative data through 1991.
The LSOA public-use datasets are available from three
sources: The National Technical Information Service
(NTIS), the Division of Health Interview Statistics,
NCHS, and the National Archives of Computerized Data on
Aging. The multiple cause-of-death diskette is
available from NITS.
Second Supplement on Aging (SOA II)
Replace the entire section with the following:
From 1994-1996, the National Center for Health
Statistics conducted the Second Supplement on Aging
(SOA II) as part of the National Health Interview
Survey. Interviews were conducted with a nationally
representative sample of 9,447 civilian
noninstitutionalized Americans 70 years of age and
over. The study will provide important data on the
elderly that can be compared with similar data from the
1984 SOA. In addition, the SOA II will serve as a
baseline for the Second Longitudinal Study of Aging
(LSOA II), which will follow the baseline cohort
through one or more reinterview waves.
Information for the SOA II comes from several
sources: the 1994 NHIS core questionnaire, Phase 1 of
the National Health Interview Survey on Disability
(NHIS-D), and Phase 2 of the NHIS-D, conducted
approximately one year after Phase 1. The survey
questions and methodology are similar to the first
LSOA, but improvements reflect a number of
methodological and conceptual developments that have
occurred in the decade between the LSOA and LSOA II, as
well as suggestions made by users of the LSOA and
others in the research community.
A primary objective of the SOA II is to examine
changes which may have occurred in the physical
functioning and health status of the elderly over the
past decade. To this end, questions concerning physical
functioning and health status and their correlates were
repeated in the SOA 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 SOA II
questionnaire was 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.
These data, when used in conjunction with data from
the LSOA, will enables users 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 researchers and
policy planners with an opportunity to examine trends
and determinants of ``healthy aging.''
National Health and Nutrition Examination Survey III
Replace the entire section with the following:
The National Health and Nutrition Examination Survey
(NHANES) provides valuable information available through direct
physical examinations of a representative sample of the
population. The most recently completed cycle of this survey,
NHANES III (1988-94), provides a unique data base for older
persons. A number of important methodologic changes were made
in the survey design. There was no upper age limit, (previous
surveys had an age limit of 74) and the sample was selected to
include approximately 1,300 persons 80 or older. Data for 1988-
94 will be released in 1997.
The focus of the survey included many of the chronic
diseases of aging that cause morbidity and mortality, including
cardiovascular disease, osteoarthritis, osteoporosis, pulmonary
disease, dental disease, and diabetes. Additional information
on diet and nutritional status and on social, cognitive, and
physical function was incorporated in the survey. An
abbreviated exam in the home was included for many of those
unable or unwilling to travel to the survey's mobile
examination center. A sampling of reports already produced from
the NHANES III information include:
Looker A, Johnson C, Wahner H, Dunn W, Calvo M,
Harris T, Heyse S, Lindsay R (1995): Prevalence of low
femoral bone density in older US women from NHANES III.
J Bone Mineral Research 10(5): 796-802.
Redford M, Drury TF, Kingman A, Brown LJ (1996):
Denture use and the technical quality of dental
prostheses among persons 18-74 years of age: United
States, 1988-1991. J Dent Res 75 (Spec Iss): 714-725.
Sempos CT, Johnson CL, Carroll MD, Briefel RR (1995):
Current levels and trends in serum total cholesterol in
the United States adults 65 years of age and older. The
NHANES. In: Nutritional Assessment of Elderly
Populations. Raven Press, New York, pp. 121-134.
Planning is underway for the survey to return to the field
in 1999. NHANES is to become a continuous program, with
changing focus on a variety of health and nutrition
measurements to meet emerging needs. Current plans are for a
continued emphasis on the health of older Americans, and
persons 60 and over will be over-sampled for the survey.
NHANES I Epidemiologic Follow up Study
Replace the entire section with the following:
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 reinterviews 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 followups of the NHEFS population were
conducted by telephone in 1986 (limited to persons age
55 and over at baseline), 1987, and 1992.
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.
National Health Care Survey (NHCS)
Replace with the following:
The National Health Care Survey (NHCS) is an integrated
family of surveys conducted by the National Center for Health
Statistics to provide annual national data describing the
Nation's use of health care services in ambulatory, hospital
and long-term care settings. Use of health care services by the
elderly may be investigated using NHCS data. Currently, the
NHCS includes six national probability sample surveys and one
inventory. These seven data collection activities include:
the National Hospital Discharge Survey--discharges
from non-Federal, short-stay and general hospitals;
the National Survey of Ambulatory Surgery--visits to
hospital-based and freestanding ambulatory surgery
centers;
the National Ambulatory Medical Care Survey--office
visits to non-Federal, office-based physicians;
the National Hospital Ambulatory Medical Care
Survey--visits to emergency and outpatient departments
of non-Federal, short-stay and general hospitals;
the National Health Provider Inventory--a national
listing of nursing homes, hospices, home health
agencies and licensed residential care facilities;
the National Home and Hospice Care Survey--hospices
and home health agencies and their patients; and
the National Nursing Home Survey--nursing homes and
their residents.
Details on specific surveys relevant to the elderly are
presented below by specific survey.
The following sections are recorded to match the order of
the indented items above.
National Hospital Discharge Survey
Replace with the following:
The National Hospital Discharge Survey (NHDS) is the
principal source of national information on inpatient
utilization of non-Federal, short-stay and general
hospitals. The NHDS was redesigned in 1988 as one of
the components of the National Health Care Survey. This
national sample survey collects data on the demographic
characteristics of patients, expected source of
payment, diagnoses, procedures, length of stay, and
selected hospital characteristics.
Data reports and public use data tapes are available
from 1970-1995. A multi-year data set covering the
years 1979-92 is also available from the National
Technical Information Service. Diskettes containing
tabulations published in the Series 13, Detailed
Diagnoses and Procedures Report, are available for
1985-94.
National Survey of Ambulatory Surgery (NSAS)
Replace with the following:
The National Survey of Ambulatory Surgery was
initiated in 1994 as an annual national survey to
provide data on patients and their treatment in
hospital-based and freestanding ambulatory surgery
centers. The NSAS was conducted in 1995-96. The NSAS
provides data on patient demographics, diagnoses and
procedures, anesthesia, source of payment, and facility
type.
Data from the 1994 and 1995 surveys have been
published in NCHS Advance Data and Series reports.
Public use data are available in electronic form from
the National Technical Information Service.
Insert new section:
National Ambulatory Medical Care Survey
The National Ambulatory Medical Care Survey (NAMCS) is a
national probability sample survey of office visits made by
ambulatory patients to non-Federal physicians, who are in
office-based practice, and who are primarily engaged in direct
patient care. Included are visits to physicians in solo,
partnership, and group practice settings, and visits that occur
in private non-hospital-based clinics and health maintenance
organizations. Excluded are visits to specialists in radiology,
anesthesiology, or pathology, and visits to physicians who are
principally engaged in teaching, research or administration.
Telephone contacts and non-office visits also are excluded.
The NAMCS provides information on office visits in terms of
patient, physician and visit characteristics. Data include:
patient demographics, the patient's reason for visit, type of
physician seen, physician's diagnoses, expected source of
payment, ambulatory surgical procedures, medication therapy,
disposition, and duration of the visit.
The NAMCS was conducted from 1973-81, in 1985, and has been
conducted annually from 1989-96. Data through 1996 have been
released in NCHS Advance Data and Series reports.
Public use data are available in electronic form from
the National Technical Information Service.
Insert new section:
National Hospital Ambulatory Medical Care Survey
The National Hospital Ambulatory Medical Care Survey
(NHAMCS) is a national probability sample survey of visits to
the emergency and outpatient departments of non-Federal, short-
stay and general hospitals. The NHAMCS was initiated in 1992
and has been conducted annually since that time. The survey
includes data on the demographic characteristics of the
patient, expected source of payment, patient's complaints,
physician's diagnoses, procedures, medication therapy,
disposition, and types of health professionals seen.
Data through 1996 have been released in NCHS Advance Data
and Series reports. Public use data are available in electronic
form from the National Technical Information Service.
National Health Provider Inventory (NHPI)
Replace with the following:
The National Health Provider Inventory, formerly
called the National Master Facility Inventory, was last
conducted in 1991. This mail survey includes the
following categories of health care providers; nursing
and related care home, licensed residential care
facilities, facilities for the mentally retarded, home
health agencies, and hospices. Data from the 1991 NHPI
was used to provide national statistics on the number,
type and geographic distribution of these health
providers and to serve as sampling frames for future
surveys in the Long-Term-Care component of the National
Health Care Survey. The NHPI public use data tapes are
available at the National Technical Information
Service.
National Home and Hospice Care Survey
Replace with the following:
The National Home and Hospice Care Survey (NHHCS) is
a national probability sample survey of home health and
hospice care agencies, and their patients. The NHHCS
was conducted annually from 1992-94 and in 1996.
Agencies providing home health and hospice care were
included in the survey without regard to licensure or
to certification status under Medicare and/or Medicaid.
Information about the agency was collected through
personal interviews with the administrator. Information
was collected on a sample of current patients and
discharged patients through personal interviews with
designated agency staff.
Data from the NHHCS may be used to examine the
relationships between utilization, services offered,
and charges for care, as well as provide national
baseline data about home health and hospice care
agencies, and their patients. Data through 1996 have
been released in NCHS Advance Data and Series reports.
An Advance Data report (based on data from the 1994
NHHCS) on the use of home health care by the elderly
has been published. Public use data are available in
electronic form from the National Technical Information
Service.
National Nursing Home Survey
Replace with the following:
During 1995, the National Center for Health
Statistics conducted the National Nursing Home Survey
(NNHS) to provide information about the residents in
nursing homes. The NNHS was conducted in 1973-74, in
1997, and again in 1985. The NNHS data are from two
perspectives--that of the provider and that of the
recipient of services. Data about the facilities
includes: size, ownership, Medicare/Medicaid
certification, and services provided. Data about the
residents include: demographic characteristics, marital
status, place of residence prior to admission, health
status and services received. Data from the 1995 survey
has been published. An Advance Data report (based on
data from the 1995 NNHS) on the use of nursing home
services by the elderly has been published. Public use
data tapes are available through the National Technical
Information Service. Plans call for the NNHS to be
fielded in 1997 and in 1999.
National Nursing Home Survey Follow up
Replace with the following:
The National Nursing Home Survey Follow up (NNHSF) is
a longitudinal study which follows the cohort of
current residents and discharged residents sampled from
the 1985 NNHS described above. The NNHSF builds on the
data collected from the 1985 NNHS by extending the
period of observation by approximately 5 years. Wave I
was conducted from August through December 1987, and
Wave II was conducted in the fall of 1988. Wave III
began in January of 1990 and continued through April.
The study was a collaborative project between NCHS,
HHS, and the National Institute on Aging (NIA). The
Follow up was funded primarily by NIA and was developed
and conducted by NCHS.
The NNHSF interviews were conducted using a computer-
assisted telephone interview system. Questions
concerning vital status, nursing home and hospital
utilization since the last contact, current living
arrangements, Medicare number, and sources of payment
were asked. Respondents included subjects, proxies, and
staff of nursing homes.
The NNHSF provides data on the flow of persons in and
out of long-term care facilities and hospitals. These
utilization patterns can be examined in relation to
information on the resident, the nursing home, and the
community. Public-use computer tapes for Waves I, II,
and III of the NNHSF are available through the National
Technical Information Services (NTIS). In addition, the
National Nursing Home Survey Follow up Mortality Data
Tape, 1984-1990 is also available through NTIS.
National Employer Health Insurance Survey (NEHIS)
Replace with the following:
The National Employer Health Insurance Survey was
jointly conducted by the National Center for Health
Statistics, the Health Care Financing Administration,
and the Agency for Health Care Policy and Research in
1994 to provide data necessary to produce national and
State level estimates of total employer sponsored
private health care insurance premiums, the employer
and employee premium share, the total amount of
benefits provided, and the administrative cost. In
addition to the number of workers, retirees, and former
workers covered, the survey provides the breadth of
policy benefits and the number and characteristics of
plans in each establishment.
The NEHIS was conducted in all 50 States and the
District of Columbia. Computer assisted telephone
interviews were completed for approximately 39,000
business establishments, sampled from several size
categories. Data will be released to the public in the
form of published reports and electronic data products.
The estimates will be used to investigate the
geographic variations in spending for health care and
the probable differential impacts that proposed health
policy initiatives will have by State. As the private
sector, State and Federal Governments develop and
implement reforms of the health care system, there are
likely to be major changes in the extent and form of
private health insurance coverage, benefits, and
premium sharing. No discussion of the impact of the
reform upon business and individuals can be complete
without analysis of these changes. Over the past
several years, the task of producing national private
health insurance premiums and benefit estimates has
increased in difficulty as the industry has become more
complex. Simultaneously, the importance of accurate
health care costs estimates has increased as the
pressure or burden of health care costs have mounted on
the primary health care payers such as government,
business and households and as initiatives to contain
cost growth have been discussed and implemented
Replace title ``Improving Questions on Functional
Limitations'' with new title ``The Questionnaire Design
Research Laboratory'' and replace text with following:
Testing of cognitive functioning question.--In 1996,
NCHS collaborated with the Survey Research Laboratory
of the University of Illinois to test a variety of
questions dealing with cognitive functioning in persons
age 70 or older. Methods used in this investigation
included a focus group and face-to-face and telephone
cognitive interviews. The study found that when testing
cognitive functioning and memory in a survey
environment, questions of various types should be
asked. These include subjective memory appraisals,
current behaviors, and short-term memory tests. Any
single question or type of question may be confounded
with measurement problems, social desirability issues,
and other physical problems.
Results will be presented at the Conference on
Cognition, Aging, and Survey Measurement, February 8,
1997, Ann Arbor, Michigan. Study results are also
forthcoming in O'Rourke, D., Sudman, S., Johnson, T., &
Burris, J., ``Cognitive testing of cognitive
functioning question'', in N. Schwarz, D. Park, B.
Knauper, & S. Sudman (Eds.), Aging, cognition, and
self-reports. Washington, DC: Psychology Press.
Improving our understanding of responses to health
status and quality of life questions.--This study
investigated issues related to question interpretation,
strategies used by respondents, and adequacy of
response scales for health status measures currently
used in the Behavioral Risk Factor Surveillance System.
Cognitive interviews were conducted with 18 subjects 70
years of age or older and 30 subjects under the age of
70; a field experiment was also conducted to validate
laboratory findings. Results indicated that elderly
respondents may have difficulty providing responses to
survey questions that ask for reports of number of days
(e.g., ``...how many days during the past 30 days was
your physical health not good?'') Ease or difficulty of
formulating a response may depend on the complexity of
the pattern of health status that represents the
person's life. Because elderly people are more likely
to have complex health patterns, it may be that their
difficulty derives not from cognitive processes
associated with aging, but rather with measurement
problems inherent in assessing quality of life for this
age group.
Results will be presented at the Conference on
Cognition, Aging, and Survey Measurement, February 8,
1997, Ann Arbor, Michigan. Study results are also
forthcoming in Schechter, S., Beatty, P., and Willis,
G. ``Asking survey respondents about health status:
Judgement and response issues'', in N. Schwarz, D.
Park, B. Knauper, & S. Sudman (Eds.), Aging, cognition,
and self-reports. Washington, DC: Psychology Press.
Cognitive Laboratory Testing of Cognitive Functioning
Questions.--The Questionnaire Design Research
Laboratory conducted two rounds of testing with senior
respondents during the summer of 1996 in collaboration
with the staff of LSOA II. The LSOA II staff has been
directed by the funding agency (NIA) to produce a
survey that combined questions from earlier surveys of
aging in order to bring consensus to the results. The
goal of the lab testing was to conduct validity and
reliability research on the modules as the
questionnaire was developed, by testing the adequacy
and suggesting improvements to the questions which had
been removed from their contextual framework in the
earlier surveys.
(4) National Center for Infectious Disease
Paragraph 4
Line A--delete ``80-90'' and insert ``about 60''
Lines 8 & 9--delete the phrase ``however, the benefits to
the population, and to society in general, would significantly
increase with a more effective vaccine.''
Paragraph 5
Line 2--Change 20 to 15
Line 5--After ``antiviral drugs.'' Add the sentence:
``Respiratory syncytial virus vaccines are being evaluated for
use by the elderly population.''
Corrected paragraph should read:
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 be treated with antiviral drugs.
Respiratory syncytial virus vaccines are being
evaluated for use by the elderly population.
Consequently, it is important to define the role of
these viruses and risk factors for these infections
amongthe elderly population. CDC is completing a
collaborative investigation of RSV, the parainfluenza viruses, and
adenovirus infections associated with lower respiratory tract
infections among hospitalized adults to determine the proportion caused
by these viruses and associated risk factors.
Paragraph 8
Line 3--After ``with diarrhea in the United States.'' Add
the sentence: ``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 but the
diagnostic tests needed for confirmation are now in rapid
development. This could lead to new strategies for detection of
etiologic agents and prevention of disease through the
interruption of patterns of transmission.''
Then continue with the rest of the paragraph ``The recent
identification * * *
Add a new paragraph to the section:
The role of infections in chronic diseases (e.g.,
chlamydia pneumoniae and cardiovascular disease; H.
pylori and gastric cancer; hepatitis B and C and liver
cancer) is becoming increasingly evident. CDC is
developing research activities to better define
relations between infectious agents and chronic disease
sequelae; infections may play a role in many chronic
diseases which severely impair quality of life and
length of life among the elderly.
(5) National Center for Injury Prevention Control
The following intramural projects should be included in the
report for 1995-1996:
Medical Conditions and Driving.--It is hypothesized that
certain medical conditions increase the risk of motor vehicle
crashes and may also affect the decision to stop driving. With
data from a longitudinal data base we will be vetter able to
understand the interrelationships between medical conditions,
crashes, and why senior citizens stop driving. Some of the
questions to be asked are: (1) What is the vehicle crash
experience over the last five years of older drivers, and (2)
which drivers are at high risk of crashes?
Longitudinal Study of Older Drivers: Medical Conditions and
Risk.--A longitudinal data base that will allow for additional
older driver information to be analyzed is being used to ask
several research questions: (1) Are driving patterns related to
alcohol/medication use, smoking, or other socio-psychological
and lifestyle factors, and (2) are driving patterns (e.g.
miles/week) associated with medical conditions or health
status?
Older Drivers: Why Do They Stop Driving?--A module was
added to one state's Behavioral Risk Factor Surveillance System
to assess driving decisions made by older drivers in that
state. Data were collected throughout 1995 and include the
additional demographic information collected routinely in this
survey. Descriptive information will enable a closer look at
why older drivers stop driving.
Older Drivers Risk to Other Road Users.--A study was
conducted using a linked data base (hospital discharge data and
police accident reports for one state) to determine the degree
to which older drivers impose an excess risk of death or injury
serious enough to require hospitalization on other road users.
(6) National Immunization Program
On page 187, please delete the second paragraph and replace
with: ``CDC continues to include adult immunization issues in
its annual National Immunization Conferences. Posters and oral
presentations are consistently used to address numerous adult
immunization issues.''
Please delete the fourth paragraph and replace with: ``In
September, the Department of Health and Human (HHS) approved a
department-wide action plan to enhance activities to protect
adults against vaccine-preventable diseases and maximize
accruable health care cost savings. The strategy for addressing
adult immunization includes developing nationwide prevention
strategies that focus on providers to reduce missed
opportunities. Though no additional resources have been
identified to support this effort, a CDC Working Group is
assessing ways in which current activities on adult
immunization can be used to monitor progress on increasing
coverage in adult populations.''
The fifth paragraph, second line should read ``* * * a
network of more than 95 private, professional, volunteer
organizations * * *''
The fifth paragraph, last sentence should read: ``The
objectives of the NCAI are accomplished by three working Action
Groups--Influenza/Pnuemococcal, Measles-Mumps-Rubella-
Varicella, and Hepatitis B--that conduct * * *''
The sixth paragraph, first sentence should read: ``* * * at
risk of complication is 58 percent.''
The sixth paragraph, second sentence should read: ``* * *
have steadily improved from 23 percent in 1985 to 58 percent in
1995.''
Please delete the third sentence from paragraph 6 regarding
preliminary data from the National Health Interview survey as
more current data is reflected in the sentence change above.
Last paragraph, please add this as a second sentence:
``Data through 1996 are being collected and analyzed for this
study.''
FOOD AND DRUG ADMINISTRATION
As the percentage of elderly 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. FDA has been
focusing on several areas for the elderly that fall under its
responsibility in the regulation of foods, drugs, biologics and
medical devices. Efforts in education, labeling, drug testing,
drug utilization, and adverse reactions are of primary
interest. Working relationships exist with the National
Institute on Aging, the Centers for Disease Control, and the
Administration on Aging of the Department of Health and Human
Services to further strengthen programs that will assist the
elderly now and in the future. Some of the major initiatives
that are underway are described below.
Project on Caloric Restriction
The National Center for Toxicological Research (NCTR) in
partnership with the National Institute on Aging has been
working for several years on the role caloric restriction (CR)
plays in the aging process and what effect a reduced caloric
diet has on disease etiology. 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 effects the normal aging
process. Studies over the last year have focused on the premise
that by using a single paradigm (caloric manipulation) and
through interdisciplinary studies a comprehensive integrated
approach can be developed to understand the effect diet has on
the initiation and development of disease. The hypotheses that
support this paradigm are mechanistically based and include the
following: CR acts through its effects on body growth, on
glucocorticoids and inflammation, on DNA damage, repair and/or
gene expression, on toxicokinetics and/or its modification of
oxidation and fat metabolism. All of these hypotheses have been
explored through interdisciplinary studies being conducted at
NCTR or at other institutions in collaboration with scientists
at NCTR.
Body Growth
Rodent studies at NCTR have found that body weight can be
used to predict tumorigenicity. For most organs, size is
directly proportional to the body weight of the animal and it
has been shown that organ weight can be used to predict
tumorigenicity. CR inhibits the induction of tumor expression
and growth and changes the state of differentiation in
replicating cells. It has also been that CR can specifically
alter drug metabolism and reduce drug toxicity. This could be
very useful in treating and diagnosing disease. In addition,
the relevance of CR to the human population has been
strengthened by the fact the biomarkers observed in rodents are
associated with the risk of chronic disease in humans. Plans
are in place to extend the CR observation in rodents to
clinical studies in humans.
Oxidation and Fat Metabolism
A common hypothesis for tumor induction suggests that DNA,
the blue print of the cell, is damaged by oxidative chemical
species in the cell released by the metabolism of fat. CR has
been shown to reduce the impact of oxidative damage at the
organ level by increasing the oxygen scavengers in the liver
and in muscle. Similarly, it has been shown that CR reduces
high fat induced oxidative damage in cellular DNA/
Glucocorticoids and Inflammation
Glucocorticoids are used to diminish normal but undesirable
body responses to noxious stimuli and trauma, advantages are
gained by their use in counteracting stressful situations and
in decreasing pain and discomfort. Another group of normal
protective agents are stress proteins, which are produced in
the body whenever the body undergoes a stress induced response.
CR has been shown to elevate glucocorticoid levels shortly
after inception, and has also been shown to alter stress
proteins levels in the brain.
DNA Damage, Repair and/or Gene Expression
As mentioned above DNA is the blueprint of the cell,
therefore any damage done to DNA has the potential of resulting
in a disease response. CR has been shown to inhibit genes that
are associated with tumor induction and enhances various forms
of DNA repair. One hypothesis for tumor induction suggests that
chemicals exert their damage to DNA by binding to the
components of DNA forming adducts. Animals exposed to a CR
regime and carcinogenic insult show an altered induction of
various forms of DNA adducts.
Toxicokinetics
Toxicokinetics refers to the compartmentalization of a
toxicant within the body. Organs are complicated structures
that are made up of different kinds of cells, transport
structures and biological functioning units. CR has been shown
to alter water transport, fat deposition and waste transport,
thus complicating cellular compartmentalization, and toxic
exposure of certain cells to damaging substances.
Although the work over the last year has concentrated on
the mechanisms of toxic interaction in the body and the role CR
has on this process, studies with calorically restricted
animals have repeatedly shown that CR extends the lifetime of
animals. How this effects aging is still in question; however,
the research being conducted in this area is continuing to chip
away at the problem of how diet effects the aging process, and
what elements or lack thereof in the human diet may help to
extend human life.
Rare Diseases Affecting Primarily Older Americans
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. Between 1983--when the Orphan Drug Act was
passed--through the end of 1996, 145 products to treat small
populations of patients were approved by FDA.
By the end of 1996, there were 645 designated orphan
products. One hundred and two [16 percent] of these designated
orphan products represent therapies for diseases predominately
affecting older Americans. Sixty-seven are for treating rare
cancers in the elderly--for instance ovarian cancer, pancreatic
cancer, and metastatic melanoma. Twenty of the orphan products
designated for treating elderly populations are for rare
neurological diseases, such a amyotrophic lateral sclerosis
[ALS], and advanced Parkinson's disease. Twenty-one 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 products grants had their beginning in 1983 as
one of the incentives of the Orphan Drug Act. This incentive of
the Act 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 grants
program have contributed to the marketing approval of twenty-
one of these 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: for
example, women, children, or a population of elderly. Under the
orphan drug program, disease populations are small; in many
instances, the firms themselves are very small. The goal of
orphan product development is to bring to market products for
rare diseases or conditions. In so doing, it is evident that
the goals of the Orphan Drug Act promote research and labeling
of drugs for use by and for special populations.
The orphan products grant program has funded 39 studies
specifically aimed at treatment of diseases affecting adults
and older adults. The IV Formulations of Busulfan is being
studied for use in geriatric patients and undergoing bone
marrow transplantation.
Alzheimer's Disease Research
Alzheimer's disease currently affects approximately four
million people age 65 and older, with the number produced to
increase to fourteen million by the year 2050. Development of
new drugs to diagnose, treat, and prevent this disease
represents a goal of profound importance. Alzheimer's drug
research efforts depend in part upon the availability of
patients who can participate in clinical studies of these new
drugs.
During 1996, FDA's Office of Special Health Issues [OSH]
conducted a search and assessment of information in the public
domain regarding Alzheimer's drug development, and particularly
opportunities to participate in Alzheimer's drug research. It
was learned that little information is publicly available
regarding Alzeimer's research and opportunities to participate
in Alzheimer's drug development.
To address this problem, OSHI has undertaken an initiative
with the National Institute on Aging [NIA] to develop a
database containing information regarding opportunities to
participate in clinical trials of Alzheimer's drugs. This
database, which received some initial funds from the FDA, will
be maintained at the NIA's Alzheimer's Disease Education and
Referral [ADEAR] Center, and will be accessible by toll-free
telephone and the NIA home page on the world wide web. OSHI and
NIA developed the database and announced the initiative to
pharmaceutical manufacturers involved in domestic development
of Alzheimer's drugs. Some manufacturers have submitted
information for entry into the database, which will be
operational in Spring 1998.
FDA Approves First Treatment for Stroke
On June 18, 1996, the FDA approved the first therapy shown
to improve neurological recovery and decrease disability in
adults following acute ischemic stroke, the most common type of
stroke, caused by blood clots that block blood flow. Treatment
must start within 3 hours of the start of the stroke and only
after bleeding in the brain has been ruled out by a cranial
computerized tomography [CT] scan.
The drug, alteplase, a genetically engineered version of
tissue plasminogen activator [t-PA], is already approved as a
blood clot dissolver to treat heart attacks and to dissolve
blood clots in the artery going to the lungs.
Because of the known risks of bleeding with alteplase and
other thrombolytic therapies, selecting stroke patients who are
most likely to benefit from treatment is critical. It is also
critical that patients be treated within 3 hours of the onset
of a stroke with the correct dose.
Each year, about 500,000 people in the United States have
strokes, with approximately 150,000 dying as a result. Of these
strokes, 400,000 are ischemic, or caused by a blood clot
reducing or blocking blood flow to the brain. The rest are
hemorrhagic strokes, caused by bleeding into and around the
brain.
Postmarket Drug Surveillance and Epidemiology
The Office of Epidemiology and Biostatistics, FDA Center
for Drug Evaluation Research [CDER], prepares an annual
report--entitled ``Annual Adverse Drug Experience [ADE]
Report''--which provides summary statistics describing some of
the activities of the postmarketing drug risk assessment
program. Each year this report contains a number of tabulations
which show the number of reports received and evaluated by such
factors as age group, sex, source of report, drug or type of
outcome. In 1995, there were 130,950 evaluable reports that
were evaluated and added to the database. In this same year,
30, 190 or 23 percent of the reports of adverse drug
experiences were for individuals age 60 or older. There were
41,427 reports [31.6 percent] that did not specify age. In
1996, the Agency added 159,504 reports to the evaluation
database, 41,841 [26.2 percent] for persons 60 years of age or
older who experienced an adverse drug reaction with 43,352
[27.2 percent] for whom no age was specified.
Intraocular Lenses
Over 1 million intraocular lenses are implanted each year
in the U.S. predominately in the senior population. These
implants have revolutionized the treatment of cataracts, which
a few decades ago were the leading cause of blindness in the
adult population. A number of flexible lens models have been
aprpoved by FDA in the last few years and are now on the
market. These lenses permit smaller incisions which heal more
rapidly with less scarring and subsequent distortion of the
optics of the eye.
However, flexible lenses have led to a number of unexpected
post-approval consequences. Discoloration, haziness, and
glistening have all been reported. In 1996, primarily because
of FDA laboratory testing and discovery of such problems, one
company voluntarily recalled all distributed units of its
recently approved flexible IOL model. FDA verified that the
recall was effective and that monitoring was in place to access
patients implanted before the recall. FDA tasked all involved
firms with identifying the sources of these problems and
revising their quality control to prevent future occurrences.
FDA's devise laboratory developed methods and tested lenses to
assess the effect of these problems on vision.
Data on intraocular lenses (IOLs) have demonstrated that a
high proportion (85-95 percent) of the patients who have
undergone cataract surgery and IOL implantation will be able to
achieve 20/40 or better corrected vision with a low risk of
significant postoperative compliactions. Because of the proven
safety and effectiveness of IOLs, they have become the
treatment of choice for the correction of visual loss caused by
cataracts. This has allowed elderly patients to maintain their
sight and a normal lifestyle. FDA continues to monitor some
investigational IOLs and to date has approved thousands of
models that have demonstrated safety and effectiveness.
The first IOLs were all ``monofocal,'' which were designed
to provide good vision at one distance, usually far. Patients
who receive monofocal IOLs usually need spectacles to obtain
satisfactory near vision. Typically, these patients will need
bifocal spectacles to obtain optimal distance and near vision.
On September 5, 1997, FDA approved the first ``multifocal''
IOL. The multifocal IOL is designed to provide clear distance
and near vision. The advantage of the multifocal IOL is that
there is a greater chance that the patient may have
satisfactory distance and near vision without spectacles, or
will only need ``monofocal'' (not bifocal) spectacles to
improve both distance and near vision. The disadvantages of
multifocal IOLs are: (1) distance vision may not be quite as
``sharp'' as with a monofocal IOL; (2) there is a higher chance
of difficulty with glare and holos than with a monofocal IOL;
and (3) under poor visibility conditions, vision may be worse
than with a monofocal IOL.
Throughout the time period of this update, FDA has worked
closely with industry, ophthalmologists, and researchers to
assure that the regulatory requirements for new intraocular
lens models are scientifically valid, but not overly
burdensome. This activity has occurred via work with both the
ANSI and ISO standards organizations. FDA also participates in
the Eye Care Forum, an annual meeting sponsored by the National
Eye Institute to address issues of mutual interest to the
clinical, research, and regulatory communities.
Prosthetic Heart Valves
Approximately 80,000 people in the U.S. have artificial
heart valves implanted every year, both mechanical and
bioprosthetic (pig, bovine valves). The characteristics of the
blood flow through these valves can affect the risk of thrombo-
embolism and ultimate valve failure. Turbulence, stagnation and
caviation (bubble formation and collapse) may all cause adverse
effects. For the past few years, and currently, the FDA has had
programs in place, both research and regulatory, to evaluate
the flow characteristics of these devices and their impact on
the valves and blood components.
These programs include the development of: (1) improved
techniques to directly measure the flow patterns associated
with valves using fluorescent particle visualization and
Dopplier ultrasound; (2) mathematical models to assess flow
patterns as a function of valve design and aortic geometry; (3)
guidance for manufacturers to standardize and improve their
testing; (4) techniques to acoustically detect flow induced
caviation; (5) methods to directly assess effects on red blood
cells. Also evaluation of specific valve designs, both
currently implanted and protype is ongoing. Finally, analysis
of a much used diagnostic tool, color Doppler, is being
undertaken to improve diagnosis or diseased or faulty valves.
Pacemakers
On October 28, 1994, the EP Technologies, Inc.'s Cardiac
Ablation System, the first radio frequency powered catheter
ablation system was approved. It is indicated for interruption
of accessory atrioventricular (AV) conduction pathways
associated with tachycardia, treatment of AV nodal re-entrant
tachycardia, and for creation to complete AV block in patients
with a rapid ventricular response to an aerial arrhythmia.
On December 20, 1995, the Thoratec Ventricular Assist
Device System was approved. It is indicated for use as a bridge
to cardiac transplantation to provide temporary circulatory
support for cardiac failure in potent transplant recipients at
imminent risk of dying before donor heart procurement. The
System may be used to support patients who have left
ventricular (LVAD), right ventricular (RVAD), or biventricular
failure (BVAD). The Thoratec VAD differs from theother two
previously approved VADs in that it can be used for right heart and/or
biventricular failure.
On May 15, 1996, a new indication for use was approved for
CPI Guidant's family of Implantable Cardioverter Defibrillators
(ICDs). The PMA supplement was received in six days and
contained clinical data in electronic format from the
Multicenter Defibrillator Implant Trial (MADIT). The new
patient population consists of patients who have a Left
Ventricular Ejection Fraction of less than 35%, and a
documented episode of non-sustained ventricular tachycardia
with inducible, non-suppressible, ventricular tachycardia.
Previously, only patients who had sustained ventricular
tachycardia were candidates for implantation. The MADIT data
provided evidence that an ICD used in high risk, asymptomatic
patients produces significantly better results than drugs in
reducing deaths.
Renal Dialysis
There were a projected 244,000 patients with kidney failure
in the United States in 1996. More than 100 individuals are
diagnosed with end sage renal disease (ESRD) each day. ESRD
patients will need to remain on either hemodialysis or
peritoneal dialysis for the rest of their lives unless they are
able to receive a successful kidney transplant. Therapy can be
delivered at dialysis facilities or in the home, depending on
various factors.
Today, more than 50 percent of the ESRD population is over
60 years of age. Through age 50, the average remaining life
span is grater than 5 years for ESRD patients. Although the
remaining lifetimes are shorter for the elderly ESRD
population, the general population also faces higher mortality
with aging. The projected expected remaining lifetime for
dialyzed patients with ESRD is approximately one-fourth to one-
sixth that for the general population through age 50, while the
ratio is often closer to one-third for older patients. These
figures are based on actuarial calculations and assumed death
rates, and are taken from the U.S. Renal Data System 1997
Annual Data Report.
Because of the nature of the underlying disease and
necessary supportive therapy, ESRD patients are at risk for a
number of potential complications during or as a result of
their therapy. Many of the potential complications can occur
from a failure to correctly maintain or use dialysis equipment,
insufficient attention to safety features of the individual
dialysis system components, or insufficient staffing or
personnel training. FDA's Center for Devices and Radiological
Health (CDRH), in conjunction with major hemodialysis
organizations, such as the Health Industries Manufacturers
Association (HIMA), the Renal Physicians Association (RPA), and
the American Nephrology Nurses Association (ANNA), developed
several educational videotapes which address human factors,
water treatment, infection control, reuse, and delivering the
prescription, as well as manuals on water treatment and quality
assurance. Complimentary videos illustrating health and safety
concerns and the use of proper techniques have been distributed
to very ESRD facility in the United States. These videos have
received a favorable acceptance from the nephrology community.
On October 6, 1995, CDRH completed the final draft of the
Guidance Document on Hemodialyzer Reuse labeling for safe and
effective reprocessing for reuse manufacturers. A letter was
issued to Manufacturers and Initial Distributors of
Hemodialyzers on May 23, 1996 to inform them of the requirement
to obtain 510(k) clearance for ReUse labeling for all
hemodialyzers which were being marketed for clinics reusing
their dialyzers. They were given until February 25, 1997, to
comply with the request. A video on the methods for correct
reprocessing and reuse of hemodialyzers developed by the FDA,
RPA, and other concerned groups is available. The video
attempts to follow the standard protocols that have been
detailed in the Association for the Advancement of Medical
Instrumentation (AAMI) Recommended Practice for the Reuse of
Hemodialyzers. These practices also have been adopted by HCFA
as a condition of coverage to ESRD providers that practice
reuse.
A multistate study conducted for the FDA in 1987 indicated
that dialysis facilities appeared to have inconsistent quality
assurance (QA) techniques for many areas of dialysis treatment.
To address this problem, FDA funded a contract to develop
guidelines that could be used by all dialysis facility
personnel to establish effective QA programs. The guidelines
printed in February 1991 were mailed to every dialysis facility
in the United States free of charge.
During 1995-1996, FDA prepared a Draft Guidance Document
for the Content of Premarket Notifications for Water
Purification Components and Systems for Hemodialysis. This
document was circulated for comment by regulated industry and
other government agencies and was presented at both AAMI and
Water Quality Association Meetings. The purpose for preparing
this document was to remind the water treatment community of
the Federal requirement for submission of premarket
notifications for these types of device systems (21 CFR
876.5665). The importance of the quality of the water used for
preparation of hemodialysate solutions used during hemodialysis
was strongly emphasized in these presentations and the Guidance
Document.
In September 1996, seven patients in Alabama received
hemodialysis when the blood alarms activated on six of the
seven patients. Subsequently, the patients began to exhibit
serious central nervous (CNS) symptoms. FDA field staff, CDRH
and CDC investigated the various aspects of the incident. The
epidemiological analysis suggests a causal relationship between
the age of the dialyzer filters used (ten plus years), and the
injuries reported to the patients. As a result, CDRH and CDC
issued a joint Public Health Advisory in December 1996, with
the simple message to ``rotate your dialysis stock using first-
in-first-out practices,'' to avoid this type of problem in the
future. FDA laboratories began a research program to
investigate the effects of aging on dialyzer filters, with the
objective of establishing safe expiration dating labeling.
FDA has continued to work cooperatively with the nephrology
community and the ESRD patient groups to improve the quality of
dialysis delivery. These efforts appear to be yielding
positives results. CDRH has also been cooperating with CDC and
HCFA in the exchange of information to try to increase the
safety of dialysis delivery.
Fluoroscopically-Guided Interventional Procedures
An increasing number of therapeutic procedures are being
employed for a variety of conditions, such as coronary artery
disease or irregular heart rhythms, which require x-ray
fluoroscopy to provide visualization and guidance during the
procedures. Due to the time required to complete these
procedures, the potential for large radiation exposures leading
to acute skin injury exists. During the early 1990s, the FDA
received reports of such injuries, investigated the
circumstances and issued an FDA Public Health Advisory to alert
physicians and health care facilities to this concern. This
advisory was sent to hospitals and specialist physicians who
perform such procedures. During 1995 and 1996, the FDA
continued activities to increase the awareness of physicians to
this problem, including publishing supporting information for
physicians, an article in the radiology literature and numerous
presentations at medical professional meetings. These
activities brought the attention of physicians to this issue
and resulted in activities in many healthcare facilities to
assure proper attention is given to this concern. As may of
these interventional procedures are performed on older
patients, this activity contributed to improved care for older
Americans.
Mammography
Since 1975, CDRH [formerly the Bureau of Radiological
Health (BRH) has conducted a great many mammography activities.
These have been done with several goals in mind:
To reduce unnecessary radiation exposure of patients
during mammography to reduce the risk that the
examination itself might induce breast cancer; and
To improve the image quality of mammography so that
early tiny carcinoma lesions can be detected at the
state when breast cancer is most treatable with less
disfiguring and more successful treatments.
The National Strategic Plan for the Early Detection and Control of
Breast and Cervical Cancer
FDA, the National Cancer Institute, and the Centers for
Disease Control have coordinated a combined effort to cover 75
professional, citizen, and government groups to develop the
National Strategic Plan for the Early Detection and Control of
Breast and Cervical Cancer. The goal of this plan, approved by
the Secretary of Health and Human Services on October 16, 1992,
is to mount a unified effort by all interested groups to combat
these two serious cancer threats. FDA staff took the lead in
writing the Breast Cancer Quality Assurance section, one of six
components of the plan, and participated in the development of
the other components.
Mammography Quality Standards Act of 1992
On October 27, 1992, the president signed into law the
mammography Quality Standards ACT [MQSA) of 1992. This Act
requires the Secretary of Health and Human Services to develop
and enforce quality standards for all mammography of the
breast, regardless of its purpose or source of reimbursement.
Since October 1, 1994, any facility wishing to produce,
develop, or interpret mammograms has had to meet these
standards to remain in operation. The Secretary delegated the
responsibility for implementing the requirements to FDA on June
1, 1993, and Congress first appropriated funds for these
activities on June 6, 1993. Implementation of MQSA is a key
component of Secretary Shalala's National Strategic Action Plan
Against Breast Cancer.
FDA's accomplishments since the Agency was delegated
authority to implement MQSA in June 1993 include--staffing of a
new division; development of final standards; approval of four
accreditation bodies; certification of 10,000 facilities by the
statutory deadline of October 1, 1994, implementation of a
rigorous training program for inspectors; development of a
compliance and enforcement strategy [coordinated with the
Health Care Financing Administration (HCFA); outreach to
facility and consumer communities; and planning for program
evaluation.
MQSA inspections have supplanted the Health Care Financing
Administration's Medicare Screening Mammography Inspections.
Under MQSA, HCFA has agreed to recognize FDA-certification of a
mammography facility as meeting quality standards for
reimbursement purposes.
Blood Glucose Monitoring
A proposed ISO standard [draft ISO TC 212/WG3] was proposed
for evaluating the performance of self-monitoring blood glucose
monitors by comparing monitor results to those obtained by
clinical laboratory methods. Because the draft standard did not
address how to select a clinical laboratory method, an attempt
was made, based upon telephone surveys and discussions with
CAP, the three most commonly used clinical methods for analysis
of blood glucose. A strategy was developed to evaluate the
accuracy of these methods by comparison to the recently
released Standard Reference Material from the National
Institute of Standards and Technology that has three certified
levels of glucose in human sera. Criteria were developed for
selection of high performance clinical laboratories in order to
minimize effects due to analysts.
Patient Restraints
Patient restraints are intended to limit the patient's
movement to the extent necessary for treatment, examination, or
for the protection of the patient or others.
One of the most common uses of these devices has been to
protect the elderly from falls and other injuries. Seventy-nine
documented deaths have been reported to FDA's Medical Device
Reporting System (MDR) related to patient restraint use.
Scientific literature suggeststhat annual deaths related to the
use of restraints may be as high as 200. These alarming numbers of
deaths, with the use of protective restraints raised serious concerns
regarding the safe use of these devices and prompted the FDA to alert
the healthcare community about these problems.
The agency worked closely with industry in arriving at
solutions to help reduce the risk of injury and death
associated with the use of these devices. As a result, in
November 1991, FDA moved to make protective restraints
prescription devices to be used under the direction of licensed
health care practitioners. In addition, manufacturers were
required to label patient restraints as ``prescription only''
to help ensure appropriate medical intervention with the use of
these devices. In July 1992, FDA issued a Safety Alert to
healthcare providers to heighten their awareness of the
potential hazards associated with the use of these devices. FDA
identified labeling as its primary focus for intervention in
resolving this issue, and provided additional labeling
recommendations as guidance to manufacturers to ensure safer
designs. Education and training of personnel in the application
of these devices has also been emphasized.
Today, healthcare providers are electing the restraint-free
alternative. As a result, current literature reports that
restraint use is dropping.
Hearing Aids
Several events occurred in 1995-1996 which related to FDA's
development of a guidance document that indicated criteria for
clinical hearing aid study protocols. Manufacturers met with
FDA staff to review proposed clinical studies, consultants met
with FDA to discuss interpretations of the guidance document
and how they might best interface with the regulated industry,
and FDA had meetings with the Hearing Industries Association
(HIA), representing many of the major manufacturers of hearing
aids, wherein the use of the guidance document was discussed.
In addition, members of FDA's Hearing Aid Working Group
completed its draft of the proposal to amend the 1977 hearing
aid regulation. This new regulation, if adopted, would cover 21
CFR 801.420 and 801.421, Hearing Aids, Professional and Patient
Labeling and Conditions for Sale.
Orthopaedic Implant Porous Coatings
Porous coatings are widely used in both the orthopedic and
dental implant industries to fix prosthetic devices through the
process of bony in-growth without the aid of cements. However,
the coating qualities such as strength, solubility, and
abrasion resistance vary considerably depending on
manufacturing methods and have significant impact on durability
of the implants. Concern over the long-term revision rates for
plasma sprayed porous coatings prompted the FDA to require
post-market surveillance studies for these types of coatings.
FDA also began a program to evaluate tests to assess the
durability of such coatings in order to help in the development
of longer-lived implants.
Hazards With Hospital Beds
On August 21, 1995, FDA issued a Safety Alert, Entrapment
Hazards with Hospital Bed Side Rails. The Alert noted that the
majority of deaths and injuries reported to FDA involving bed
rails were to elderly patients, and recommended a number of
actions to prevent deaths and serious injuries. This Alert was
sent to nursing homes, hospitals, hospices, home healthcare
agencies, nursing associations, and biomedical and clinical
engineers throughout the United States.
Retinal Photic Injuries
On October 16, 1995, FDA issued a Public Health Advisory,
Retinal Photic Injuries from Operating Microscopes During
Cataract Surgery. Cataract surgery is most frequently performed
on elderly patients. The Advisory discussed the types of
injuries to patients reported to FDA, and recommended actions
to reduce the risk of retinal photic injury. The Advisory was
sent to ophthalmologists and cataract centers throughout the
United States.
Electric Heating Pads
On December 12, 1995, FDA working with the CPSC, issued a
Public Health Advisory, Hazards Associated with Use of Electric
Heating Pads. At the time of the Advisory, 45% of those
reporting injuries from using heating pads, were over the age
of 65. The Advisory pointed out that patients who may be unable
to feel pain to the skin because of advanced age, diabetes,
spinal cord injury, or medication, are at high risk for injury.
This Advisory was sent to hospitals, nursing homes, hospices,
home healthcare agencies, and biomedical and clinical engineers
throughout the United States.
FDA Problem Reporting System for Medical Devices
The Office for Surveillance and Biometrics receives reports
involving medical devices through reporting from consumers,
medical professionals, manufacturers, distributors, and user
facilities. On the 191,537 reports received during the calendar
years 1995 and 1996 from all sources, 22,749 (12 percent)
reported the age of the patient. Of these, 10,855 (48 percent)
were for individuals 60 years of age or older. Prior to August
1, 1996, manufacturers of medical devices were not required to
provide age information. In many instances when manufacturers
were required to provide age information, the information was
unknown and therefore not reported.
Markers of Bone Metabolism
Osteoporosis is a major health concern. It is estimated
that 1.5 million fractures are attributable to osteoporosis in
the United States each year. One third of women older than 65
years suffer vertebral crush fractures, and the lifetime risk
of hip fracture is 15%. The mortality rate accompanying hip
fracture may be as high as 20%. Twenty-five percent of the
survivors are confined to long-term care in nursing homes. The
estimated cost of medical care for osteoporosis each year is
more than $10 billion.
If a woman has postmenopause-associated osteoporosis, an
assessment of bone turnover may be helpful. Because of an
increasing interest in bone disease and a greater understanding
of bone metabolism, a number of urinary markers of bone
turnover were cleared by the FDA in 1995 and 1996. The rate of
bone loss is related to an overall increase of bone turnover
which can be assessed using these biochemical indicators.
Year 2000 Health Objectives
A consortium of over 300 government and private agencies
developed a set of health objectives for the Nation which is
serving as a national framework for health agendas in the
decade leading up to the year 2000. The overall program is
called ``Healthy People 2000.'' FDA co-chairs the working group
responsible for monitoring progress on the set of 21 objectives
that focus on nutrition, dietary improvements and availability
of nutrition services and education. In the food and drug
safety area, objective 12.6 sets as a target to:
Increase to at least 75 percent the percentage of
health care providers who routinely review all
prescribed and over-the-counter medicines taken by
their patients 65 years and older each time medication
is prescribed or dispensed.
Objective 12.8 sets as a target to:
Increase to at least 75 percent the proportion of
people who receive useful information verbally and in
writing for new prescriptions from prescribers or
dispensers.
FDA's Marketing Practices and Communications Branch
conducted a number of studies that track patients' receipt of
medication information from doctors and pharmacists from 1982
to 1996. The most recent survey shows that 67% of Americans 65
and over received at least some oral information about
prescriptions from physicians and 43% from pharmacists, while
13% received written information about their prescription
medications from physicians and 62% received such information
from pharmacists. Only 2% reported asking questions at the
doctor's office, and 3% at the pharmacy. The survey is being
conducted again in 1998 to track progress toward meeting this
objective. An article outlining results of the surveys from
1982-1994 will be published in Medical Care in October 1997.
During the coming year, FDA will work with private sector
organizations to advance medication counseling activities.
Food Labeling
Food labeling is very important to the elderly. Elderly
people have a greater need for more information about their
food to facilitate preparation of special diets, maintain
adequate balance of nutrients in the face of reduced caloric
intake, and ensure adequate levels of specific nutrients which
are known to be less well absorbed as a result of the aging
process [e.g., vitamin B12].
The new food label, which is now required on most foods
offers more complete, useful, and accurate nutrition
information to help the elderly meet their nutritional needs.
Significant labeling changes include: nutrition labeling for
almost all foods; information on the amount per serving of
saturated fat, cholesterol, dietary fiber, and other nutrients
of major concern to today's consumers; nutrient reference
values to help consumers see how a food fits into an overall
daily diet; uniform definitions for terms that describe a
food's nutrition content [e.g., light, low fat, and high-
fiber], claims about the relationship between specific
nutrients and disease, such as sodium and hypertension;
standardized serving sizes; and voluntary quantitative
nutrition information for raw fruit, vegetables, and fish.
Manufacturers were required to comply with most of the new
labeling requirements as of May 1994--although a 3-month
extension was granted to firms who were unable to meet the May
deadline. Regulations pertaining to health claims became
effective a year earlier in May 1993. A recent survey indicates
that a vast majority of food in the stores now carries the new
food label and that more than 87 percent of the nutritional
information accurately measures what is in the package. A
second survey of retail stores was completed and showed that
there continues to be substantial compliance with FDA's
voluntary nutrition labeling program for raw fruits,
vegetables, and fish. This is an important indication to
consumers that they can trust what it says on the food label.
To help consumers get the most from the new food label,
educational materials are being widely disseminated. Among
materials now available is a large-print brochure, ``Using the
New Food Label to choose Healthier Foods,'' which is easier to
read for senior citizens who may have vision problems.
A food label education program has been developed that
coordinates the efforts of FDA and USDA with various public and
private sector organizations to educate consumers about the
availability of new information on the food label and the
importance of using that information to maintain healthful
dietary practices. Consumer Research was used to guide the
development of educational materials and their messages. Print
and video materials were developed for diverse target
audiences, emphasizing skills and tips on how to use the food
label quickly and easily to achieve a healthier diet. The
agency has released two ``Questions and Answers'' documents,
giving answers to about 400 frequently asked questions. Volume
II, released in August 1995, primarily addresses questions
pertinent to restaurants and other related establishments.
FDA's food labeling education program seeks to coordinate
the Government's efforts with those of the public and private
sector to insure consistent, action-oriented label
educationmessages. A key goal is to promote integrating label education
into new and existing nutrition education programs for diverse target
audiences (for example, through national video teleconferences on
nutrition interventions, children's games and nutrition-oriented
programs on CD ROM's, and community-based programs for multi-cultural
populations). Public information and education materials are available
from FDA's Office of Consumer Affairs and have also been posted on
CFSAN's home page of the World Wide Web (WWW).
Dietary Supplements
The Dietary Supplement Health and Education Act of 1994 was
signed by the President in 1994. This Act required FDA to
withdraw its Advanced Notice of Proposed rulemaking requesting
comment on approaches to assuring the safety of dietary
supplements. The Act also defines supplements, defines new
dietary ingredients as dietary ingredients that were not
marketed in the U.S. before October 15, 1994, places the burden
of proof for safety on FDA, and sets standards for the
distribution on third party literature [e.g. books,
publications, and articles].
The law also allows statements of nutritional support under
certain conditions. Such statements may describe the role of a
nutrient or ingredient intended to affect the structure or
function in humans or describe general well-being from
consumption of a nutrient or dietary supplements ingredient.
The manufacturer must be able to substantiate that such a
statement is truthful and not misleading, and the statement
must contain the following disclaimer, ``This statement has not
been evaluated by the FDA. This product is not intended to
diagnose, treat, cure, or prevent disease.''
The law authorizes the FDA to issue regulations for Good
Manufacturing Practices for dietary supplements, including
expiration date labeling. It also establishes a 7-member
Commission on Dietary Supplement Labels to conduct a study and
issue a report making recommendations on the regulation of
label claims for dietary supplements by October 25, 1996. The
law further requires the Secretary of HHS to establish an
``Office of Dietary Supplements'' at the National Institutes of
Health.
FDA published proposed regulations for the nutrition
labeling of dietary supplements in December 1995. The
regulations, when finalized, will require that dietary
supplement labels contain information on the nutrient content
and composition of dietary supplements that will enable the
elderly to make informed choices on whether a particular
dietary supplement is appropriate for their particular needs.
Total Diet Studies
The Total Diet Study, as part of FDA's ongoing food
surveillance system, provides a means of identifying potential
public health problems related to the diets of the elderly and
other age groups. Through the Total Diet Study, FDA is able to
measure the levels of pesticide residues, toxic elements,
chemicals, and nutritional elements in selected foods of the
U.S. food supply. In addition, the study allows FDA to estimate
the levels of these substances in the diets of 14 age groups:
infants 6 to 11 months old; children 2, 6, and 10 years old;
14- to 16-year-old-boys; 14- to 16-year-old girls; 25- to 30-
year-old men; 25- to 30-year-old women; 40- to 45-year-old men;
40- to 45-year-old women; 60- to 65-year-old men; 60- to 65-
year-old women; men 70 years and older; and women 70 years and
older. Because the Total Diet Study is conducted yearly, it
also allows for the determination of trends and changes in the
levels of substances in the food supply and in daily diets.
Postmarket Surveillance of Food Additives
FDA's Center for Food Safety and Applied Nutrition (CFSAN)
monitors complaints from consumers and health professionals
regarding food and color additives and dietary practices as
part of its Adverse Reaction Monitoring System. Currently, the
database contains 11,939 records. Of the complainants who
reported their age, approximately 18 percent were individuals
over age 60.
CFSAN also monitors complaints regarding dietary
supplements as part of the Adverse Reaction Monitoring System
and has an additional 5057 reports. There is no information in
the database on the age of the complainants for these products.
Medical Foods
The Orphan Drug Amendments of 1988 enacted a definition for
a medical food. It defined the term ``medical food'' to mean
``[a] food which is formulated to be consumed or administered
enterally under the supervision of a physician and which is
intended for the specific dietary management of a disease or
condition for which distinctive nutritional requirements, based
on recognized scientific principles, are established by medical
evaluation.'' FDA published an advanced notice of proposed
rulemaking (ANPR) in November 1996. The ANPR announced that FDA
intended to initiate a re-evaluation of its regulatory approach
to these products. Its purpose was to ensure that the products
marketed as medical foods bear claims that are truthful and not
misleading, that such claims are supported by sound science,
and that label information is adequate to inform consumers and
health care providers how to use them in a safe manner. The
initiative is important to the elderly because they may often
rely on these products during periods of illness or to
supplement their diets to meet specific nutrient needs not
being met by their regular diets.
Medicare Coverage Determinations
FDA provides representatives and scientific input to the
Health Care Financing Administration's Technology Advisory
Committee (TAC). The TAC is a committee of government
employees, which advises HCFA on national coverage decisions
for Medicare recipients. FDA also provides input and expert
review for technology assessments produced by the Agency for
Health Care Policy and Research (AHCPR). AHCPR technology
assessments are used by HCFA and the Civilian Health and
Medical Program of the Uniformed Services (CHAMPUS) as a basis
for coverage decisions.
During the 1995-1996 reporting period, FDA and HCFA
formulated an arrangement to afford beneficiaries Medicare
coverage for investigational medical devices determined by FDA
to constitute only a minor change from an already covered
device. This arrangement allows manufacturers to validate the
safety and efficacy of improved products without denying
coverage during the period of study.
Pharmacy Initiative
During 1995 and 1996, DHHS and FDA have sought to encourage
greater pharmacy-based counseling. Through speeches, articles,
and editorials in major medical and pharmacy journals, DHHS and
FDA have encouraged the increased role of pharmacists, using
computers to print information to informing patients about the
uses, directions, risks and benefits of prescription
medications. The pharmacy profession has responded positively,
bringing many examples of their initiatives to FDA's attention.
In particular, several organizations have informed FDA of the
expanded use of new technology to provide patient instructional
materials to their customers. In August of 1996 Congress took
up this issue and developed performance goals for the private
sector to meet. In December of 1996 the private sector had
developed an Action Plan with criteria on how to determine the
usefulness of information for consumers. The Plan would then be
presented to the Secretary of HHS for concurrence. A survey by
FDA, with data collected beginning December 1996, showed 67% of
patients reporting that they received written information with
their prescription drugs. FDA will conduct studies in the
future to review the usefulness of that information and will
continue to work closely with private sector organizations in
an effort to increase the dissemination of useful information
to patients about their prescription medications.
Health Fraud
Health fraud.--the promotion of false or unproven products
or therapies for profit--is big business. 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, more often than the general population, are
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, the 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. Also, evaluation efforts
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.
FDA has worked with the National Association of Attorney's
General [NAGS] 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
[FTC], the U.S. Postal Service [USPS], 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.
In 1995 and 1996, FDA's Public Affairs Specialists [PASs]
continued to alert diverse and culturally specific elderly
populations throughout the United States by sponsoring
community-based education programs, information exchanges, and
outreach efforts. Dietary supplements remained a key issue. In
addition to health fraud workshops and other community-based
programs, the PASs also convey this important information
through additional networks such as radio, television shows,
and public service announcements. With respect to enforcement,
in 1995 and 1995, the Agency took action against distributors
of common gas grill ignitors that were promoted for the relief
of pain due to arthritis and other conditions.
Women's Health
information about drug effects in certain populations
Over the past decade there has been growing concern that
the drug development process does not provide sufficient
information about drug effects in certain populations,
including minorities and women of all ages. On September 8,
1995, the FDA, in an effort to collect this necessary
information, proposed to amend its regulations regarding the
format and content of investigational new drug applications
(INDs) and new drug applications (NDAs). The proposed rule
would require IND sponsors of drugs and biological products to
include in their annual reports a characterization of study
subjects by subgroups, such as age, gender, and race. Sponsors
would also be required to present safety and efficacy data by
subgroup when submitting NDAs. This rule has since gone into
effect and will assist in the determination of the optimal use
of drugs in special populations which have a variety of factors
that can lead to different responses to medical products.
women's health research agenda
During 1995 and 1996, FDA participated with the NIH Office
of Women's Health in defining specific objectives of the
research agenda for the 21st century. The effort culminated in
plans for a workshop including experts from the federal
government and universities to be held in 1997. Some specific
age-related conditions were evaluated including cardiovascular
and pulmonary diseases, oral health, bone and musculoskeletal
disorders, kidney conditions, and cancer.
hispanic women's health conference
On May 9-10, 1996, the Office of Women's Health sponsored
the Hispanic Women's Health Conference held in Miami, Florida.
Over 150 people attended the conference which was designed as a
grassroots effort to bring together community based
organizations, academia, federal, state and local agencies and
public/private health care providers concerned with Hispanic
women's health issues, many of which affect aging American
women. The two day meeting featured national and local speakers
who addressed key Hispanic health concerns in the areas of
diabetes, heart disease, cancer, mental health, substance
abuse, osteoporosis, and HIV/AIDS. Its purposes were to create
an ongoing network of health professionals in Southern Florida
to address this community's health needs, and to consider
priority issues on which ongoing public education should occur.
minority women health empowerment: workshops
The office sponsored this series of Conferences in 1995,
1996 and 1997. The purpose of the workshops was to equip
minority women, including the aging, in urban areas of the New
Jersey and Delaware Valley with information on how to take care
of themselves, how to prevent illness and disease, and what the
benefits are of early detection and treatment. This project
targeted women who were at high risk for HIV/AIDS,
cardiovascular disease, breast and other cancers, and diabetes.
The programs were conducted in community centers, Head Start
Centers, local parish halls, school auditoriums, and hospital
conference rooms. Audiotapes in English and Spanish were given
to participants at the end of the workshop.
women's health: take time to care
In 1996, the FDA Office of Women's Health (OWH) conceived
of a new program partnering with American women. In order to
enhance the health of women, the FDA wanted to provide mid-life
and older women, particularly in under served populations, with
the information they need to promote and protect their own
health. OWH met with 46 advocacy groups representing women, the
elderly, and disease conditions, to discuss their health
concerns. The theme, Women's Health: Take Time To Care, will be
used for a variety of health prevention messages. Women, as
represented by these organizations, told us that the first
message should be presented Use Medicines Wisely. As major
consumers of pharmaceuticals, women and their health are
significantly affected by the use of medications. In 1997,
Pilot programs using this message were conducted in Chicago, IL
and Hartford, CT. FDA provided the printed materials and
information and community organizations sponsored numerous
public awareness events. This program will be rolled out
nationally in 1998 and will be brought to 15 cities, rural
empowerment zones, and Native-American reservations across the
country.
``before time runs out''
Breast cancer is the number one cause of cancer related
deaths among African American women. The FDA Office of Women's
Health provided funds to educate African American women in the
Houston area about the importance of screening and the impact
of breast cancer on the African American community through the
use of a locally-inspired play. This drama, which was written
and produced by an African American playwright (Thomas
Meloncon) entitled ``Before Time Runs Out'' was inspired by Mr.
Meloncon's sister who died of breast cancer. The play was
followed by a panel discussion and pertinent brochures were
distributed. This series was presented in selected churches in
under served communities in Houston in 1996 and 1997.
public education brochures
Asian Pacific Islander women have low rates of utilization
of breast and cervical cancer screening procedures due to
language barriers and a subsequent lack of understanding of the
importance of these tests. In 1995, the Office of Women's
Health sponsored the translation of mammography and cervical
cancer screening materials into several languages to address
the needs of linguistically isolated Asian Pacific Islander
women.
Outreach and Exhibits
The Office of Consumer Affairs [OCA] sent information to
older Americans through ``Dear Consumer'' letters, faxes, phone
calls, and personal visits to notify, inform, and elicit
feedback from consumers in the areas of Mammography Quality
Standards, MedGuide, direct-to-consumer advertising for
prescription drugs, plasma product withdrawals and recalls,
food labeling, informed consent and issues pertaining to FDA
advisory committees.
OCA participated in and exhibited at the Native American
Aging Council. Over 300 publications were distributed on
nutrition for the elderly as well as ``The Age Page''
publications from the National Institutes of Health.
Community-Based Programs
Public Affairs Specialists, located throughout the country
in FDA field offices, conducted a variety of community-based
programs in 1995-1996 to address the health concerns and
information needs of older Americans. The topics addressed by
field programs and outreach efforts are timely and diverse,
including such topics as food labeling [how to get the most for
your dollars and how to meet the requirements of special
diets]; the safe use of medications; questions to ask your
physician or health care provider; health fraud; clinical
trials; blood safety; vaccines; hormone replacement therapy;
and cancer screening.
One of the major ongoing initiatives undertaken by FDA
Public Affairs Specialists focused on informing older Americans
about the Nutrition Labeling and Education Act and how to use
the new food label for a healthy or special diet. These
Specialists developed information kits for older people and
distributed these kits in communities throughout the country.
These kits included wallet cards on the new food labeling law;
large-print face sheets; place mats; and trainer guides. Senior
volunteers were trained in a nutrition program sponsored by
DHHS Region V Administration on Aging in Chicago, Illinois to
disseminate information on food labeling to senior citizen,
especially older people in minority communities.
Examples of other community-based programs and outreach
initiatives carried out by FDA Public Affairs Specialists
include:
Health fraud activities focusing on health fraud
scams and products that target older people such as a
statewide health fraud conference held in Kentucky; a
health fraud symposium in New Jersey with a federal
panel comprised of the FDA, Federal Trade Commission,
and the Consumer Product Safety Commission, addressing
``Knowing Your Rights is the Key to Consumer
Protection''; and working with state officials in
Hawaii to assemble a task force to teach older people
about health fraud products and ploys; and
Workshops addressing proper medication storage,
understanding OTC/Rx labeling, food and drug
interactions, drug and drug interactions and medication
usage; and
Participating with community organizations such as
the local health department, Alzheimer's Association,
Arthritis Foundation, local department on aging, and
other partners to sponsor health fairs for older
people; and
Carrying out daily activities with state and local
agencies, local media, nonprofit organizations,
professional associations, and public health
institutions to meet the information and service needs
of older people within communities across the country.
HEALTH CARE FINANCING ADMINISTRATION
Long-Term Care
The mission of the Health Care Financing Administration
(HCFA) is to promote the timely delivery of appropriate,
quality health care to its beneficiaries--over 75 million aged,
disabled, and poor Americans.
Medicaid and Medicare are the principal sources of funding
long term care in the United States. The primary types of care
reimbursed by these programs of HCFA are a variety of
institutional (e.g., skilled nursing facilities (SNFs),
intermediate care facilities for the mentally retarded (ICFs/
MR), inpatient rehabilitation) and home and community based
care services (e.g., home health, personal care).
HCFA's Office of Research and Demonstrations (ORD) conducts
demonstration projects that demonstrate and evaluate optional
coverage, eligibility, delivery system, payment and management
alternatives to the present Medicare and Medicaid programs. ORD
also conducts research studies on a range of issues relating to
long term care services and their users, providers, quality and
costs.
demonstration activities
Demonstration activities in ORD include the development,
testing, and evaluation of:
Alternative methods of service delivery for post
acute and long term care, focusing on service delivery
systems that integrate acute and long term care;
Innovative quality assurance systems and methods; and
Alternative payment systems for post acute and long
term care systems.
In 1996, HCFA continued work on several major initiatives
to test innovative systems of integrated acute and long term
care. ORD has devoted extensive effort to the testing of
capitated payment systems for a combination of acute and long
term care services, including conducting and evaluating the
Program of All-inclusive Care for the Elderly (PACE) and the
Social Health Maintenance Organization (Social HMO)
demonstrations. The PACE demonstration has the purpose of
replicating a unique model of managed care service delivery for
very frail community dwelling elderly, most of whom are dually
eligible for Medicare and Medicaid coverage and all of whom are
assessed as being eligible for nursing home placement. Work
continued on the evaluation of this demonstration, as well as
the development of a quality assurance system that could be
used by HCFA and State Medicaid agencies in monitoring
providers, as well as by the providers for internal quality
improvement activities. Work is also continuing to develop and
implement a ``second generation'' model of the Social HMO, and
the first of these sites began enrollment and service delivery
in 1996. The first State-initiated integrated system of care
for dually eligible beneficiaries was also implemented in
Minnesota, the Minnesota Senior Health Options demonstration.
The provision of integrated acute and long term care services
to children and youth who are disabled and eligible for
Supplemental Security Income is being test in theDistrict of
Columbia's Health Services for Children with Special Needs.
Implementation of this prepaid, capitated project began in late 1995,
and 3,000 children and youth with disabilities are targeted for
voluntary enrollment.
In 1996, ORD continued testing capitation payment systems
for home health care and long term nursing home care, under the
auspices of the Community Nursing Organization (CNO) and
EverCare demonstrations. HCFA awarded contracts to four CNO
sites in 1992. This demonstration tests the feasibility and
effect on patient care of a capitated, nurse-directed delivery
system for home health and other community based services. The
CNO sites completed a 1-year development period and began a 3-
year operational period in January 1994. HCFA is also working
with the United HealthCare Corporation, Inc. to implement the
EverCare demonstration. This demonstration tests the
effectiveness of managing acute care needs of nursing home
residents by pairing physicians and geriatric nurse
practitioners who will function as primary medical care givers
and case managers. Payment is on a prepaid, capitated basis.
Five sites were operational by the close of 1996.
In 1996 HCFA also continued operation of major
demonstrations designed to test prospective payment of home
health and SNF care. The Medicare home health prospective
payment demonstration is being conducted in two phases. The
first phase involved testing of prospectively established per-
visit payment rates for Medicare covered home health visits. A
second phase, implemented in 1995, is testing per-episode
payment rates for an episode of Medicare covered home health
care. In 1995, ORD also implemented the MultiState Nursing Home
Case Mix and Quality demonstration in four States. This
demonstration is testing innovative quality assurance and
prospective case-mix adjusted payment for nursing homes that
participate in Medicare and Medicaid.
New demonstrations designed to provide greater consumer
direction and autonomy were under development in 1996. The
Consumer-Directed Durable Medical Equipment demonstration,
designed to provide greater consumer direction and control in
the purchase and maintenance of Medicare durable medical
equipment was designed in 1996, with site selection targeted
for 1997. HCFA also worked collaboratively with the Assistant
Secretary for Planning and Evaluation and the Robert Wood
Johnson Foundation to develop a demonstration of cash payments
and counseling services for Medicaid personal assistance
services. Four sites were selected for demonstration
participation in 1996, and implementation of this demonstration
is expected in late 1997.
HCFA continues its interest in the development and testing
of outcome based quality assurance systems. A demonstration to
test the effectiveness of outcome based quality assurance
activities in Medicare home health was implemented in 46 home
health agencies in 1996, while a demonstration of outcome based
quality assurance for persons with developmental disabilities
was implemented in the State of Minnesota in 1996.
research activities
Long term care research activities in ORD can be classified
according to the following objectives:
Examining trends in disability and the relationship
between disability, need for and use of long term care
services;
Examining the effect of the Medicare Catastrophic
Coverage Act on subacute and long term care services
and providers as well as ongoing changes in the use of
post acute and long term care;
Examining alternative quality assurance, financing
and payment systems for long term care; and
Supporting data development and analyses.
Because the long term care population is diverse and its
composition continues to change over time, it is important to
examine changes in rates of disability as well as the
relationship between types of disability, need for and use of
long term care services. For example, the most rapidly growing
segments of the Medicare population are beneficiaries under age
65 with disabilities and those who are 85 years or older--both
segments with significantly higher rates of disability and
related use of services.
A major responsibility of ORD is assessing the effects of
various Medicare and Medicaid programs and policies on subacute
and long term care services. Since the passage of the Medicare
Catastrophic Coverage Act and its subsequent repeal, ORD has
been assessing the effects of this change on other parts of the
health care system. Included in this research is the
examination of changes in subacute and long term care case mix,
utilization, quality, and costs. Changes in the supply of long
term care providers are also being studied. Major research
projects are underway to analyze the appropriateness of post
hospital care and the course and outcomes of that care. In
recent years, there has been an increased emphasis on examining
episodes of care rather than utilization of just one type of
services. Medicare files, which link hospital with post
hospital care, continue to be analyzed to provide information
on trends in the post acute care utilization. In addition,
another purpose of funding this research was to gather
information about decision making at the point of hospital
discharge and the types of patients who are referred to the
various post acute modalities of care. These research studies
involve collection and analysis of data in order to provide
Medicare coverage, quality assurance and payment policy
recommendations relating to subacute care (e.g., nursing homes,
rehabilitation hospitals and home health).
Several studies address alternative financing, payment and
quality assurance systems. Although the majority of the elderly
are covered by both Medicare and supplemental insurance, a
large portion of long term care services remain uncovered.
Medicaid covers long term nursing home and community based
care, but only after elderly individuals have depleted personal
resources. Research is being conducted that identifies sources
of financing long term care, examines beneficiaries' personal
resources to purchase long term care insurance, and examines
the risk of catastrophic expenditures. Other research is
continuing in the payment area, as work was initiated to
develop case-mix payment systems for home health, as well as
for Medicaid payments for persons with disabilities. Work to
develop outcome-based quality assurance systems also continues.
Efforts are also underway to improve the data bases,
statistics and baseline information upon which future
assessment of needs, problem identification, and policy
decisions will be based. HCFA continues to support the
Disability Supplement to the 1994 and 1995 National Health
Interview Survey, the Medicare Current Beneficiary Survey, the
National Recurring Data Set project and the Long Term Care
Program and Market Characteristics data base.
One subgroup of increasing importance to both the Medicare
and Medicaid programs is individuals who receive services under
both programs. ORD began analysis with the Medicare Current
Beneficiary Survey, designed to improve our understanding of
the demographic characteristics of dually eligible individuals,
their service use and costs, as well as any potential access
problems they might experience. These analyses are also
intended to support the development of demonstrations targeted
to dually eligible individuals, in which service delivery,
quality and payment innovations will be tested.
Information follows on specific HCFA demonstrations and
research.
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.
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 Senior Health 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, with the exception of the
Medicare payment for end stage renal disease. 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 has 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
continuing to develop collaborative projects with other
organizations in the San Francisco Bay area. A pilot agreement
with the Institute on Aging (IOA) has been completed and the
twoorganizations have entered in a venture agreement in which
IOA will be establishing an adult day health center and operating it
under the rules of the Program of All-Inclusive Care for the Elderly
protocol. The site will be established in the Richmond area of San
Francisco. On Lok will provide quality assurance oversight as well as
marketing and enrollment support. IOA will receive a portion of On
Lok's capitation it receives via the HCFA demonstration and a portion
will be retained by On Lok to cover administrative expenses.
Program of all-inclusive care for the elderly
Period: June 1990-January 1997 (yearly continuation).
Funding: Waiver only.
Grantees: See below.
Mandated by Public Law 99-509, as amended by section
4118(g)(1)(2) of Public Law 100-203 and section 4744 of Public
Law 101-508, the Health Care Financing Administration will
conduct a demonstration that replicates, in not more than 15
sites, the model of care developed by On Lok Senior Health
Services in San Francisco, California. The Program of All-
Inclusive Care for the Elderly demonstration replicates a
unique model of managed-care service delivery for 300 very
frail community-dwelling elderly persons, most of whom are
dually eligible for Medicare and Medicaid coverage and all of
whom are assessed as being eligible for nursing home placement,
according to the standards established by participating States.
The model of care includes--as core services--the provision of
adult day health care and multidisciplinary case management
through which access to and allocation of all health and long-
term-care services are arranged. Physician, therapeutic,
ancillary, and social support services are provided on site at
the adult day health center whenever possible. Hospital,
nursing home, home health, and other specialized services are
provided off site. Transportation is provided for all enrolled
members who require it. This model is financed through
prospective capitation of both Medicare and Medicaid payments
to the provider. Demonstration sites are to assume financial
risk progressively over 3 years, as stipulated in the Omnibus
Budget Reconciliation Act of 1987. The ten sites and their
State Medicaid agencies that have been granted waiver approval
to provide services are:
Elder Service Plan
Period: June 1990-January 1997 (yearly continuation).
Grantee: East Boston Geriatric Services, Inc., 10 Gove St.,
East Boston, MA 02128.
Period: June 1990-January 1997 (yearly continuation).
Grantee: Massachusetts State Department of Public Welfare,
180 Tremont St., Boston, MA 02111.
Providence Elder Place
Period: June 1990-January 1997 (yearly continuation).
Grantee: Providence Medical Center, 4805 Northeast Glisan
Street, Portland, OR 97213.
Period: June 1990-January 1997 (yearly continuation).
Grantee: Oregon State Department of Human Services, 313
Public Service Building, Salem, OR 97310.
Comprehensive Care Management
Period: February 1992-January 1997 (yearly continuation).
Grantee: Beth Abraham Hospital, 612 Allerton Ave., Bronx,
NY 10467.
Period: February 1992-January 1997 (yearly continuation).
Grantee: New York State Department of Social Services, 40
North Pearl Street, Albany, NY 12243-0001.
Palmetto Senior Care
Period: October 1990-January 1997 (yearly continuation).
Grantee: Richland Memorial Hospital, Fifteen Richland
Medical Park, Columbia, SC 29203.
Period: October 1990-January 1997 (yearly continuation).
Grantee: South Carolina State Health and Human Services
Finance Commission, P.O. Box 8206, Columbia, SC 29202-8206.
Community Care for the Elderly
Period: October 1990-January 1997 (yearly continuation).
Grantee: Community Care Organization, 5228 West Fond du Lac
Avenue, Milwaukee, WI 53216.
Period: October 1990-January 1997 (yearly continuation).
Grantee: Wisconsin State Department of Health and Social
Services, P.O. Box 7850, Madison, WI 53707-7850.
Total Longterm Care, Inc.
Period: August 1991-January 1997 (yearly continuation).
Grantee: Total Longterm Care, Inc., 3202 West Colfax,
Denver, CO 80204.
Period: August 1991-January 1997 (yearly continuation).
Grantee: Colorado Department of Social Services, 1575
Sherman Street, Denver, CO 80203-1714.
Bienvivir Senior Health Services
Period: June 1994-January 1997 (yearly continuation).
Grantee: Bienvivir Senior Health Services, 6000 Welch,
Suite A-2, El Paso, TX 77905-1753.
Period: December 1991-November 1997 (yearly continuation).
Grantee: Texas Department of Human Services, P.O. Box
149030 (MC-E-601), Austin, TX 78714-9030.
Independent Living for Seniors
Period: March 1992-March 1997 (yearly continuation).
Grantee: Rochester General Hospital, 311 Alexander Street,
Rochester, NY 14604.
Period: March 1992-March 1997 (yearly continuation).
Grantee: New York State Department of Social Services, 40
North Pearl Street, Albany, NY 12243-0001.
Sutter Senior Care
Period: May 1994-April 1997 (yearly continuation).
Grantee: Sutter Health System, 2800 L Street, Sacramento,
CA 95816.
Period: May 1994-April 1997 (yearly continuation).
Grantee: California Department of Health Services, 714/744
P Street, P.O. Box 942732 Sacramento, CA 94234-7320.
Center for Elders' Independence
Period: April 1995-March 1997 (yearly continuation).
Grantee: Center for Elders' Independence, 1411 East 31st
Street, Ward B2, Oakland, CA 94602.
Period: April 1995-March 1997 (yearly continuation).
Grantee: California Department of Health Services, 714/744
P Street, P.O. Box 942732 Sacramento, CA 94234-7320.
Evaluation of the Program of All-inclusive Care for the Elderly
demonstration
Period: June 1991-January 1997.
Funding: $4,486,514.
Contractor: Abt Associates Inc., 55 Wheeler Street,
Cambridge, MA 02138.
Investigator: David Kidder, Ph.D.
The Program of All-Inclusive Care for the Elderly (PACE)
Demonstration replicates a unique model of managed-care service
delivery for 300 very frail community-dwelling elderly, most of
whom are dually eligible for Medicare and Medicaid coverage and
all of whom are assessed as being eligible for nursing home
placement according to the standards established by
participating States. The model of care includes--as core
services--the provision of adult day health care and
multidisciplinary team case management through which access to
and allocation of all health and long-term-care services are
arranged. This model is financed through prospective capitation
of both Medicare and Medicaid payments to the provider. One
purpose of the evaluation is to examine PACE sites before and
after assumption of full financial risk, with the purpose of
determining whether the PACE model of care, as a replication of
the On Lok Senior Health Services model of care, is cost-
effective to the existing Medicare and Medicaid programs.
Another purpose is to examine the decision to enroll in PACE in
order to understand how PACE enrollees differ from those who
are eligible for PACE but refuse to enroll in the program; to
determine the impact of PACE on participant health services
utilization, expenditures, and outcomes; and to explore the
subobjectives of PACE or the link between PACE and the outcomes
of interest.
This project initiated primary data collection in January
1995 that will continue through the end of this contract.
Reports based on site visits to demonstration sites operating
under capitated Medicare and Medicaid payments have been
received annually. Preliminary impact results have been
received and suggest the following: (1) PACE reduces nursing
home and hospital use, while increasing use of ambulatory and
other non-institutional services; (2) PACE is associated with
improved health status, quality of life and satisfaction,
though not with measurable improvement in physical function;
(3) although PACE participants survive longer than non-
participants, the difference is not statistically significant;
and (4) PACE appears to be more effective at reducing
institutional utilization and improving health status and
satisfaction for participants with high levels of physical
impairment than for the less impaired.
Program for All-inclusive Care for the Elderly data management
Period: March 1992-August 1995.
Funding: $613,014.
Contractor: On Lok, Inc., 1333 Bush Street, San Francisco,
CA 94109.
Investigator: Marleen L. Clark, Ph.D.
The purpose of this project is to provide continuing data
management through out the Program for All-Inclusive Care for
the Elderly (PACE) demonstration period to ensure that a valid,
reliable data set is maintained for monitoring project
operations and for use by the Health Care Financing
Administration's independent evaluator. The PACE demonstration
replicates a unique model of managed-care service delivery for
very frail community-dwelling elderly persons, most of whom are
dually eligible for Medicare and Medicaid coverage and all of
whom are assessed as being eligible for nursing home placement
according to the standards established by the participating
States. DataPACE maintains a data set on PACE enrollees,
including demographic and enrollment information, health and
functional status, and service use. For the PACE demonstration
project, On Lok has established a minimum dataset and has
implemented data collection procedures at the PACE sites for
this data set. This dataset includes the variables and program
information originally designed to be used by evaluators. This
contract has been concluded.
Program of All-inclusive Care for the Elderly data management
Period: September 1995-August 1998.
Funding: $590,630.
Contractor: On Lok, Inc., 1333 Bush Street, San Francisco,
CA 94109.
Investigator: Marleen L. Clark, Ph.D.
The purpose of this contract is to provide data management
for the Program of All-Inclusive Care for the Elderly (PACE)
demonstration period to ensure that a valid, reliable data set
is maintained for monitoring project operations and for use by
the Health Care Financing Administration's independent
evaluator. This is a continuation of the previous contract with
On Lok, Inc. to provide this service. DataPACE maintains a data
set on PACE enrollees and manages data collection procedures at
the PACE sites. In the course of this second contract, service
utilization data are scheduled to be used by the PACE
demonstration programs's independent evaluator. The DataPACE
software and data management routines have been implemented at
all sites and continue to be used to monitor data quality and
provide feedback to the sites. The first round of data
transmissions to the independent evaluator have taken place.
External assessment of quality assurance in the Program for All-
inclusive Care for the Elderly
Period: September 1993-March 1996.
Funding: $389,218.
Contractor: Abt Associates Inc., 55 Wheeler Street,
Cambridge, MA 02138.
Investigator: David Kidder, Ph.D.
The purpose of this study is to develop and test an
external quality assurance program for the Program for All-
Inclusive Care for the Elderly (PACE) model of care based on
structured implicit review. These measures may be used by the
Health Care Financing Administration and State Medicaid
agencies in quality assurance monitoring of the PACE program.
The two key approaches that form the basis for the development
of a quality assurance program are: (1) a``tracer approach''
that identifies certain events whose existence represents a sign of
unsatisfactory care; and (2) ``general patient-centered measures'' of
health outcomes that reflect the total effects of care on the
individual patient. The quality assurance approach encompasses both
process and outcome elements. Tracer conditions have been developed by
the University of Minnesota, the subcontractor for this delivery order.
The University of Minnesota has obtained copies of medical records from
each of the PACE sites and has abstracted the necessary information
from the medical records. Final reports describing the success of
structured implicit review, information about patient satisfaction and
the feasibility of conducting this type of monitoring system on a group
of control patients have been submitted. The results suggest cautious
optimism about using structured implicit review on a wide scale.
Although this approach can detect differences in patterns of care,
inter-rater reliability is not high.
Program for All-inclusive Care for the Elderly (PACE) Quality Assurance
Period: September 1996-March 1999.
Funding: $1,837,148.
Contractor: Center for Health Policy Research, 1355 S.
Colorado Blvd, Suite 306, Denver, CO 80222.
Investigator: Peter Shaughnessy, Ph.D.
This project will develop an outcome-based quality
assurance and performance improvement system for the Program
for All-Inclusive Care for the Elderly (PACE) for use by Health
Care Financing Administration (HCFA) and States in monitoring
sites and for continuous quality improvement (CQI). The CQI
system will consist of two phases. In the first phase risk-
adjusted outcome reports will be produced, while during the
second phase the PACE sites will examine why and how they are
achieving specific outcomes and make recommendations for
improvements in the case of poor outcomes. This project is
currently in its design phase.
Social Health Maintenance Organization Project for long-term care
Period: August 1984-December 1997.
Funding: Waiver only.
Grantees: See below.
In accordance with section 2355 of Public Law 98-369, this
project was developed to implement the concept of a social
health maintenance organization (S/HMO) for acute and long-term
care. A S/HMO integrates health and social services under the
direct financial management of the provider of services. All
services are provided by or through the S/HMO at a fixed,
annual, prepaid capitation sum. Four demonstration sites were
selected to participate; of the four, two were health
maintenance organizations that have added long-term-care
services to their existing service packages and two were long-
term-care providers that have added acute-care service
packages. The demonstration sites use Medicare and Medicaid
waivers, and all initiated service delivery by March 1985.
HealthPartners (formerly Group Health in Minneapolis-St. Paul,
Minnesota), one of the original sites, discontinued
participation on January 1, 1995. On three separate occasions,
this demonstration has been extended by legislation. Current
legislation, Public Law 103-66, extends the demonstration
period through December 31, 1997.
Elderplan, Inc.
Grantee: Elderplan, Inc., 6323 Seventh Avenue, Brooklyn, NY
11220.
Medicare Plus II
Grantee: Kaiser Permanente Center for Health Research, 3800
North Kaiser Center Drive Portland, OR 97227-1098.
SCAN Health Plan
Grantee: Senior Care Action Network, 3780 Kilroy Airport
Way, Suite 600, P.O. Box 22616, Long Beach, CA 90801-5616.
Site development and technical assistance for the Second Generation
Social Health Maintenance Organization demonstration
Period: September 1993-September 1998.
Funding: $2,251,123.
Contractor: University of Minnesota, School of Public
Health, Institute for Health Services Research, D-351 Mayo
Memorial Building, 420 Delaware Street, SE., Box 197
Minneapolis, MN 55455-0392.
Investigator: Robert L. Kane, M.D.
In January 1995, the Health Care Financing Administration
selected six organizations to participate in the Second
Generation Social Health Maintenance Organization (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 social HMO model which was initiated as a
demonstration in 1985.
Although the same services are provided under both of these
projects the Second Generation Social HMO Demonstration
features a greater emphasis on geriatric care and a more
inclusive case management system. Another distinguishing
characteristic of the project it is 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, San Francisco are providing technical
assistance and support in the development, implementation, and
operation of the Second Generation Social HMO Demonstration.
The developmental phase of the Second Generation Social HMO
Demonstration began in January 1995. Since that time the
University of Minnesota and the University of California, San
Francisco have been providing technical assistance to the
organizations participating in the project. They have also
developed a questionnaire that will be used to determine a
beneficiary's capitated payment rate, a series of geriatric
protocols to help physicians identify and treat certain health
conditions, and a care coordination assessment instrument to
assist case managers with care planning. The Health Plan of
Nevada began enrolling beneficiaries into the demonstration in
November 1996. Enrollment at the other five organizations is
scheduled to begin in May 1997.
Second generation of Social Health Maintenance Organization
demonstration
Period: November 1996-November 1997.
Funding: Waiver only.
Grantees: See below.
In accordance with section 2355 of Public Law 98-369, the
concept of a social health maintenance organization (S/HMO) was
developed and implemented. The 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 of 1990
authorized the expansion of the Social Health Maintenance
Organization 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 will also provide
an opportunity to test more geriatrically oriented models of
care. Six organizations have been awarded waivers to implement
the project.
Grantee: CAC Ramsey Health Plan, 75 Valencia Avenue, Coral
Gables, FL 33134.
Grantee: Contra Costa County Health Plan, 595 Center
Avenue, Suite 100, Martinez, CA 94553.
Grantee: Fallon Community Health Plan, Chestnut Place, 10
Chestnut Street, Worcester, MA 01608.
Grantee: Health Plan of Nevada, Inc., P.O. Box 15645, Las
Vegas, NV 89114.
Grantee: Richland Memorial Hospital, Five Richland Medical
Park, Columbia, S.C. 29203.
Grantee: Rocky Mountain Health Maintenance Organization,
2775 Crossroads Boulevard, Grand Junction, CO 81505.
State of Minnesota ``Senior Health Options (SHO) Project''
Period: April 1995-December 2000 (yearly continuation).
Funding: Waiver only.
Grantees: Minnesota Department of Human Services, Human
Services Building, 444 Lafayette Road, St. Paul, MN 55155.
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 is
targeting the elderly dually entitled population that resides
in the 7-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 will be 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 will be treated as a health plan that
contracts with Health Care Financing Administration to provide
services, and provides those services through subcontracts with
various appropriate providers. The State will continue 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 would
continue to apply to the overall demonstration and managing
entity, which would be the State.
MAINE-NET: Medicaid- and Medicare-managed care for the elderly and
physically disabled in Maine
Period: September 1994-September 1997.
Funding: $944,940.
Grantees: Maine Department of Human Services, Bureau of
Medical Services, State House Station No. 11, Augusta, ME
04333.
Investigator: Carreen Wright.
This project is designed to demonstrate integrated models
for the financing and delivery of managed health care and
social services for Medicare and Medicaid elderly and
physically disabled persons in Maine. The project seeks to
promote the development of regional service delivery networks
or health plans, particularly in rural areas of the State that
would be responsible for the management, coordination, and
integration of services, including multidisciplinary approaches
to care planning and service delivery. The demonstration will
provide a comprehensive package of primary, acute, and long-
term-care institutional and noninstitutional services as part
of a prepaid-capitated health plan for the target populations.
The demonstration seeks to expand upon nursing home quality
indicators developed in the Health Care Financing
Administration sponsored multistate Case-Mix Demonstration
Project and incorporate HCFA's quality assurance guidelines for
managed care plans. In addition, the project will develop and
use an activity of daily living-based case-mix adjustment for
long-term-care services in the construction of capitation
payment rates, using the Resource Utilization Group III,
Version classification system also developed in the multistate
demonstration project. For services provided in boarding homes
and in the community, two new case-mix methodologies will be
developed for use by the demonstration.
This project is now in its second year. During this period,
a concept paper describing theState's health care environment
and the challenges facing the proposed demonstration program was
drafted. In addition, an analysis of the cost and use patterns of State
elderly and disabled Medicare and Medicaid beneficiaries has been
undertaken, and is expected to be complete by November 0f 1996. During
year two, a request for information was created and issued, and the
responses were reviewed by the State. The data from these responses,
along with a detailed county-by-county environmental analysis informed
the criteria used for the selection of the two sites for the proposed
demonstration. The State currently anticipates submitting the waiver
application in February 1997.
Managing medical care for nursing home residents
Period: December 1992-December 1998.
Funding: Waiver only.
Grantee: United HealthCare Corporation, Inc., P.O. Box
1459, Minneapolis, MN 55440-8001.
Investigator: Jeannine Bayard.
The objective of this demonstration is to study the
effectiveness of managing acute care needs of nursing home
residents by pairing physicians and geruiatric nurse
practitioners (GNPs) who will function as primary medical
caregivers and case managers. The major goals of the
demonstration are to reduce medical complications and
dislocation trauma resulting from hospitalization and to save
the expense of hospital care when patients could be managed
safety in the nursing home with expanded services. The
operating principal of this demonstration is EverCare, a
subsidiary of United Health Care Corporation, Inc. EverCare
will receive a fixed capitated payment (based on a percentage
of the adjusted average per capita cost) for all nursing home
residents enrolled and will be at full financial risk for the
cost of acute care services for enrollees. GNPs will provide
initial assessments of enrollees; make monthly visits;
authorize clinic, outpatient and hospital visits; and
communicate with the patients' physicians, nursing facility
staffs, and families. Physician incentive plans will be
structured to offer a higher reimbursement rate for nursing
home visits and lower reimbursement rates for services
furnished in physicians' offices or in other settings. By
increasing the intensity and availability of medical services,
EverCare believes that the model will reduce total care costs;
improve quality of care received by participants through better
coordination of appropriate acute care services; and improve
the quality of life for and level of satisfaction of enrollees
and their families.
Waivers were awarded in the summer of 1994 and currently
sites are operational in Atlanta, Baltimore, Boston, and
Phoenix; sites in Denver and Tampa are expected to initiate
services in 1997.
Randomized controlled trial of expanded medical care in nursing homes
for acute care episodes: Monroe County Longterm Care Program,
Inc.
Period: March 1992-December 1996.
Funding: $1,054,007.
Grantee: Monroe County Longterm Care Program, Inc., 349
West Commercial Street, Suite 2250, Piano Works East Rochester,
NY 14445.
Investigator: Gerald Eggert, Ph.D.
The objective of this demonstration is to develop,
implement, and evaluate the effectiveness of expanded medical
services to nursing home residents who are undergoing acute
illnesses that would ordinarily require hospitalization. The
intervention will include many services that are available in
acute hospitals and are feasible and safe in nursing homes.
These include an initial physician visit, all necessary
followup visits, diagnostic and therapeutic services, and
additional nursing care (including private duty), if necessary.
The major goals are to reduce medical complications and
dislocation trauma resulting from hospitalization and to save
the expense of hospital care when patient could be managed
safely in nursing homes with expanded services. The design
phase of the demonstration has been completed. The design is
currently being evaluated to determine the impact of the
implementation of the Multistate Nursing Home Case-Mix and
Quality Demonstration on the implementation of this
demonstration.
Community Nursing Organization Demonstration
Period: September 1992-December 1996.
Contractors: See below.
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 multispeciality clinic. All CNO sites have undergone a 1-
year development period and began a 3-year operational period
in January 1994, which continued in 1996. 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: Carle Clinic Association, 307 East Oak, Suite
3, P.O. Box 718, Mahomet, IL 61853.
Contractor: Carondelet Health Services, Inc., Carondelet
St. Mary's Hospital, 1601 West St. Mary's Road, Tucson, AZ
85745.
Contractor: Living at Home/Block Nurse Program, Ivy League
Place, Suite 225, 475 Cleveland Avenue North, St. Paul, MN
55104.
Contractor: Visiting Nurse Service of New York, 107 East
70th Street, New York, NY 10021.
Evaluation of the Community Nursing Organization Demonstration
Period: September 1992-June 1998.
Funding: $3,014,634.
Contractor: Abt Associates Inc., 55 Wheeler Street,
Cambridge, MA 02138.
Investigator: Robert J. Schmitz, Ph.D.
The Community Nursing Organization (CNO) Demonstration was
mandated by section 4079 of the Omnibus Budget Reconciliation
Act of 1987. The legislation directs the Secretary of the
Department of Health and Human Services to conduct a
demonstration project at four or more sites to test a
capitated, nurse-managed system of care. The two fundamental
elements of the CNO 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. The
CNO sites receive a monthly capitation payment for each
enrollee. The capitation rate is modeled on the average
adjusted per-capita cost-payment used for Medicare health
maintenance organizations. The CNO per-capita payment rate will
be set at a level that is equal to 95 percent of the adjusted
average per-capita Medicare payment for community and
ambulatory services in the CNO's geographic area. The
legislation mandates the use of two types of CNO per-capita
payment methods. Payment Method A adjusts the per capita
payment according to an individual's age, gender, and prior
home health use. Payment Method B adjusts the per capita
payment according to an individual's functional status in
addition to age, gender, and prior home health use. The
evaluation of the CNO demonstration will test the feasibility
and effect on patient care of a capitated, nurse case-managed
service-delivery model. Both qualitative and quantitative
components are included in the evaluation design. The
qualitative component will use a case study approach to examine
the operational and financial viability of the CNO model. The
quantitative component will use a randomized design to measure
the impact of the CNO intervention on mortality,
hospitalization, physician visits, nursing home admissions, and
Medicare expenditures, as well as on such nurse-sensitive
outcomes as knowledge of health problems and management of
care.
The four CNO demonstration sites completed a 1-year
developmental period and began a 3-year operational period in
January 1994. A 1-year extension of the demonstration and
evaluation has been granted. Collection of baseline data for
CNO enrollees began in January 1994. Site visit reports
summarizing site activities for the first and second
operational years have been completed. An interim report was
prepared by the evaluation contractor. A second interim report
is expected in Spring 1997.
Community Nursing Organization Demonstration External Quality Assurance
Period: July 1994-July 1997.
Funding: $535,304.
Contractor: Abt Associates Inc.
Investigator: David Kidder, Ph.D.
The purpose of the Community Nursing Organization (CNO)
Demonstration External Quality Assurance project is to conduct
an external review of the quality of health care delivered to
Medicare beneficiaries participating in the CNO demonstration
(a risk-reimbursed coordinated care program for home health and
selected ambulatory services). The CNO Demonstration External
Quality Assurance project includes a quarterly review of client
medical records for a sample of clients receiving Medicare-
covered mandatory CNO services, and a quarterly review of CNO
assessments and provision of CNO interventions on a sample of
all enrollees. Under this project, the awardee will be
responsible for monitoring the quality of care management and
health education services provided through the CNO and
implementing corrective actions, when necessary. The quality of
traditional Medicare home health services will be monitored.
The awardee also will conduct a use review of the home health
services provided to enrollees to validate or support changes
in capitation payment rates. The evaluation contractor will be
provided with accurate and complete documentation of the
findings and interventions of the quality assurance process.
Rehabilitating Medicare beneficiaries at home
Period: April 1993-April 1994.
Funding: $80,000.
Grantee: Wellmark Healthcare Services, Inc., 60 William
Street, Wellesley, MA 02181.
Investigator: Samuel Scialabba.
Wellmark intends to conduct a 2-year Medicare demonstration
that will provide beneficiaries will acute rehabilitation
services at home as an alternative to more expensive inpatient
rehabilitation hospital services. The Health Care Financing
Administration has awarded a cooperative agreement to Wellmark
to further refine its project design to develop information on
specific eligibility and screening criteria for patient
enrollment, detailed cost data on the proposed service package,
and informed consent policies to adequately inform patients and
caregivers of the risks and responsibilities of rehabilitative
home care. Medicare waivers will be required to allow Wellmark
reimbursement as a prospective payment, system-exempt
rehabilitation hospital. Funding for the evaluation will be
provided by the Robert Wood Johnson Foundation as part of a
national study entitled ``Evaluation of Innovative
Rehabilitation Alternatives and Critical Dimensions of
Rehabilitative Care.'' The final report has been submitted. A
request for Medicare waivers to implement the project was
withdrawn by the agency in May 1995.
Randomized controlled trial of primary and consumer-directed care for
persons with chronic illnesses
Period: September 1994-September 1997.
Funding: $345,243.
Grantee: Monroe County Longterm Care Program, Inc., 349
West Commercial Street, Suite 2250, Piano Works, East
Rochester, NY 14445.
Investigator: Gerald Eggert, Ph.D.
This demonstration will assess differences in outcome for
three treatment groups: a consumer-directed group, a case-
managed service group, and a model that combines both treatment
patterns. Findings will be compared with a control group that
receives no additional services or benefits. Eligibility for
participation is determined by residence in the community (at
home or in an assisted living setting) and by Medicare coverage
with a diagnosis of irreversible dementia or three or more
limitations in activities of daily living. In addition,
participants must be at risk for hospitalization (i.e., their
participation is based on prior use of hospitals or emergency
rooms). This project has completed the developmental phase. A
waiver package has been prepared and this is under review.
Implementation is anticipated in December 1996.
Managed care system for disabled and special needs children: District
of Columbia
Period: December 1995-November 1998.
Funding: Waiver only.
Grantee: The District of Columbia, Department of Human
Services, Commission on Health Care Finance, 2100 Martin Luther
King Jr. Avenue., S.W., Suite 302, Washington, D.C. 20020.
In December 1995 the District of Columbia was awarded a
section 1115 Medicaid waiver to test the efficacy of a managed-
care service delivery system designed for disabled and special
needs children. Participants in the demonstration are children
and adolescents who are under the age of 22, are eligible for
Supplemental Security Income (SSI) payments (i.e., considered
disabled according to SSI guidelines), and are subsequently
eligible for Medicaid as well. The District of Columbia hopes
to use the program to eliminate both barriers to access and
other health care delivery problems that children who are
disabled and their families encounter in the current Medicaid
fee-for-service program. This managed-care program seeks to
improve the health status and quality of life for these
children, while reducing the overall health care costs
associated with their care. Enrollment in the demonstration is
voluntary; however, eligible children who do not explicitly
choose to remain in the current fee-for-service system after
being informed of the new program are assigned to HSCSN after a
specified notice period. Enrollment cannot be finalized,
however, until a health needs assessment is completed for each
new member. Health services under this demonstration are being
coordinated by Health Services for Children with Special Needs,
Inc. (HSCSN), a non-profit corporation established specifically
for the purpose of providing managed care for children
enrolling in the demonstration.
The project was implemented in December 1995. As of October
1996, approximately 1,500 of the 3,000 eligible children have
chosen to enroll in HSCSN, while approximately 500 children/
families have chose to remain in the fee-for-service system.
Evaluation of the District of Columbia's demonstration project,
``Managed Care System for Disabled and Special Needs Children''
Period: September 1996-March 2000.
Funding: $1,203,963.
Contractor: Abt Associates Inc., 55 Wheeler Street,
Cambridge, MA 02138-1168.
Investigator: Carol Irvin, Ph.D.
The District of Columbia submitted a waiver-only request
for Medicaid waivers under section 1115(a)(1) for a 3-year
demonstration project to test the efficacy of a managed care
service delivery system designed for children and adolescents
under the age of 22 who are eligible for Medicare and are
considered disabled according to Supplementary Security Income
(SSI) Program guidelines. This study represents a unique
opportunity to examine the experiences of a managed-care system
with voluntary enrollment of children with disabilities. The
project, which seeks to integrate acute and long-term-care
services for children with disabilities into a single capitated
payment methodology, is the first approved demonstration of its
kind. The information gathered will be used to inform both
State and Federal policymakers who have increasingly come to
regard managed care as a mechanism to contain growing health
care expenditures.
This study will provide for a special analysis of the
enrollment and disenrollment processes, as well as of the
project's implementation process (including enrollment and
participation, services/benefits, provider participation and
training, organizational and administrative issues, contracting
and risk-sharing arrangements, provider fee schedules,
community involvement, and quality assurance, administrative
and data management systems). Outcome analyses will focus on
enrollee/family outcomes (including care management, service
utilization and costs, enrollee/family satisfaction, quality of
care and health status indicators, access to care, and family/
informal care giving), organizational outcomes (including an
analysis of HSCSN's financial performance, and the risk sharing
arrangement between HSCSN and the District of Columbia), and
the impact upon the provider community. Data for the evaluation
will come from surveys (primary data collection), case study
interviews, focus groups, Medicaid Management Information
System and encounter data, and SSI data. The project was
awarded in September 1996, and is in the early stages of
development and implementation.
Special Care managed care initiative
Period: February 1992-December 1996.
Funding: $656,270.
Grantee: Wisconsin State Department of Health and Social
Services, 1 West Wilson Street, P.O. Box 309, Madison, WI
53701-0309.
Investigator: Howard Garber, Ph.D.
The purpose of the special care initiative project is to
gain improved understanding of the need, use, and cost of
delivery of health services to high-risk, severely disabled
persons. The severely disabled population is a significant user
of medical services. Moreover, cost between 1988 and 1991
increased at a rate double that of population increase.
Therefore, an important objective is to contain the cost and
use of Medicaid services by severely disabled persons, while
maintaining or improving the level of client satisfaction.
Special Care, Inc. (SCI) is an independent, nonprofit
organization that represents a joint venture between the
Milwaukee Center for Independence, a Milwaukee rehabilitation
facility, and the Wisconsin Health Organization, an established
health maintenance organization. SCI will create specialized
services, including a dedicated physician panel, case-
management services, and clinical services as strategies to
assess medical need and to better coordinate service resources
available in the community. The State of Wisconsin will use a
capitation methodology for reimbursement to SCI. Enrollment of
SCI members will be voluntary.
As a research and demonstration program, it aims to improve
the understanding of the need, use, costs, and cost-management
opportunities associated with the delivery of health services
to high-risk, severely disabled persons. These individuals are
disabled, categorically needy, noninstitutionalized, exempt
from the spenddown provisions, eligible for Medicaid, and
eligible for Supplemental Security Income disability benefits.
The diagnostic distribution of cases in this population is 41
percent mental retardation, 17.4 percent chronic mental
illness, 13.5 percent skeletal/muscular, 11.2 percent epilepsy,
9.3 percent cerebral palsy, 1.6 percent cardiac/circulatory,
1.2 percent autism, and 4.9 percent other. This is a severely
disabled and generally unemployable population whose medical
care use and cost experience show a non-normalized pattern. The
average hospital length of stay for members of this group is 7
times longer than that for the general population. Their
hospital costs are 4 times higher without clear explanation.
To measure the performance of the SCI program, a management
information system (MIS) file will be created to match the
demographic characteristics of program participants with the
cost and use data obtained from the history files maintained by
the Wisconsin Medicaid program. Medicaid data will include
service and procedure frequencies, service mix, billings and
reimbursements, provider practices, and certain medical status
indicators. MIS files will contribute additional information on
disability condition, enrollment information, benefit
coordination, and case management. In addition, data on client
satisfaction, quality of care, and enrollment/disenrollment
decisions will be collected.
The State is operating this project under a section 1915(a)
State Plan exception. The program officially began in June
1994. As a point of clarification, Special Care signifies the
initiative proposed to the Health Care Financing Administration
(HCFA) for the managed care program, while Independent Care (I
Care) is the formal community name of the managed care company.
In July 1996, a no-cost extension was granted to the State to
allow for a full 3-year operational period.
The evaluation contract with the Human Services Research
Institute (HSRI) was signed in May 1994, after it was reviewed
and approved by HCFA. This evaluation contractor submitted its
final working plan at the beginning of grant year 03. HSRI
proposes a 3-year evaluation, which will combine survey data
with HCFA's Medicaid Statistical Information System
Administrative files. The evaluator developed and piloted an
interview protocol, the Cross-Disability Integrated Health
Outcomes Survey for use with the I Care recipients and control
group members. Evaluation activities will include the selection
of comparison groups, using cost cluster information from a
State-developed profile of a sample of I Care patients. This
sample was drawn from an aggregate of all 1994 paid claims for
every Milwaukee and Racine county Supplemental Security Income
beneficiary who is disabled and was then assigned to one of
three cost categories--low, medium, or high. Interim evaluation
findings are expected in December 1996.
Rhode Island Long-Term Care Waiver: CHOICES
Period: May 1995-July 1996.
Funding: $150,000.
Grantee: Rhode Island Department of Human Services, 600 New
London Avenue, Cranston, RI 02902.
Investigator: Christine C. Ferguson.
In 1994, the State of Rhode Island Department of Human
Services (DHS) and Department of Mental Health, Retardation and
Hospitals (MHRH) submitted a waiver-only proposal which intends
to consolidate all current State and Federal funding streams
for approximately 4,000 adults with developmental disabilities
under one managed care Title XIX waiver program. The State
proposed a 5-year demonstration with a two-phase transition
process. The State wants to consolidate into a single program
with a single set of rules the following separate Title XIX
programs:
Intermediate Care Facilities for the Mentally
Retarded (ICF-MR);
Home and Community Based Waiver;
State Plan Rehabilitation Services;
Acute/Medical Care.
Rhode Island envisions a publicly administered managed-care
system with a single-payer model. Each eligible person will be
enrolled in a private health maintenance organization or
approved health plan for acute health care. Managed care plans
participating in Rhode Island's RIte Care program may be asked
to participate in the CHOICES program and provide managed
health care for people with developmental disabilities, thus
bringing together Rhode Island's two managed care initiatives.
Alternatively, a statewide health care plan will be established
for adults with developmental disabilities and the employees of
the service agencies.
Under CHOICES, a case-management system will also be
available to assist each eligible individual to obtain required
long-term supports. The State intends to ascribe to all
eligible persons a dollar amount with which they, with
technical assistance from a broker or other source, will choose
to manage the long-term care services directly themselves via a
voucher, or choose an agency that can support their needs
within the identified resources available. This dollar amount
will be based on a methodology prepared by the assessment/
authorization work group.
Services covered by CHOICES can be divided into several
categories:
Supported living services;
Alternative living arrangements;
Day supports;
Acute care/medical services.
The covered target population under CHOICES consists
principally of persons with MR or related conditions, and the
developmentally disabled, who are already eligible for and
receiving services under various currently operating Title XIX
programs.
In addition to its current population, CHOICES will serve
up to 25 individuals with traumatic brain injury who are in
need of long-term community living supports and who may
beinappropriately institutionalized or living in the community with
inadequate support; approximately 500 individuals now receiving
supported employment services funded with State monies; about 40 people
currently in the State-funded developmental disabilities program for
whom there is no Federal financial participation; and approximately 125
people turning 21 and graduating from special education, applying for
services from the Division of Developmental Disabilities under the
Department of Human Services for Rhode Island. The State was awarded a
grant in June 1995 to further develop the project design. Waivers have
not yet been awarded.
Demonstration of Integrated Care Management Systems for high-cost/high-
risk Medicaid beneficiaries
Period: October 1995-October 2000.
Funding: Waiver only.
Grantee: Department of Health and Mental Hygiene, State of
Maryland, 201 West Preston Street, Baltimore, MD 21201.
Investigator: Martin P. Wasserman, M.D., J.D.
Maryland is testing a new case-management system for high-
cost/high-risk Medicaid beneficiaries and those at risk to
become high cost. The program seeks to maintain or improve
access to providers and the quality of the care provided. The
demonstration also should lower health care costs by reducing
hospital readmission rates and by maintaining patients in the
lowest cost medically appropriate setting. The University of
Maryland at Baltimore County, Center for Health Program
Development and Management, under contract to the State, is
responsible for the demonstration's operations. This project
was approved in October 1995. In October 1996, the State
requested to withdraw the waivers, as the project was
incorporated in Maryland's statewide waiver, approved in
October 1996.
Community-Supported Living Arrangements Program: Process evaluation
Period: September 1993-March 1997.
Funding: $411,941.
Awardee: SysteMetrics/MedStat, 104 West Anapamu Street,
Santa Barbara, CA 93101.
Investigator: Marilyn Ellwood.
The Community-Supported Living Arrangements (CSLA) Program
is designed to test the effectiveness of developing, under
section 1930 of the Social Security Act, a continuum of care
concept as an alternative to the Medicaid-funded residential
services provided to individuals with mental retardation and
related conditions (MR/RC) as an optional State plan service.
The CSLA program serves individuals with MR/RCs who are living
in the community either independently, with their families, or
in homes with three or fewer other individuals receiving CSLA
services. This model of care includes personal assistance;
training and habilitation services necessary to assist
individuals in achieving increased integration, independence,
and productivity; 24-hour emergency assistance; assistive
technology; adaptive technology; support services necessary to
aid these individuals in participating in community activities;
and other services, as approved by the Secretary of the
Department of Health and Human Services. Costs related to room
and board and to prevocational, vocational, and supported
employment services are excluded from coverage. In accordance
with the legislatively set maximum, California, Colorado,
Florida, Illinois, Maryland, Michigan, Rhode Island, and
Wisconsin have implemented CSLA programs. The purpose of this
contract is to provide an evaluation of the CSLA program to the
Health Care Financing Administration's Medicaid Bureau and
Congress for their consideration of policy options regarding
the continuation and/or expansion of the Medicaid State Plan
optional service. The evaluation will address five areas:
Philosophy or goals guiding States' CSLA program;
Description of CSLA programs with respect to
recipients, types of services received, and the cost of
such services;
Description and discussion of quality assurance
mechanisms being implemented;
Exploration of the question of compatibility of the
supported living concept with current goals and the
structure of the Medicaid program;
Exploration of the relationship between the supported
living concept and the Americans with Disabilities Act.
The contract was awarded on September 30, 1993. As of
September 1996, the eight site visits to the participating
States have been conducted. Six of the eight State case studies
have been reviewed and are approved for distribution. Secondary
data analysis will be conducted using data available from the
participating CSLA States. A final evaluation report is
expected in March 1997.
Texas Nursing Home Case-Mix and Quality Demonstration
Period: February 1992-December 1998.
Funding: $532,830.
Grantee: State of Texas Department of Human Services, P.O.
Box 149030 (MC-E-601), Austin, TX 78714-9030.
Investigator: Ken. C. Stedman.
Texas will participate in the Multistate Nursing Home Case-
Mix and Quality (NHCMQ) Demonstration. The objective of the
demonstration is to test the feasibility and cost effectiveness
of a case-mix payment system for nursing facility services
under the Medicare and Medicaid programs that are based on a
common patient classification system. The addition of Texas
enhances the Health Care Financing Administration's ability to
project the results of the demonstration on a national basis.
Texas represents a western pattern of service using more
proprietary multistate chain providers than is the pattern used
in the East. Twenty Texas Medicare facilities were part of the
original data collection for the development of the resource
utilization group (RUG) III system. Texas has the second
largest number of hospital-based facilities in the country.
There are more than 20 metropolitan statistical areas of
varying size. In addition, the State has a large number of
rural areas. The State was traditionally a flat-rate
intermediate care facility Medicaid system until 1989, when it
implemented a RUG-type Medicaid payment system. This RUG-type
payment system makes Texas well-suited for inclusion in the
Medicare portion of the demonstration.
During the first year of participation, the Texas
Department of Human Services worked with the Texas Department
of Health to change the resident assessment being used in the
State. In April 1993, Texas implemented the minimum data set
plus statewide as its resident assessment instrument. Analyses
of 1990 Medicare Cost Report data, Medicare provider analysis
and review Part A skilled nursing facility stay data, and the
Texas Client Assessment an Review Evaluation (CARE) data have
been conducted for use in developing the demonstration's
Medicare case-mix payment system. Under the Medicaid
demonstration, Texas began development of the Quality
Evaluation System of Texas, a resident characteristic
information and reporting system using the CARE instrument.
During the first year, the staff continued the development and
enhancement of the system, which was codified into Law by the
Texas Legislature in Summer 1993. They now are producing
facility-level reports with statewide comparisons for Texas
providers on a twice-a-year basis. The Medicare portion of the
NHCMQ demonstration was implemented July 1, 1995, in Texas.
Multistate Nursing Home Case-Mix and Quality Demonstration
Period: June 1989-December 1998.
Funding: $5,322,941.
Project Nos.:
Kansas, 11-C-99366/7
Maine, 11-C-99363/1
Mississippi, 11-C-99362/8
South Dakota, 11-C-99367/8
Grantees: State Medicaid Agencies.
This project builds on past and current initiatives with
nursing home case-mix payment and quality assurance. The 6-year
demonstration will design, implement, and evaluate a combined
Medicare and Medicaid nursing home resident classification and
payment system in Kansas, Maine, Mississippi, and South Dakota.
The purpose of the demonstration is to test a resident
information system with variables for classifying residents
into homogeneous resource use groups for equitable payment and
for quality monitoring of outcomes adjusted for case mix. The
new minimum data set plus (MDS+) for resident assessment will
be used for resident-careplanning, payment classification, and
quality-monitoring systems. The project consists of three
phases: systems development and design, systems implementation
and monitoring, and evaluation.
The project has conducted a field test of the minimum data
set on 6,660 nursing home residents. The average direct-care
staff time across the States is 115 minutes per day per
resident. A new patient classification system and a Multistate
Medicare/Medicaid Payment Index containing 44 groups has been
created. The States have collected and reviewed over 3 million
MDA+ documents on over 500,000 different residents assessed
between September 1990 and July 1996. In developing the payment
systems, facility cost reports and resident characteristic data
were analyzed to determine the case mix of residents and
patterns of service use. The Medicare case-mix-adjusted payment
system was implemented in August 1995. The quality-monitoring
information system has been tested, and 30 quality indicators
are being used for monitoring facility-level and resident-level
quality.
New York Case-Mix Payment and Quality Demonstration
Period: May 1990-December 1998.
Funding: $981,718.
Grantee: New York State Department of Health, Empire State
Plaza, Room 1683, Corning Tower, Albany, NY 12237.
Investigator: Robert W. Barnett.
New York State will participate in the multistate Nursing
Home Case-Mix and Quality (NHCMQ) Demonstration. The objective
of the demonstration is to test the feasibility and cost
effectivess of a case-mix payment system for nursing facility
services under the Medicare and Medicaid programs that are
based on a common patient classification system. The addition
of New York State enhances the Health Care Financing
Administration's ability to project the results of the
demonstration on a national basis. New York represents a
heavily regulated, northern, industrialized area with larger,
high-cost nursing facilities that are medically sophisticated
and highly skilled. Sixteen percent of the national Medicare
skilled nursing facility (SNF) days are incurred in New York
State. New York is uniquely suited for inclusion because it
already has implemented a complementary system for its Medicaid
nursing facility payment program.
In early 1991, the project staff completed the minimum data
set field test in 25 facilities on 993 residents. These data
have been added to the database and analyzed to develop the new
NHCMQ Medicare/Medicaid classification system. The inclusion of
the New York State data has resulted in the addition of a very
high rehabilitation group to the upper end of the
classification. The State has implemented the minimum data set
plus (MDS+) statewide as its resident assessment instrument. In
November 1992, New York State began receiving the information
monthly from all facilities; by July 1, 1996, it had received a
total of 2,000,000 assessments. In developing the Medicare
payment system, the 1990 Medicare cost reports were used, as
well as the MDS+ data and the Medicare provider analysis and
review file. The Medicare case-mix-adjusted payment system was
implemented July 1, 1995, in New York. By Summer 1996, there
were over 350 SNFs participating in the SNF demonstration, 7 of
which are hospital based.
Implementation of the Multistate Nursing Home Case-Mix and Quality
Demonstration
Period: February 1994-December 1998.
Funding: $3,209,538.
Contractor: Allied Technology Group, Inc., 1803 Research
Boulevard, Suite 601, Rockville, MD 20850.
Investigator: Robert E. Burke, Ph.D.
This contract will support the implementation phase of the
Multistate Nursing Home Case-Mix and Quality Demonstration. The
demonstration combines the Medicare and Medicaid nursing home
payments and quality monitoring system across several States:
Kansas, Maine, Mississippi, New York, South Dakota, and Texas.
This project builds on past and current initiatives with case-
mix payment and quality assurance in nursing homes. The purpose
of the demonstration is to test a resident information system
with variables for classifying residents into homogeneous
resource utilization groups for equitable payment and for
quality monitoring of process and outcomes adjusted for case
mix. The project will have three phases: systems design and
development, systems implementation and monitoring, and
evaluation.
The objectives of the implementation phase are as follows:
Recruit facilities in the six demonstration States to
participate in the Medicare portion.
Develop and operate the Medicare case-mix system of
the demonstration for the Health Care Financing
Administration that involves the fiscal intermediaries
and the Medicare skilled nursing facility (SNF)
provider;
Conduct a staff-time measurement study to validate
the Resource Utilization Group, Version III (RUG III)
classification system and add a valid therapy payment
component;
Validate the quality indicators (QIs) and implement
the quality monitoring system in the demonstration
States through the States' nursing home survey process;
Implement an administrative management and
operational system that links distinctcomponents of the
demonstration (e.g., classification of residents, Medicare coverage
determination, payment systems, outcome monitoring for quality
assessment reliability); and
Implement a field auditing system that monitors
States and nursing homes participating in the Medicare
portion.
In July 1993, implementation of the Medicaid prospective
payment systems was begun, with full participation in 1994.
Maine, Mississippi, Kansas, and South Dakota are beginning to
routinely use the QI reports in the survey and certification
process as of October 1995, based on the pilot test report and
the first nine validation visits.
In Fall 1996, there are over 2,100 Medicare SNFs in the 6
demonstration States, in contrast to 1,120 in 1990. There were
over 1,500 invitations sent to providers in October 1996, for
Phase III (routine and rehabilitation) of the demonstration
expressing interest in further information by summer 1995.
Phase I operation of the Medicare prospective payment system
began in July 1995. By Fall 1995, there were 300 facilities
being paid for routine services using the 3 regional Multistate
Medicare Payment Indices.
The RUG III validation staff-time measurement data
collection was completed in 7 States by July 1, 1995, including
the minimum data set 2.0 (MDS2.0) on 2,056 residents across
approximately 80 study units in 7 States, not counting New
York. Data collection in New York will be completed in early
1996 and added to the validation database. The resident level
validation data file is currently being compiled. The multiple
analyses will be carried out during winter 1995, with the
rehabilitation (occupational, physical, and speech therapy)
index added to the Medicare payment system in spring 1996.
Phase II of the Medicare portion of the demonstration will
begin at the start of providers' fiscal years beginning January
1, 1996. In January 1996 and each calendar year thereafter to
the end of the demonstration, the prospective rates will be
inflated on January 1st. Phase III of the demonstration, when
the rehabilitation therapies will be added to the prospective
payment, will begin April 1996 in the fiscal year of the
provider. Recruitment of SNF participation will end in 1997.
Evaluation of the Nursing Home Case-Mix and Quality Demonstration
Period: September 1994-September 1999.
Funding: $2,980,219.
Contractor: Abt Associates Inc., 55 Wheeler Street,
Cambridge, MA 02138.
Investigator: Robert J. Schmitz, Ph.D.
Under the Nursing Home Case-Mix and Quality (NHCMQ)
Demonstration, the Health Care Financing Administration is
testing the feasibility of paying skilled nursing facilities
(SNFs) for Medicare skilled nursing services on a prospective
basis. Currently, SNFs are reimbursed on a retrospective basis
for their reasonable costs. A case-mix classification, called
resource utilization groups, is being used to classify
patients, permitting HCFA to pay facilities for each covered
day of care, according to the case mix of patients residing in
the facility on any given day. Though some costs will continue
to be paid on a retrospective cost basis under the
demonstration, the prospective rate will eventually include
inpatient routine nursing costs and therapy costs. To guard
against the possibility that inadequate care would be provided
to patients with heavy care needs, a system of quality
indicators has been developed that will be used to monitor the
quality of care.
The demonstration project was implemented in six States
(Kansas, Maine, Mississippi, New York, South Dakota, and Texas)
in Summer 1995, with Medicare-certified facilities in these
States being offered the opportunity to participate on a
voluntary basis.
The evaluation of this demonstration project will seek to
estimate specific behavioral responses to the introduction of
prospective payment and to test hypotheses about certain
aspects of these responses. The principal goal of the
evaluation of the NHCMQ Demonstration is the estimation of the
effects of case-mix-adjusted prospective payment on the health
and functioning of nursing home residents, their length of
stay, and use of health care services; on the behavior of
nursing facilities; and on the level and composition of
Medicare expenditures.
The evaluation design has been finalized and visits to a
sample of demonstration facilities began. Current analytic
activities center around sampling and data collection. Of
special interest is collection of data on the provision of
therapy services from both demonstration sites and comparison
sites which will entail some primary data collection because
the quantity and duration of therapies may not be reliably
ascertained from Medicare claims data. The data collection plan
is being developed pursuant to an assessment of the form in
which most facilities maintain their records, and nurses are
being recruited to abstract medical records. A key issue that
will be analyzed is whether the probability of discharge or
transfer changes under case-mix-adjusted prospective payment
and what circumstances surround discharges or transfer from
nursing facilities.
Implementation of the Home Health Agency Prospective Payment
Demonstration
Period: June 1990-November 1995.
Funding: $1,629,606.
Contractor: Abt Associates Inc., 55 Wheeler Street,
Cambridge, MA 02138.
Investigator: Henry Goldberg.
This contract implements and monitors the demonstration
design for the Home Health Agency Prospective Payment
Demonstration, which was developed under an earlier contract
with Abt Associates, Inc. Under this project, two methods of
paying home health agencies (HHAs) on a prospective basis for
services furnished under the Medicare program will be tested.
The prospective payment approaches to be tested include
payments per visit by type of discipline (Phase I), and
payments per episode of Medicare-covered home health care
(Phase II). HHA participation is voluntary. In each phase, HHAs
that agree to participate are randomly assigned to either the
prospective payment method or to a control group that continues
to be reimbursed in accordance with the current Medicare
retrospective cost system. HHAs participated in the
demonstration for 3 years.
Following an initial recruitment of HHAs, operations under
Phase I were implemented on October 1, 1990. Forty-nine HHAs
were recruited. All agencies under Phase I completed their 3-
year participation by October 1994. An evaluation of Phase I
was conducted by Mathematica Policy Research, Inc., through a
separate contract (see 500-90-0047 in this edition of Active
Projects Report. Recruitment for Phase II agencies began in
Fall 1994. The implementation of Phase II, the per-episode
payment phase, will be conducted by Abt Associates under a
separate contract.
Evaluation of the Home Health Prospective Payment Demonstration
Period: September 1990-November 1995.
Funding: $2,858,676 (Phase I).
Contractor: Mathematica Policy Research, Inc., P.O. Box
2393, Princeton, NJ 08543-2393.
Investigator: Randall S. Brown, Ph.D.
The purpose of this contract is to evaluate Phase I of the
demonstration designed to test the effectiveness of using
prospective payment methods to reimburse Medicare-certified
home health agencies (HHA) for services provided under the
Medicare program. In Phase I, a per visit payment method that
sets a separate payment rate for each of six types of home
health visits (skilled nursing, home health aide, physical
therapy, occupational therapy, speech therapy, and medical
social services) is being tested. Mathematica Policy Research
is evaluating the effects of this payment method of HHAs'
operations, service quality, and expenditures. The awardee is
also analyzing the relationship between patient characteristics
and the cost and utilization of home health services.
By October 1994, all demonstration agencies exited the
demonstration. Mathematica has completed their evaluation. The
article ``Do Preset Per Visit Payment Rates Affect Home Health
Agency Behavior?'' by Phillips, B.R., Brown, R.S., Bishop,
C.E., and Klein, A.C. discusses preliminary results from Phase
I of the demonstration and appears in the health Care Financing
Administration, Volume 16, Number 1, pages 91-107, Fall 1994.
Findings from the full demonstration suggest that per visit
prospective payment had no significant effect on quality of
care, selection and retention of patients, cost per visit,
visit volume, use of non-Medicare services, and use and
reimbursement of Medicare-covered services. But it appears that
treatment agencies may have responded to the opportunities to
earn profits under the demonstration by increasing their volume
of visits faster than they would have in the absence of
prospective ratesetting.
Phase II implementation of the Home Health Agency (HHA) Prospective
Payment Demonstration
Period: September 1995-September 1999.
Funding: $1,811,184.
Contractor: Abt Associates Inc., 55 Wheeler Street,
Cambridge, MA 02138.
Investigator: Henry Goldberg.
This contract implements and monitors Phase II of the Home
Health Agency (HHA) Prospective Payment Demonstration. Under
phase II, a single payment per episode approach will be tested
for Medicare-covered home health care. HHA participation is
voluntary. It is expected that approximately 100 agencies in
California, Florida, Illinois, Massachusetts, and Texas will
participate in the demonstration. HHAs that agree to
participate will be randomly assigned to either the prospective
payment method or a control group that continues to be
reimbursed in accordance with the current Medicare
retrospective cost system. HHAs will participate in the
demonstration for 3 years.
Phase II recruitment began in Fall 1994 under a previous
contract with Abt Associates, Inc. The HHA entered into the
demonstration at the beginning of their fiscal years. Several
HHAs began receiving per-episode payments in June 1994, with
the majority entering the demonstration in January 1996. The
episodic payment rates are prospectively set for each HHA,
reflecting their previous practice and cost experience. Rates
are to be adjusted annually. As a protection to both the HHAs
and the Medicare program, there will be retrospective
adjustments for sharing of gains or losses and for changes in
an HHA's projected case mix.
Evaluation of Phase II of the Home Health Agency Prospective Payment
Demonstration
Period: September 1994-September 1999.
Funding: $3,528,408.
Contractor: Mathematica Policy Research, Inc., P.O. Box
2393, Princeton, NJ 08543-2393.
Investigator: Barbara Phillips, Ph.D.
This contract will evaluate Phase II of the Home Health
Agency Prospective Payment Demonstration. This demonstration is
testing two alternative methods of paying home health agencies
(HHA) on a prospective basis for services furnished under the
Medicare program. The prospective payment approaches being
tested include payments per visit by type of HHA visit
discipline (Phase I) and payment per episode of Medicare-
covered home health care (Phase II). Implementation of Phase
II, which will test the per episode payment approach, is
scheduled to begin in Spring 1995. HHAs that agree to
participate are randomly assigned to either the prospective
payment method or to a control group that continues to be
reimbursed in accordance with the current Medicare
retrospective cost system. HHAs will participate for 3 years.
The evaluation will combine estimates of program impacts on
cost, service use, access, and quality, with detailed
information on how agencies actually change their behavior to
produce a full understanding of what would happen if
prospective payment replaced the current cost-based
reimbursement system nationally. 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. This information will
be of great value for estimating the potential savings from a
shift to prospective payment for home health care, for
indicating where potential savings from a shift to prospective
payment for home health care, for indicating where potential
problems with quality of care might exist, and for identifying
types of patients who might be at risk of restricted access to
care as a result of their need for an unusually large amount of
care. Because of the relatively small number of agencies
participating, the use of qualitative information obtained in
discussions with agencies concerning their characteristics and
behavior will be essential for avoiding erroneous inferences.
The first round of site visits to participating agencies has
been completed.
Quality assurance for Phase II of the Home Health Agency Prospective
Payment Demonstration
Period: September 1995-September 2000.
Funding: $2,799,265.
Contractor: Center for Health Policy Research, 1355 South
Colorado Boulevard, Suite 306, Denver, CO 80222.
Investigator: Peter W. Shaughnessy, Ph.D.
This contract provides for developing and implementing a
quality review mechanism for use by home health agencies (HHAs)
participating in Phase II of the Home Health Agency Prospective
Payment Demonstration. This demonstration is testing two
alternative methods of paying HHAs on a prospective basis for
services furnished under the Medicare program. The prospective
payment approaches being tested include payments per visit by
type of discipline (Phase I), and payments per episode of
Medicare-covered home health care (Phase II). To ensure that
incentives created under Phase I did not result in the
provision of inadequate care to Medicare beneficiaries, the New
England Research Institute, Inc. (NERI) implemented a
qualityassurance (QA) approach that utilized patient record reviews for
a sample of Medicare beneficiaries. However, since one of the goals of
Heath Care Financing Administration's Medicare Home Health Initiative
is to move toward the implementation of an outcome-based, patient-
centered (QA) system for Medicare home health, it was felt that the
second phase of this demonstration provided an opportunity to
incorporate a scaled-down version of the outcome-based program
developed by the Center for Health Services Research at the University
of Colorado.
During the first project year, the contractor developed
software for electronic submission of (QA) data from
participating home health agencies, completed preliminary
agency training, initiated the collection of (QA) data,
developed and implemented a data receipt tracking and control
system, and has continued to provide additional technical
assistance and retraining for agencies as necessary.
Design and Implementation of Medicare Home Health Quality Assurance
Demonstration
Period: September 1994-May 1999.
Funding: $3,234,881.
Contractor: Center for Health Policy Research, 1355 South
Colorado Boulevard, Suite 706, Denver, CO 80222.
Investigator: Peter W. Shaughnessy, Ph.D.
Currently, Medicare's home health survey and certification
process is primarily focused on structural measures of quality.
Although this process provides important information about home
health care, an approach based on patient outcome measures
would substantially increase the Medicare program's capacity to
assess and improve patient well-being. To address this need,
the Medicare home health quality demonstration will test an
approach to developing outcome-oriented quality assurance and
promoting continuous quality improvement in home health
agencies. The demonstration is designed to serve two purposes:
increase Health Care Financing Administration's capacity to
assess the quality of Medicare home health care services and
increase home health care agencies' ability to systematically
evaluate and improve patient outcomes. The proposed quality
assurance approach would complement existing home health
certification and review programs and could be used with
current survey and certification and peer review organization
intervening care screen approaches. The study's conceptual
framework for home health quality assessment is based on home
health outcomes measures developed under a HCEA-funded study by
the University of Colorado, entitled ``Development of Outcome-
Based Quality Measures in Home Health Services'' (Contract No.
500-88-0054). Fifty agencies have been recruited for this
demonstration and began demonstration operations in January
1996. In early 1997, agencies will receive their first outcome
reports.
Project demonstration and evaluating alternative methods to assure and
enhance the quality of long-term care services for persons with
developmental disabilities through performance-based contracts
with service providers
Period: September 1994-September 1997.
Funding: $800,000.
Grantee: Minnesota Department of Human Service, Health Care
Administration, 44 Lafayette Road, St. Paul, MN 55155-3853.
Investigator: Elaine J. Timmer.
The purpose of this project is to determine whether and how
well the implementation of new approaches to quality assurance,
with outcome-based definitions and measures of quality, will
replace the input and process measures of quality and, in the
process, contribute to improving the quality of life of persons
with developmental disabilities. The Minnesota Department of
Human Services will seek Federal authority to waive necessary
provisions of the intermediate care facilities for the mentally
retarded (ICF-MR) regulations to permit alternative quality
assurance mechanisms in selected demonstration, residential,
and support service programs. The department will enter into
performance-based contracts with counties and participating
ICF-MR providers. These contracts will specify the amount and
conditions of reimbursement, requirements for monitoring and
evaluation, and expected client-based outcomes. These client-
based outcomes will be determined by the client and by the
legal representative, if any, and with the assistance of the
county case manager and provider. Some desirable outcomes
include enhancement of consumer choice and autonomy,
employment, and integration into the community. Criteria for
measuring participating agency achievement will be drawn from,
but not limited to, the outcome standards developed by the
National Accreditation Council on Services for Persons with
Developmental Disabilities; the ``values experiences'' of
Frameworks for Accomplishment; and the goals established in
Personal Futures Plans, Essential Lifestyle, and Person-
Centered planning. According to the proposed quality assurance
framework, monitoring of individual outcomes will be done
jointly among family members, case managers, and other members
of the local review team on a quarterly basis.
The award was made to Minnesota Department of Human
Services on September 30, 1994. The first year of the
cooperative agreement was used to further develop the
demonstration. In December of 1995, the State was granted a
section 1115 waiver to implement the demonstration.
Significant progress has been made toward meeting the
program objectives. During the first operational year the
following goals were achieved: (1) the establishment of
baseline data on outcome indicators to be used for the purpose
of establishing performance target for the second operational
year; (2) The development of Quality Enhancement Teams to
conduct the annual performance reviews. These teams are
comprised of consumers, advocates, volunteers, and state staff;
(3) Training and technical assistance was provided to all
parties involved in the project's implementation to ensure that
they could successfully fulfill their roles in the new outcome-
based ICF/MR service delivery system; and (4) the first phase
of the qualitative/case study review of the project's
implementation was completed.
Several approaches have been taken to develop alternative
means of ensuring that quality services are provided. Providers
were granted variances to existing State licensing rules
governing ICFs-MR, waived services, semi-independent living
services and day training and habilitation services; waiver to
parts of the rule licensing supervised living facilities; and
changes to the statute governing case management through an
established reform process.
The University of Minnesota is under contract with the
State to provide project participants with technical assistance
and training in the following areas: (1) personal futures
planning; (2) self determination; and (3) organizational
management and change.
Minnesota's Department of Human Services entered into a 3-
year contract with the University of Minnesota Institute on
Community Integration for the evaluation of the performance-
based contracting demonstration project It is central to this
demonstration and its evaluation to be able to establish that
the alternative quality assurance approaches improve or at
least do not decrease the quality of life and services for the
persons involved. This evaluation will include both process and
outcome components. The process evaluation will describe and
evaluate the procedures and activities undertaken to develop
alternative outcome-based quality assurance programs. The
process evaluation is by its nature qualitative, relying
heavily on interviews with key people in the process of
developing, implementing and otherwise being affected by the
approaches being developed. Other qualitative data collection
will include on-site direct observation and document review.
The outcome evaluation component of the demonstration is
primarily a quantitative data collection activity seeking to
obtain objective quantifiable measures of the products of the
programs and services under the alternative assurance programs.
Quantitative measures will include frequencies of different
types of activities, access to, utilization and satisfaction
with the services provided, ratings of changes in the content,
quality and person-centeredness of service plans, nature and
frequency of social relationships and so forth. Process and
outcome evaluation components will be examined independently in
descriptive analyses, but also inferentially to determine if
any process variables (independent) may be associated with
outcomes (dependent variables). A control condition will also
be established. A matched group sample for comparison of
demonstration and non-demonstration group outcomes will be
drawn from Minnesota samples currently participating in the
Minnesota Longitudinal Study and the 1992 participants in the
independent assessment of Minnesota's Medicaid Home and
Community Based Services waiver program.
Synthesis of unmet need for log-term care services
Period: June 1991-August 1995.
Funding: $27,400.
Contractor: Lewin/VHI, Inc., 9302 Lee Highway, Suite 500,
Fairfax, VA 22031.
Investigator: David Kennell.
The purpose of this study is to conduct a literature review
and prepare a synthesis of previous work in the area of unmet
need for long-term-care services. This project concentrated on
identifying unmet need using secondary analysis of survey data.
Included is an analysis of data from the National Long-Term
Care Surveys, the 1984 Supplement on Aging, the Longitudinal
Study of Aging, and the Channeling demonstration projects. This
study explores possible measures that can be constructed from
national databases to assess unmet need for long-term-care
services. The study evaluates the merits of alternative
measures, establishes, definitions of unmet need, using survey
data, and then develops a framework for comparing this analytic
work with earlier studies. This work was completed by Barbara
Lyons of the John Hopkins University School of Hygiene and
Public Health under subcontract to Lewin/VHI, Inc. The final
report has been received and is under review.
Combining formal and informal care in serving frail elderly people
Period; June 1992-December 1995.
Funding: $93,700.
Contractor: Lewin/VHI, Inc., 9302 Lee Highway, Suite 500,
Fairfax, VA 22031.
Investigator: David Kennell.
The purpose of this study is to determine whether formal
care substitutes for or complements informal care. To determine
the relationship between formal care and informal care, a data
set generated by the management agency Connecticut Community
Care, Inc. (CCCI) is analyzed. CCCI conducts patient
assessments of all publicly supported long-term-care patients
in Connecticut This dataset offers a unique opportunity to
conduct an in-depth longitudinal analysis of the effect of
providing formal care on the provision of informal care for a
large population of elderly persons. Although surveys have
repeatedly found that older persons strongly prefer community
services to services offered in nursing homes, policymakers
have resisted a major expansion of home-care services even
though community services are usually less expensive than
nursing home services. The most important reasons for this
resistance is the fear that a publicly funded home-care program
will encourage family caregivers of the elderly to substitute
formal care for informal care. This project is complete and is
included in the proceedings from the Brooking's Conference,
Persons with Disabilities. This publication is available from
the Brooking's Institute.
Characteristics and outcomes of persons screened into Connecticut's
2176 Program
Period: June 1992-November 1994.
Funding: $132,400.
Contractor: Lewin/VHI, Inc., 9302 Lee Highway, Suite 500,
Fairfax, VA 22031.
Investigator: David Kennell.
In recent years, a major focus of research on home and
community based care (HCBC) has been on the number of persons
who would be eligible for services based on dependencies in
activities of daily living (ADLs). While previous researchers
have estimated the size of beneficiary populations under
different eligibility standards, little is known about the
number of eligibles who would actually participate in HCBC
programs. This project examines why 20 percent of persons
meeting ADL requirements for eligibility did not participate in
the Medicaid 2176 program in Connecticut. The subsequent use of
long-term-care services by these nonparticipants is compared to
the use of services by participants in the Connecticut Medicaid
2176 program. This project has been completed. Findings from
the study have been published as part of the conference
proceedings from the Brooking's Institute. The publication,
Persons with Disabilities, is available for the Brooking's
Institute.
Issues in long-term care policy for the disabled elderly with cognitive
impairment
Period January 1992-March 1995.
Funding: $180,000.
Contractor Lewin/VHI, Inc., 9302 Lee Highway, Suite 500,
Fairfax, VA 22031.
Investigator: David Kennell.
This study utilizes the National Long-Term Care (NLTC)
surveys to analyze issues related to informal caregiving to
cognitively impaired elderly people, the mix of formal and
informal services they use, and the risk of
institutionalization. The main question addressed is whether
the presence of such factors as behavioral problems or
conditions (e.g. incontinence) that imply special service needs
affect the mix of services used or the risk of
institutionalization. This work will be completed by Judith
Kasper of the Johns Hopkins University School of Hygiene and
Public Health under subcontract to Lewin/VHI.
The article, ``Cognitive Impairment and Problem Behaviors
as Risk Factors for Institutionalization,'' by Judith Kasper
and Andrew D. Shore, describes the first part of this study and
appears in the Journal of Applied Gerontology, 13(4):371-385,
December 1994. The NLTC survey data were used to develop a
predictive model for nursing home institutionalization that
includes cognitive functioning and problem behaviors in
addition to more commonly studied indicators, such as
disability. As expected, cognitive impairment is a risk factor
for institutionalization, controlling for other characteristics
such as age, living arrangement, and use of paid in-home care.
Four problem behaviors were investigated, but only one,
Wanders/Gets Lost, contributed to the model. Among cognitively
impaired persons, those who wander/get lost had a twofold risk
institutionalization. The findings suggest the need to
differentiate among difficult or problem behaviors and to
further investigate those that arouse concerns about safety and
require extensive supervision as risk factors for
institutionalization The second part of this study examining
survey data combined with Medicare claims is final.
Use of Long-Term Care Services by Mentally Ill Persons
Period: September 1994-December 1996.
Funding: $391,331.
Grantee: Center for Health Policy Research, Institute for
Policy Research and Evaluation Pennsylvania State University,
Office of Sponsored Programs, 110 Technology Center, University
Park, PA 16802.
Investigator: Dennis Shea, Ph.D.
There has been a steady increase in the utilization of
long-term-care services, particularly nursing homes, by
mentally ill persons following the closure of State and county
mental hospitals during the 1960s and 1970s. This project
examines the determinants of long-term care service use by the
mentally ill population. Data from the National Medical
Expenditures Survey (NMES) Institutional Component, the
Medicare Current Beneficiary Survey (MCBS), and the National
Nursing Home Survey (NNHS) are being used to model long-term-
care use by this population. Information on patients,
providers, and system characteristics, together with a more
complete description of current use patters, will help to
identify the potential impacts of policy changes on use of
services and total program costs.
Descriptive data from the Institutional Population
Component of the 1987 National Medical Expenditure Survey
(NMES) have been used to examine differences in nursing home
expenditures by persons with and without reported or diagnosed
mental illness. The results presented in ``Mental Illness and
Nursing Home Use,'' presented at the 1995 Meetings of the
Gerontological Society of America indicate the following:
Mental illnesses explain variations in service use,
with the effects depending on how mental illness is
defined and whether a resident or admission cohort is
examined;
Newly admitted during home residents with a mental
illness have higher charges due to lengths of stay that
are 35 percent longer than non-mentally ill admissions.
Charges vary little between persons with or without a
mental illness.
These results suggest that if future reimbursement policy in
long-term care-settings is moving toward capitation, as has
occurred in other settings, rates should take into account the
longer stay associated with persons with mental illness.
Results from the initial descriptive analyses of the MCBS
indicate that 5 years after the passage of the 1987 Nursing
Home Reform Act, which mandated treatment of mental illnesses,
there is a persistent level of untreated mental illness in
nursing homes. Only 29 percent of nursing home residents with a
mental illness were treated by mental health specialists during
the year. Regarding the use of other long-term-care services, a
significant relation has also been detected between diagnosis
of a mental illness and home health use.
Synthesis of literature on effectiveness of special assistive devices
in managing functional impairment
Period: August 1991-January 1996.
Funding: $32,600.
Contractor: Lewin/VHI, Inc., 9302 Lee Highway, Suite 500,
Fairfax, VA 22031.
Investigator: David Kennell.
This synthesis has two components. The first is a
description of the special assistive devices and a summary of
how these devices are paid for under the current system. The
second is a summary of the effectiveness of special assistive
devices in managing functional impairments. This synthesis also
discusses various policy options, which relate to alternative
financing arrangements for special assistive devices. The
analysis of assistive device usage is obtained using the 1984
Supplement on Aging and the 1990 National Health Interview
Survey Supplement on Assistive Devices. This first draft has
been received and is expected to be completed in January 1997.
Synthesis of literature on targeting to reduce hospital use
Period: September 1991-August 1995.
Funding: $30,000.
Contractor: Lewin/VHI, Inc., 9302 Lee Highway, Suite 500,
Fairfax, VA 22031.
Investigator: David Kennell.
This study synthesizes the literature on targeting across a
variety of types of programs, all of which have the goal of
reducing hospital use. These programs include geriatric
evaluation units, nursing home staffing enhancement programs,
and hospital-based programs for discharge planning and
transitional case management. Although targeting is an issue
for all of these types of programs, little attention has been
given to evaluating targeting criteria. This project has been
subcontracted to Mathematica Policy Research, Inc. This review
of the literature points to familiar gaps in the current health
care system. The review discusses the lack of overall
coordination and monitoring of care for the elderly, an
insufficient level for primary and acute care for nursing home
patients, poor access to a range of subacute services, a
shortage of physicians with geriatric training for community-
dwelling elderly persons, and insufficient efforts to reduce
the highest cost diseases and complications that arise during
hospitalization. The literature also suggests that several
groups of elderly might benefit from such interventions as
comprehensive geriatric assessment, enhanced hospital discharge
planning, and the social health maintenance organization. These
groups include individuals whose conditions are difficult to
stabilize or who require regimens of medications or diet that
must be monitored for compliance or change, individuals for
whom medications are likely to lead to adverse events, and
individuals facing nursing home placement without first being
evaluated for rehabilitative potential.
Interrelationship of medical conditions in the nursing home population
Period: January 1994-December 1995.
Funding: $67,600.
Contractor: Lewin/VHI, Inc., 9302 Lee Highway, Suite 500,
Fairfax, VA 22031.
Investigator: David Kennell.
This project, conducted in collaboration with the Health
Care Financing Administration, uses concatenated Medicare
provider analysis and review, skilled nursing facility (SNF),
and minimum data set plus (MDS+) data to develop a richer
profile of Medicare SNF patients. Data for all patients include
their clinical conditions, their subsequent use of Medicare
hospital and SNF services, and use of their non-Medicare-
covered nursing home services. This is a pilot study that
focuses on three States (Maine, Mississippi, and South Dakota)
and on patients with selected conditions (congestive heart
failure, hip fracture/replacement, chronic obstructive
pulmonary disease, pneumonia, and cardiovascular attack). This
study also examines the characteristics of nursing home
patients who are under 65 years of age. This work has been
subcontracted to The Urban Institute. A draft paper has been
received and reviewed. The project is expected to be completed
in December 1996.
Medicare Catastrophic Coverage Act evaluation: Impact on industry
Period: September 1989-September 1994.
Funding: $993,199.
Contractor: Urban Institute, 2100 M Street, NW.,
Washington, DC 20037.
Investigator: Marilyn Moon, PhD.
A series of analyses of the effects of the Medicare
Catastrophic Coverage Act (MCCA) of 1998 on hospitals, nursing
homes, and home health agencies. Two final reports summarize
the work of the contract:
Moon, M., Dubay, L. Kenney, G., Liu, K., Marsteller,
J., and Norton, S.: ``Medicare Catastrophic Coverage
Act Evaluation: Preliminary Analysis of Impact on
Industry: Final Report.'' September 1995; and
Liu, K., Kenney, G., Wissoker, D., and Marsteller,
J.: ``The Effects of the Medicare Catastrophic Coverage
Act and Administrative Changes on Medicare SNF
Participation and Utilization: 1987-1991.'' Washington,
D.C., June 1995.
Findings
Nursing facilities.--The Health Care Financing
Administration's claims data and nursing facility certification
data were used in the study of changes in facility
certification from non-Medicare SNF or intermediate care
facility (ICF) to Medicare SNFs and changes in Medicare-
certified beds, to determine how nursing homes increased or
decreased their capacity to provide Medicare SNF services.
Analysis findings are consistent with the national program
statistics, both indicating large increases in the utilization
of Medicare SNF days between 1987 and 1989, and a decline in
covered days between 1989 and 1991. The magnitude of the change
between 1987 and 1989 strongly suggests that the MCCA, along
with the clarification of coverage guidelines, had an impact on
the SNF benefit during this period. Multivariate analyses
demonstrated differential responses in the provisions of SNF
services by provider characteristics, i.e., proprietary and
larger nursing homes, rather than government-owned or smaller
nursing homes, were the most responsive to the MCCA and
coverage guidelines. Freestanding SNFs had greater increases in
covered days per bed, admissions per bed and length of stay
between 1987 and 1989 than hospital-based SNFs. Some of the
differences in growth were probably attributable to the
transfer of Medicaid residents of freestanding SNFs to Medicare
payment status: hospital-based facilities generally not
providing long-term nursing care and, hence, having fewer
patients to convert to Medicare SNF. The increase in Medicare
patients after the implementation of these policy changes was
offset by a disproportionate decrease in private-pay patients,
indicating that the policies increased the role of public
financing for nursing home care. Nursing homes in states that
employ a case-mix adjustment in setting their Medicaid nursing
home payment were generally more likely than homes in other
States to begin participating in Medicare and to have had
greater growth in Medicare utilization. Medicare-certified
service provision expanded greatly even with the repeal of the
MCCA, and more nursing beds became certified for Medicare over
the study period. The expansions in access are likely the
consequence of (1) the coverage clarifications that may have
served to make nursing homes more willing to serve Medicare
patients because of greater certainty regarding Medicare
coverage policy; (2) MCCA may have given nursing homes greater
familiarity with Medicare; and (3) staffing data suggest that
OBRA 1987 led to increases in staff levels, making it easier
for more nursing homes to serve Medicare patients. Although
Medicaid still dominates the financing in the nursing home
industry, the policy and industry changes have pushed Medicare
more to the forefront of financing nursing home care.
Home health.--Analyses of the changing home health market
in response to MCCA and other regulatory changes suggest a
complicated set of relationships and causal factors. The
descriptive analysis suggested an inverse relationship between
SNF use and home health use. Similarly, the simultaneous
regression results did not show a substantial number of
Medicare enrollees shifting away from the Medicare home health
benefit in favor of the Medicare SNF benefit as a result of
MCCA. Although analyses found no offset between nursing home
and home health utilization, they did show that larger
increases in home health occurred in areas with higher Medicare
discharges in diagnosis-related groups with high use of
postacute care. Larger increases in home health use also
occurred in areas with higher proportions of dually eligible
enrollees. Findings that much of the growth in home health care
was associated with less skilled agencies suggest that the
service needs of new Medicare beneficiaries are more likely to
involve personal care rather than specialized care such as
physical therapy or medical services. Users of rehabilitation
services seem to be similar to those using home health services
across many dimensions; SNF users, in contrast, are older and
more likely to be female and/or unmarried. The ratio of home
health agencies per enrollee and nursing home bed moratoria had
significant effects on use of health services. Home health
agencies substantially expanded the scope of services offered
between 1983 and 1989, with urban areas offering more
comprehensive services than rural settings.
Hospitals.--Analyses concluded that MCCA decreased
beneficiary out-of-pocket expenditures. Even though overall bad
debt in hospitals increased, the bad debt for hospitals with
the largest maternity load decreased, reflecting the impact of
MCCA's Medicaid eligibility expansion for poor/pregnant women
and their infants.
Medicare Catastrophic Coverage Act evaluation: Beneficiary and program
impact
Period: September 1989-September 1995.
Funding: $2,846,906.
COntractor: Abt Associates Inc., 55 Wheeler Street,
Cambridge, MA 02138.
Investigator: David Kidder, Ph.D.
MCCA of 1988 expanded and simplified Medicare hospital
coverage effective January 1989, only to be repealed, effective
January 1990. The legislation reduced Medicare beneficiary
liability to one hospital deductible per year, eliminated the
concept of ``spell of illness,'' and eliminated the coinsurance
calculations necessary under the original Medicare program. The
legislation made the Part A Extended Care Benefit more generous
by increasing the day limit on skilled nursing facility care
from 100 to 150 days per year, and eliminated the prior 3-day
hospital stay. The coinsurance requirements were revised, and
the rate was lowered to 20 percent of the daily cost of nursing
home care instead of being linked to the average cost of a day
of hospital care. Also, the coinsurance was to apply only to
the first 8 days of the stay, instead of applying to the 21st
through 100th day. These changes meant that more beneficiaries
would qualify forcoverage and that longer stays would be
covered. The skilled nursing facility changes went into effect in
January 1989 and were rescinded, effective January 1990. Changes to the
Medicare hospice benefit, implemented in January 1990 and rescinded in
January 1990, eliminated the 210-day lifetime limit on hospice
benefits, but retained a cost limit. None of the other Medicare
benefits (Part A or Part B or Drug) of MCCA were implemented, having
been scheduled for implementation after the date that the provisions
were repealed. The Medicaid provisions of the legislation were left
intact, including the payment of Part B premiums, deductibles and
copayments for qualified (poor) Medicare beneficiaries, and mandatory
Medicaid coverage for pregnant women and their infants with income of
up to 100 percent of the Federal poverty level. (The coverage was
phased in--75 percent by July 1989 and 100 percent by July 1990).
The evaluation contract comprised a series of research
projects related to the analysis of Medicare benefit changes
and Medicaid beneficiary expansions introduced by the Medicare
Catastrophic Coverage Act (MCCA) of 1988. The analyses focused
on the Medicare benefit changes in skilled nursing care and
hospice care. The analyses also addressed the MCCA-introduced
payment of Part A and Part B premiums, and the deductibles and
copayments for low-income qualified Medicare beneficiaries by
State Medicaid programs. Data on use in a private nursing home
chain were studied, and nursing home episodes for Medicare
beneficiaries are identified through a linkage of Part A and
Part B bills. Post-hospital use was studied through two tracer
conditions-stroke and hip fracture. The Medicaid analyses
primarily focused on the effects of the expansions for pregnant
women and their infants. Analyses of birth and death records
were conducted on national vital statistics data; Missouri
birth and infant death data were linked with Medicaid
eligibility and utilization data and analyzed for changes in
Medicaid enrollment of pregnant women and the birth outcomes of
their infants. Analysis of a year of infant health care
utilization includes data from birth certificates and mothers'
Medicaid eligibility. A trend analysis of Massachusetts
hospital discharge data focuses on shifts in Medicaid use,
lengths of stay, severity of birth outcomes, and neonatal
intensive care unit use before and after the MCCA legislation.
Two final reports summarize the findings:
(1) Laliberte, L., Mor, V., Berg, K., Banaszak-Holl, J.,
Calore, K., Intrator, O., and Hiris, J., ``Medicare
Catastrophic Coverage Act Evaluation: The Impact of the
Medicare Catastrophic Coverage Act on the Long-Term Care
System.'' June 1995. and
(2) Coulam, R.F., Cole, N., Irvin, C., Kidder, D., and
Schmitz, R.J.: ``Evaluation of the Medicare Catastrophic Care
Act: Final Report, ``December 19, 1995, which summarizes the
MCCA impacts on maternal and child health programs and
beneficiaries.
All reports are being prepared for submission to the
National Technical Information Service.
Long-Term Care Studies (Section 207)
Period: September 1989-March 1996.
Funding: $3,790,000.
Contractor: Lewin/VHI, Inc., 9302 Lee Highway, Suite 500,
Fairfax, VA 22031-1207.
Investigator: David Kennell.
The purpose of this project is to conduct research related
to the Health Care Financing Administration's (HCFA's) Medicare
and Medicaid programs in the area of long-term-care (LTC)
policy development. The contractor has focused on four major
areas:
The financial characteristics of Medicare
beneficiaries who receive or need LTC services;
How the Medicare beneficiaries' characteristics
affect their use of institutional and noninstitutional
LTC services;
How relatives of Medicare beneficiaries are affected
financially and in other ways when beneficiaries
require or receive LTC services; and
How the provision of LTC services may reduce
expenditures for acute care health services.
Analyses used existing LTC and other survey databases
(e.g., the National Long-Term Care Surveys, the Longitudinal
Study of Aging, the National Nursing Home Survey, the Medicare
Current Beneficiary Survey, the Survey of Income and Program
Participation, the National Medical Care Expenditure Survey).
Medicare administrative records and other extant information
also will be used. A number of focused analytic studies, policy
reports, syntheses, and special studies are required under the
contract.
With the repeal of the Medicare Catastrophic Coverage Act
of 1988, this project was no longer congressionally mandated.
The following updates the status of each of the studies,
indicating which reports are final and those that are in draft
or pending final review. The final reports are as follows:
``Analysis of Choice Processes in Capitated Plan
Enrollment: Statistical Models for Evaluation of
Voluntary Enrollment to Long-Term Care Demonstration
Projects,''
``Analysis of Transitions in the Characteristics of
the Long-Term Care Population''
``Case Studies of Medicaid Estate Planning''
``Consumer Protection and Private Long-Term Care
Insurance''
``Elderly Wealth and Savings: Implications for Long-
Term Care''
``Health Care Service Use and Expenditures of the
Noninstitutionalized Population''
``Consumer Protection and Private Long Term Care
Insurance; Key Issues for Private Long-Term Care
Insurance''
``Issues in Long Term Care for the Disabled Elderly
with Cognitive Impairment''
``Nursing Home Payment by Source: Preliminary
Statistics from the Medicare Current Beneficiary
Survey''
``Potential of Coordinated Care Targeted to Medicare
Beneficiaries with Medicaid Coverage''
``Regional Variation in Home Health Episode Length
and Number of Visits Per Episode''
``Simulations of Skilled Nursing Facility Payment
Options''
``State Responses to Medicaid Estate Planning''
``Synthesis of Financing and Delivery of Long-Term
Care for the Disabled Nonelderly''
``Synthesis of Literate on Targeting to Reduce
Hospital Use''
``Synthesis of the Nursing Home Bed Supply''
``Synthesis of Unmet Need for Long-Term-Care
Services''
A conference to present selected findings was held in
November 1994 and the conference proceedings have been
published as Persons with Disabilities: Issues in Health Care
Financing and Service Delivery. This is available from the
Brookings Instute and HCFA's Office of Research and
Deomonstrations. Papers included in this book are:
``Long-Term Care: The View from the Health Care
Financing Administration''
``Private Long Term Care Insurance: Barriers to
Purchase and Retention''
``Medicaid Estate Planning: Case Studies of Four
States''
``Implications of Health Care Financing, Delivery and
Benefit Design for Persons with Disabilities''
``Program Payment and Utilization Trends for Medicare
Beneficiaries with Disabilities''
``Cognitive Impairment in Older People and Use of
Physician Services and Impatient Care''
``Catastrophic Costs of Long Term Care for Elderly
Americans''
``Characteristics and Outcomes of Persons Screened in
Connecticut's 2176 Program''
``Combining Formal and Informal Care in Serving Frail
Elderly Persons''
``Regional Variation in the Use of Medicare Home
Health Services''
``Long Term Care for the Younger Population: A Policy
Synthesis''
Studies currently in progress are:
``Catastrophic Health Care Expenditures and Medicaid
Coverage Among Community Residents''
``Synthesis of Nursing Home Reimbursement Options''
``The Effect of Geographic Variation on Medicare
Capitation for the Social HOM, PACE, CNO''
``Synthesis of Literature on Effectiveness of Special
Assistive Devices in Managing Functional Impairments''
``Catastrophic Costs and Medicaid Spenddown''
``Costs of Medicare SNF Therapy Services''
``Longitudinal Health Care Use and Expenditures of
Disabled''
``Interrelationship of Medical Conditions in the
Nursing Home Population''
``An Analysis of Post-Acute Care and Therapy Services
Using the HCFA Episode Database, Post-Acute Portion''
Final reports on these projects are expected to be
completed in Winter 1996.
Analysis of post-acute care and therapy services using the Health Care
Financing Administration Episode Database
Period: August 1994-April 1995.
Funding: $138.300.
Contractor: Lewin/VHI, Inc., 9302 Lee Highway, Suite 500,
Fairfax, VA 22031.
Investigator: David Kennell.
This two-part study uses the Health Care Financing
Administration Episode Database to do the following:
Update earlier research on post-hospital care and
rehabilitation following hospital admissions with more
recent data;
Examine trends in use over time by comparing the 1992
findings to several RAND analyses and a Lewin/VHI
analysis on therapy services conducted for the American
Association for Retired Persons;
Analyze the use of rehabilitation/therapy services
across settings; and
Contribute to the discussion of policy and payment
implications of increased use of post-acute services.
Tabulations on rehabilitation are under way. The post-acute
analysis is expected in January 1997.
Synthesis of the nursing home bed supply
Period: May 1991-September 1994.
Funding: $49,000.
Contractor: Lewin/VHI, Inc., 9302 Lee Highway, Suite 500,
Fairfax, VA 22031.
Investigator: David Kennell.
Analyses have shown that there is excess demand for using
home care. Part of this excess demand is attributed to State-
imposed constraints on the supply of nursing home beds. States
have imposed these supply constraints in an attempt to control
their Medicaid budgets and to redirect resources from
institutional to noninstitutional care. This synthesis
addresses:
How much variation is there in the supply of nursing
home beds?
Why do variations in the supply of beds exist across
States?
To what extent does a State's capital reimbursement
system encourage/discourage sufficient investment of
capital to meet its demand for new beds?
What is the relationship between certificate of need
and capital replacement?
What is ``excess demand'' and how is it measured?
This report found that much of the attention paid to the
adequacy of a State's supply of nursing home beds focuses on
the effect that supply has on access to care and often ignores
important demand-side issues. One of these issues, the
subsidization of health care expenses for Medicaid
beneficiaries, results in excess demand for nursing home
services by Medicaid beneficiaries, who are encouraged to
demand more services than they otherwise would. This study
found that, in general, access problems do not exist for
private patients. However, access problems do exist for some
Medicaid beneficiaries, especially for heavy-care persons with
head injuries, with behavioral problems, or who need
ventilators. Since each State has a unique long-term-care
system, measures of the adequacy of the supply of nursing home
beds in one State may not accurately measure the adequacy of
supply in another State. Furthermore, given the differences in
programs, laws, and market conditions across States, policies
that help control long-term-care expenses in one State may not
necessarily be appropriate for other States.
Program payments and utilization trends for Medicare beneficiaries and
disabilities
Period: December 1992-November 1994.
Funding: $175,300.
Contractor: Lewin/VHI, Inc., 9302 Lee Highway, Suite 500,
Fairfax, VA 22031.
Investigator: David Kennell.
This study is an extension of the analyses of the acute
care costs of chronically disabled persons completed using the
1984-89 National Long-Term Care Survey (NLTCS). This analysis
employs recently released 1989 NLTCS data to examine possible
cost shifts for groups of personswith very different levels of
health and functioning. Analyses were made of seven different
categories of Medicare service (short-stay hospital, home health
agency, skilled nursing facility, physician, outpatient, durable
medical equipment, and renal therapy) for 1982 to 1990 using Medicare
records linked to data on community and institutional residents from
NLTCS 1982, 1984, and 1989. The purpose of the combined survey and
administrative record analyses was to ascertain how the chronic health
and functional characteristics of community and institutional residents
using Medicare-reimbursed services changed over the period and how
those changes related to the use of each of seven categories of
Medicare services. Over this period, a number of regulatory and
legislative changes had been made in the Medicare system that altered
the use of different services by persons with specific health and
functional profiles. The final report is included in the proceedings
from the Brookings Conference entitled,: ``Persons With Disabilities''.
This is available from The Brookings Institute.
Health Care Service Use and Expenditures of the Noninstitutionalized
Population
Period: June 1993-February 1995.
Funding: $148,000.
Contractor: Lewin/VHI, Inc., 9302 Lee Highway, Suite 500,
Fairfax, VA 22031.
Investigator: David Kennell.
Using data from the 1987 National Medical Expenditures
Survey Household Component, this study addresses the following:
Differences in the utilization of health care
services by disabled and nondisabled populations;
Whether community-based long-term-care services and
expenditures substitute for acute-care expenditures for
the population using community-based long-term-care
services and the implications for costs;
Medicaid asset spenddown in the community; and
Trends in out-of-pocket expenditures and total health
care expenditures for the elderly population with
comparisons to the 1977 National Medical Care
Expenditure Survey.
Analysis files have been constructed. A draft report has been
completed. The final report is expected in January 1997.
Longitudinal health care use and expenditures of disabled persons
Period: January 1994-June 1995.
Funding: $143,000.
Contractor: Lewin/VHI, Inc., 9302 Lee Highway, Suite 500,
Fairfax, VA 22031.
Investigator: David Kennell.
This project, conducted in collaboration with the Health
Care Financing Administration, uses data from the Medicare
Current Beneficiary Survey to examine health care use by
persons with disabilities and the cost of providing these
services. In this study, Medicare beneficiaries are categorized
by different definitions of disability and by duration of
disability. An analysis of the types of health care services
and patterns of use for each subgroup is performed to determine
the extent to which differences in such constructs are
associated with differences in health care use and costs. This
study is designed, in part, to provide information parallel
with that from Lewin-VHI's analysis of National Medical Care
Expenditure Survey data and Duke University's analysis of
National Long-Term Care Survey data. This work has been
subcontracted to The Urban Institute. A draft report has been
received and reviewed. The final report is expected to be
completed in December 1996.
Changes in population characteristics and Medicaid utilization/
expenditures among children and adolescent Supplemental
Security income recipients
Period: September 1994-September 1997.
Funding: $642,035.
Grantee: Massachusetts General Hospital Children's Service,
Fruit Street, WACC715 Boston, MA 02114.
Investigator: James Perrin, M.D.
The Supplemental Security Income (SSI) program for children
and adolescents has expanded in the past 5 years as a result of
new Social Security Administration (SSA) guidelines for
determining disability caused by mental impairments, new
guidelines for determining childhood disability in general, and
major outreach efforts by SSA to identify children with
disabilities. The project has four main objectives:
Determine the current clinical characteristics of
child and adolescent SSI recipients and the changes in
these characteristics during the period of program
expansion that began in the late 1980s;
Determine patterns of Medicaid utilization and
expenditures among important clinical subgroups and
examine changes in these patterns during the period of
program expansion;
Examine the utilization trajectories and clinical
characteristics of certain SSI recipient groups over
time, including recipients with high-cost physical
conditions such as cystic fibrosis, congenital heart
disease, and spina bifida, and high-prevalence, low-
cost conditions such as attention deficit disorder,
hyperactivity, and learning disabilities; and
Determine the degree to which new recipients reflect
shifting among Medicaid eligibility categories and the
coverage and use of other insurance after getting SSI.
Data files construction is almost complete, and analyses on
three of the six States are underway and three papers have been
prepared:
``Secular Trends in Conditions Among Children
Receiving SSI Benefits,'' which found that the number
of SSI children in institutions increased minimally (3
percent), despite an 83 percent increase in SSI
enrollment. The number of children with leukemia
enrolled in SSI increased 33 percent, while those with
other physical conditions increased over 70 percent;
the number of children with mental retardation
increased 615. In contrast, the number of SSI children
with asthma increased dramatically (185 percent), but
at a rate similar to the 162 percent increase in asthma
among the non-SSI Medicaid population. A four-fold
increase in Attention Deficit Hyperactivity Disorder
among SSI enrollees is comparable to the four-fold
increase in the condition among the non-SSI Medicaid
enrolled children.
``The SSI Children's Disability Program: New Entrants
of AFDC Upgrades?,'' found that about half of the
children newly receiving SSI benefits had previously
received AFDC benefits and thus experienced a major
increase in monthly cash benefits. The other half of
new SSI recipients were new to public insurance.
``The Supplemental Security Income Children's
Disability Program: Impact of Program Growth on
Population with High Expenditures.'' This preliminary
analysis on only Georgia data found that the number of
children with costs over $25,000 decreased very
slightly from 4.3 percent of the SSI population in 1989
to 4.1 percent in 1992.
Changing roles of nursing homes
Period: September, 1994-January, 1998.
Funding: $831,182.
Grantee: Institute of Gerontology, University of Michigan,
300 North Ingalls Building, Room 900, Ann Arbor, MI 48109-2007.
Investigator: Brant Fries, Ph.D.
Although nursing homes have traditionally provided
custodial care to the physically and cognitively impaired
elderly, nursing homes are increasingly treating a more diverse
and more clinically complex patient mix. Since the
implementation of Medicare's prospective payment system for
hospitals, growing numbers of nursing homes have begun caring
for patients requiring ``subacute'' or post-acute care
following a hospital stay. Between 1986 and 1993, the number of
Medicare certified hospices in the U.S. grew from 355 to 1,445.
From 1992 to 1995, the number of special care hospice units in
nursing homes grew 100 percent, to 206.
This study examines two special nursing home populations:
hospice patients and the chronically mentally ill (other than
dementia). Several hypotheses regarding quality, use, and cost
issues will be examined for both groups, such as that residents
with chronic mental illness are more likely than are other
similarly functionally impaired residents, to experience
increasing functional impairment, to have increased behavior
problems and to be chemically restrained. It is hypothesized
that mentally ill patients will have greater overall use of
Medicare services than will non-mentally impaired nursing home
residents with similar levels of functional impairment. The
study utilizes 1993 data on the entire nursing home populations
of eight states (Kansas, Maine, Mississippi, Nebraska, New
York, Ohio, Pennsylvania, South Dakota, and Washington), about
250,000 residents, linked with the HCFA Survey and
Certification Reports, the Medicare Part A and Part B claims
files and the Area Resource File data. The Minimum Data Set for
Nursing Home Resident Assessment and Care Screening is used to
collect health status data on all residents in Medicaid-
certified, Medicare-certified and dually certified nursing
facilities. The hospice substudy will describe how nursing home
hospice services are concentrated in particular regions,
markets and facilities; compare rates of hospital use and costs
of terminal care residents in nursing homes that do and do not
use the Medicare hospice benefit; and describe the quality of
life, including pain experience and analgesics prescribed among
terminal cancer patients in nursing homes who are served by
hospice care and those not so served.
A draft report, ``Hospice in Nursing Homes,'' presents
initial analyses of longitudinal files of 1991-95 nursing home
survey data merged with patient assessment data. Multivariate
analyses indicate that hospice special care units are located
in relatively small and medium size facilities with low
occupancy, high technological capacity and a higher skill level
of staffing mix. Also, nursing home characteristics such as
being a proprietary facility, not part of a chain and being
located in a competitive environment are significantly related
to having a hospice special care unit. The authors note that
the growth in special care hospice units in nursing homes
reflects changes in reimbursement mechanisms, increases in the
proportion of all deaths occurring in nursing homes, and by
nursing home efforts to specialize. A paper, ``Special
Populations in Nursing Homes: Residents with Chronic Mental
Illness or Developmental Disabilities,'' is being presented at
the November 1996 meeting of the Gerontological Society of
America.
Predictors of access and effects of Medicare post-hospital care for
beneficiaries 65 years of age or over
Period: September 1994-September 1996.
Funding: $502,614.
Grantee: Georgetown University, Division of Community
Health Studies and Family Medicine, 3750 Reservoir Road, NW.,
Washington, DC 20007-2197.
Investigator: David L. Rabin, Ph.D.
As a consequence of regulatory and legislative changes in
the late 1980s, Medicare post-hospital care (PHC) has become
the most rapidly growing Medicare expenditure. PHC consists of
home health care, inpatient skilled nursing facility care, and
rehabilitation hospital care. The growth in use, changes in
eligibility requirements, and the increase in Medicare costs
have raised questions about equal access and the effects of PHC
use. The literature on PHC suggests two important trends. A few
Medicare prospective payment inpatient hospital diagnosis-
related-groups (DRG) account for most PHC, but within these
DRGs large variations exist in use. Personal health, economic,
sociodemographic, and household factors, as well as area and
health system characteristics, and predictive of the use of PHC
despite equal access under the Medicare program. This study
uses the Medicare Current Beneficiary Survey to investigate
three major research objectives:
Describe the personal, area, and health system
characteristics of users and those of similar persons
with unmet needs for PHC in order to access differences
by gender, race, and income class and the potential for
substitution of care modes;
Study the longitudinal effects of PHC on Medicare
program costs and rehospitalization; and
Study the personal health effects associated with
PHC.
Because of the delay experienced in releasing the Medicare
Beneficiary Cost and Use File and the dependence of this
project on the Medicare Current Beneficiary Survey Data, this
project is initiating the data analysis phase. The final report
is expected to be completed in June 1997.
Acute and long-term care: use, costs, and consequences
Period: September 1994-August 1997.
Funding: $595,787.
Grantee: The Urban Institute, 2100 M Street, NW.,
Washington, DC 20037.
Investigator: Korbin Liu, Ph.D.
This study will provide current information that will aid
policymakers in developing options to better integrate acute,
subacute, and long-term-care services. Data from the Medicare
Current Beneficiary Survey will be used to address three
issues: transitions among acute, subacute, and long-term care;
catastrophic costs resulting from the use of those services;
and interactions between Medicare and Medicaid home health
care. The transitions analysis is designed to measure
differences in the patterns of acute, subacute, and long-term-
care use by the characteristics of Medicare beneficiaries, and
to determine potential areas of access or quality of care
problems. The cost analysis is designed to access the
cumulative risks over 3 years of incurring catastrophic health
care costs or experiencing Medicaid spenddown. The effect of
the Qualified Medicare Beneficiaries program will be evaluated.
The home health care analysis is designed to estimate the
interactions and possible overlaps between two rapidly
expanding public programs that finance similar services. The
relationship between home health care use and costs and the
personal characteristics of Medicare beneficiaries and the
characteristics of geographic areas, including Medicaid
policies, will be examined.
The first part of this project is complete. A final report,
``Interactions between the Medicare and Medicaid Home Care
Programs: Insights from States,'' has been produced and is
available from Genevieve Kenny at the Urban Institute (202-857-
8568). For the second phase, this project was dependent on the
Medicare Current Beneficiary Survey's Cost and Use File. The
file has been released, and the agency is in the data cleaning
and analysis phase.
Regional variation in home health episode length and number of visits
per episode
Period: July 1993-November 1994.
Funding: $168,600.
Contractor: Lewin/VHI, Inc., 9302 Lee Highway, Suite 500,
Fairfax, VA 22031.
Investigator: David Kennell.
This study focused on two questions: (1) Why does the use
of home health care vary across the regions? (2) Is there a
corresponding variation across the regions in patient outcomes
suggesting that lower levels of care lead to poorer outcomes
for patients, or that higher levels lead to improved outcomes?
This study used the Medicare claims files, the provider of
services file, the area resource file, and the Regional Home
Health Intermediary database to determine the contribution of
three sets of factors to regional variation. These sets of
factors are patient characteristics, supply of home health
agencies and staff, and availability of alternatives to home
health care. The final report has been received and is under
review.
Sources of Medicare home health expenditure growth: Implications for
control options
Period: February 1992-December 1995.
Funding: $210,706.
Grantee: Brandeis University, Heller Graduate School,
Institute for Health Policy, 415 South Street, P.O. Box 9110,
Waltham, MA 02254-9110.
Investigator: Christine Bishop, Ph.D.
The overall objective of the project is to develop and
consider options for restraining home health expenditure
growth. The project has two phases. First is to use secondary
data to examine the composition of Medicare home health
expenditure growth between 1985 and 1989 and 1989 to 1991 to
attribute total growth to growth in persons served, visits per
person, mix of visits, and visit charges; and to attribute
growth to types of agencies by auspice and scale. Second is to
examine data from the Regional Home Health Intermediary
database to measure variation in types of patients served at
intake, and the characteristics of high-use patients, by
auspice and region, and to consider differences in mix and
intensity of services provided.
The first phase has been completed, resulting in an
overview, ``Recent Growth in Medicare Home Health: Sources and
Implications.'' An edited version of this analysis, ``Recent
Growth of Medicare Home Health,'' by Christine Bishop, Ph.D.,
and Kathleen Carley Skwara, was published in Health Affairs,
12(3):95-110, Fall 1993. The second phase, which has been
delayed, will analyze the length of Medicare home health
episodes using survival analysis techniques. A report for this
phase is expected in 1997.
Maximizing the cost effectiveness of home health care: The influence of
service volume and integration with other care settings on
patient outcomes
Period: September 1994-December 1998.
Funding: $1,231,466.
Grantee: Center for Health Policy Research, 1355 South
Colorado Boulevard, Suite 706 Denver, CO 80222.
Investigator: Peter W. Shaughnessy, Ph.D.
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 in 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, that and 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 those hypotheses, a
total of 3,600 patient records will be selected from agencies
in 20 States. Trained data collectors at each agency will
record patient outcomes and costs within the HHC episode. Long-
term, self-reported outcomes will be assessed from telephone
interview data at HHC admission and from 6-month followups.
These primary data concerning patient status and outcomes will
be combined with Medicare claims data over the episode of care
to access the relationship between service volume in HHC and in
both patient outcomes and costs. Analysis of data relating to
physician involvement and the sequence of use of other
providers will address issues of integration with other
services. Eighty-nine agencies have been recruited for this
project and are beginning to collect the necessary data.
Home care quality studies
Period: October 1989-September 1995.
Funding: $2,848,782.
Contractor: The University of Minnesota, School of Public
Health, D-351 Mayo Memorial Building, 420 DeLaware Street, SE.,
Box 197, Minneapolis, MN 55455-0392.
Investigator: Robert L. Kane, M.D.
This study examines quality of long-term care-services in
community-based and custodial settings, and the effectiveness
of (and need for) State and Federal protections for Medicare
beneficiaries that ensure adequate access to nonresidential
long-term-care-services and protection of consumer rights. The
research design focuses on in-home care, examining traditional
home health services that are reimbursed by Medicare and
Medicaid, as well as personal care and supportive services that
more recently have been covered by Federal and State sources of
funding. Primary project tasks include the following:
Development of a taxonomy clarifying the various
objectives ascribed to home and community-based care
from the various perspectives of consumers, payers, and
care providers;
Development and feasibility testing of a survey
design measuring the extent of, need for, and adequacy
of home care services for the elderly;
A study of variations in labor supply and related
effect(s) on home care quality, as well as factors that
contribute to these variations; and
Recommendations to improve the quality of home and
community-based services by identifying best practices
and promising quality assurance approaches.
The first project task--development of a taxonomy of
objectives--has been completed, and a report on this component
has been received. Findings from this task are presented in the
article, ``Perspectives on Quality of Home Care'' by Kane,
R.A., Kane, R.L., Illston, L.H., and Eustis, N.N. in the Health
Care Financing Review, 16(1):69-89, Fall 1994. Final reports
have also been submitted on the remaining three project tasks
(i.e., developing a survey to measure the adequacy of home care
for the elderly, a study of variations in labor supply and
related effects on home care quality, and an identification of
best home care practices and promising quality assurance
approaches). The final report for the project is currently
under review.
Validation of nursing home quality indicators
Period: July 1992-September 1996.
Funding: $990,094.
Grantee: The MEDSTAT Group, 104 West Anapamu Street, Santa
Barbara, CA 93101.
Investigator: Susan A. Flanagan, M.P.H.
This project is a continuation of a cooperative agreement
to investigate the usefulness of claims data from Medicaid and
Medicare administration record systems as sources of nursing
home quality-of-care measures. The previous study involved
retrospective analysis of 1987 Medicaid and Medicare claims
data and facility deficiency data from Michigan and Tennessee.
The objective of the current project is to validate these
resident-level claims-based quality of care indicators (QCI) by
recomputation of the claims-based indicators for California and
Georgia using data for 1990. To complete the validation
process, a sample of residents in a sample of nursing homes
will be drawn for these two States, and the medical records for
these patients will be reviewed by a team of physicians and
nurses. The results of the record review will then be compared
with the findings of the QCI algorithms to test the
relationship of the QCIs to cited deficiencies and adverse
outcomes.
This project has completed collection of medical record
data from California and Georgia, and the data has been
reviewed by nurse and physician evaluators. Initial analysis
had been completed and a draft report of early study findings
has been submitted. The final report is expected in early 1997.
Development of outcome-based quality assurance measures for small,
integrated services settings
Period: July 1994-January 1996.
Funding: $22,750.
Contractor: The Accreditation Council, 8100 Professional
Place, Suite 204, Landover, MD 20785.
Investigator: James Gardner, Ph.D.
The purpose of this contract is to determine the cost of
applying outcome measures in small, integrated service
settings. This study will provide a database to maintain
information on quality reviews of organizations that serve
people with disabilities, an analysis of individual and
organizational variables that relate to desirable outcomes, and
a final report that analyzes quality reviews conducted in
accordance with the outcome-based performance measures
developed by the Accreditation Council on Services for People
with Disabilities. The results will be used to assess the
quality of services in facilities serving people with chronic
mental illness, physical challenges, and mental retardation in
diverse settings such as supported independent living or
intermediate care facilities for the mentally retarded. Of
particular importance is the assessment of the extent to which
the outcome-based performance measures can coexist with the
traditional quality assurance variables, such as abuse,
neglect, safety, health, and physical and psychological
welfare.
During the period September through December 1994, seven
organizations participated in the Accreditation Council's
review process. During these reviews, staff from the
Accreditation Council interviewed 54 people served by the seven
organizations. A total of 28 organization variables (e.g.,
types of services provided, license type, disabilities of
people served, prior accreditation status) were analyzed with
regard to outcome scores. Analysis of outcome data was also
performed on the characteristics of the individual people who
were interviewed. These characteristics include age, sex,
disability, living arrangement, communication method, services
obtained, and source of person's funding. A final report is
under review.
Elderly wealth and savings: Implications for long-term care
Period: June 1991-August 1995.
Funding: $126,000.
Contractor: Lewin/VHI, Inc., 9302 Lee Highway, Suite 500,
Fairfax, VA 22031.
Investigator: David Kennell.
This study synthesizes what is known about the wealth of
the elderly and includes recent empirical research conducted
using the 1984 and 1989 Panel Study of Income Dynamics and the
1983, 1986, and 1989 Survey of Consumer Finances. The
information in this study is pertinent to the issue of long-
term care (LTC) for the elderly because much of the debate
concerning expansion of the Federal role in LTC financing
centers on the economic status of the elderly. A key issue in
the debate is whether or not the elderly have the financial
resources to pay for their own LTC cost directly or through the
purchase of private LTC insurance.
The main finding of the synthesis report is that the
elderly, as a group, are doing well economically. Incomes of
the elderly are lower than incomes of the nonelderly, but this
gap narrows when taxes and other benefits (i.e., Medicare) are
considered. Furthermore, the elderly have among the highest
wealth holdings of any age group. However, the elderly face
substantial economic risks, such as incurring unfunded
catastrophic medical expenses, and leaving poverty is harder
for the elderly than for the nonelderly. This study also funds
that existing theories on both whether and why the elderly save
sharply disagree with one another. Testing these theories is
challenging because data sources are usually poor or out of
date, and many of the theories do not yield refutable
hypotheses.
Catastrophic costs and Medicaid spenddown
Period: January 1993-May 1995.
Funding: $180,300.
Contractor: Lewin/VHI, Inc., 9302 Lee Highway, Suite 500,
Fairfax, VA 22031.
Investigator: David Kennell.
This study uses data from the Medicare Current Beneficiary
Survey (MCBS) to analyze the occurrence of catastrophic costs
among the elderly resulting from Medicaid spenddown. The
purpose of this study is to support the formulation of policy
for health care reform for the elderly. Consequently, this
study categorizes the causes of out-of-pocket costs for
different types of acute and long-term-care services that may
create financial hardships and identifies which subgroups of
the elderly are likely to incur catastrophic costs. This work
will be completed by the Urban Institute under subcontract to
Lewin/VHI, Inc. Preliminary analyses have been completed. The
final report is expected in January 1997.
Catastrophic costs of long-term care for elderly Americans
Period: December 1991-November 1995.
Funding: $50,000.
Contractor: Lewin/VHI, Inc., 9302 Lee Highway, Suite 500,
Fairfax, VA 22031.
Investigator: David Kennell.
This study employs the Brookings/Intermediate Care Facility
Long-Term Care Financing Model to examine both current and
future financial burdens associated with long-term-care costs.
This chapter focuses on the financial burden that out of pocket
expenditures will have in the next 25 years, assuming that
there are no changes in public or private financing. The
results of these long term care spending projections included
both nursing home and home health care. Catastrophic nursing
home spending patterns of selected elderly groups, by age,
gender, income financial status, length of stay and discharge
status are also described. Findings from this study have been
published in conference proceedings from the Brooking's
Institute. These proceedings, Persons with Disabilities, is
available from the Brooking's Institute.
Consumer protection and private long-term care insurance; Key issues
for private long term care insurance
Period: December 1992-December 1994.
Funding: $130,000.
Contractor: Lewin/VHI, Inc., 9302 Lee Highway, Suite 500,
Fairfax, VA 22031.
Investigator: David Kennell.
This study consists of a two-part analysis. The first is a
policy-oriented synthesis of research conducted to date on
long-term-care (LTC) insurance. The purpose of this synthesis
is to serve as a baseline of understanding for policymakers and
to identify relevant issues at which future research should be
directed. The second part focuses on regulatory issues. This
part contains case studies of Arizona, California, Florida,
Indiana, North Dakota, New York, Oregon, South Carolina, Texas,
and Wisconsin, which have passed legislation to regular private
LTC insurance, and summarizes how insurance companies have
responded to this regulation. This project was carried out
jointly by Lewin/VHI and the Brookings Institution.
The policy-oriented synthesis has been completed. This
synthesis discusses the growth of the LTC insurance market from
fewer than 50,000 policies in 1984 to nearly 3 million sold in
1992. Although this growth is significant, the market
penetration is less than expected; approximately 5 percent of
the elderly have LTC insurance, while 70 percent purchase
Medigap policies. The study reviews potential reasons for
limited market penetration, including consumer confusion,
barriers to coverage, marketing and sales abuses, concern over
product value, and regulation.
Synthesis of financing and delivery of long-term care for the disabled
nonelderly
Period: June 1991-December 1995.
Funding: $30,000.
Contractor: Lewin/VHI, Inc., 9302 Lee Highway, Suite 500,
Fairfax, VA 22031-1207.
Investigator: David Kennell.
This study synthesizes the current literature and
information from various data sources on the financing and
delivery of long-term care for the disabled nonelderly. This
study also summarizes the current knowledge of demographic and
economic characteristics of the disabled nonelderly, types of
services and patterns of service used by the disabled
nonelderly, how these services for the disabled nonelderly are
paid, and other unique issues related to the disabled
nonelderly. This work was completed by Joshua Wiener of The
Brookings Institution under subcontract to Lewin/VHI, Inc.
Findings from this project are present in the conference
proceedings from the Brookings Institute, Persons with
Disabilities. The proceedings is available from the Brookings
Institute.
State response to Medicaid estate planning
Period: May 1992-May 1993.
Funding: $41,000.
Contractor: Lewin/VHI, Inc., 9302 Lee Highway, Suite 500,
Fairfax, VA 22031.
Investigator: David Kennell.
The purpose of this report is to provide readers with an
overview of recent State initiatives regarding Medicaid estate
planning. Data for the report were collected primarily through
telephone interviews with key personnel at Medicaid eligibility
offices in 26 States. In those States where initiatives were
under way, copies of recent legislation, regulations, task
force reports, internal memoranda, and other documents were
obtained and reviewed. This project was completed by
SysteMetrics/MedStat under subcontract to Lewin/VHI, Inc.
The study found that many States are attempting to place
limitations on asset transfers in an effort to restrict
Medicaid estate-planning practices. Furthermore, States have
expressed a strong desire for Federal clarification on Medicaid
transfer-of-asset provisions and want additional Federal
legislation that further restricts the transfer of assets.
Case studies of Medicaid estate planning
Period: April 1993-December 1994.
Funding: $200,000.
Contractor: Lewin/VHI, Inc., 9302 Lee Highway, Suite 500,
Fairfax, VA 22031.
Investigator: David Kennell.
These case studies provide in-depth descriptive analyses of
State policy responses to Medicaid estate planning, including
the effectiveness of estate recovery programs. In addition, a
methodology for conducting quantitative empirical studies that
measure the extent of Medicaid estate planning activity and the
relative cost-effectiveness of alternative State policy
responses is presented. The data used were obtained from
Medicaid eligibility offices in Connecticut, Florida,
California, and New York. This project was completed by
SysteMetrics/MedStat, under subcontract to Lewin/VHI, Inc. The
report has been received and is under review.
Synthesis of reimbursement options
Period: September 1991-January 1996.
Funding: $77,600.
Contractor: Lewin/VHI, Inc., 9302 Lee Highway, Suite 500,
Fairfax, VA 22031-1207.
Investigator: David Kennell.
The purpose of this synthesis is to assist the Health Care
Financing Administration and other relevant policymakers in
answering specific questions concerning nursing home
reimbursement. The first part of the synthesis is organized
into four sections: summary, overview of the Medicaid
reimbursement system and State policy goals, design of the
details of a reimbursement system, and analysis of options for
capital reimbursement. The second part is organized into two
sections:
Synthesis of research studies relevant to modifying
the current method by which skilled nursing facilities
(SNF) receive payments under Part A of the Medicare
program;
Synthesis of research studies relevant to replacing
the current system with a system underwhich Medicare
SNF payment would be made on the basis of prospectively determined
rates.
A draft report has been received. The final report is
expected to be completed in January 1997.
Nursing home payments by source: Preliminary statistics from the
Medicare current beneficiary survey
Period: May 1992-December 1994.
Funding: $55,500.
Contractor: Lewin/VHI, Inc., 9302 Lee Highway, Suite 500,
Fairfax, VA 22031.
Investigator: David Kennell.
Although national estimates of nursing home expenditures
have been derived from various databases, direct estimates of
the distribution of nursing home patients by the amount of
payment and by the source of payment have not been derived.
This study is the first attempt to utilize a major source of
new information on nursing home payment, the Medicare Current
Beneficiary Survey, to estimate these distributions. This study
provides an indication of the differences in Medicaid and
private nursing home payments for 1992. Variations in payments
by nursing home characteristics are also presented and the
findings were compared with the National Health Accounts. This
work has been subcontracted to Korbin Liu of the Urban
Institute. This report has been submitted and is currently
under review.
Costs of Medicare skilled nursing facility therapy services
Period: July 1993-December 1994.
Funding: $160,800.
Contractor: Lewin/VHI, Inc., 9302 Lee Highway, Suite 500,
Fairfax, VA 22031.
Investigator: David Kennell.
Approximately two-thirds of all Medicare skilled nursing
facility (SNF) stays involve physical, occupational, or speech
therapy. The importance of therapy services to the Medicare SNF
benefit suggests that changes over time in charges for this
service, as well as the patterns of charges between Part A and
Part B, need to be tracked. This study employs Medicare
provider analysis and reviews SNF data to examine the
characteristics of patients who receive high and very high-
intensity therapy services. It also analyzes episodes of
illness of Medicare patients who experience an SNF stay to
elucidate the relationship between SNF use and providers of
Medicare services. A draft report was submitted to the Office
of Research and Demonstrations. The final report is expected to
be completed by December 1996.
Case-mix adjustment for a national home health prospective payment
system
Period: August 1996-January 1999.
Funding: $1,588,573.
Contractor: Abt Associates Inc., 55 Wheeler Street,
Cambridge, MA 02138.
Investigator: Henry Goldberg.
The primary focus of this study is to understand the
variation that currently exists in terms of home health
resource patterns and to use this information for the
development of a case-mix adjustment system for a national home
health prospective payment system. In this study, the Outcome
and Assessment Information Set (OASIS) which has been developed
for outcome-based quality assurance and improvement for
Medicare home health agencies will be examined to see whether
items included in this instrument will be useful for case-mix
adjustment. Detailed information, including information on
resource utilization and items needed for case-mix adjustment,
will be collected from 60 to 90 agencies. This project is
currently in its design phase.
Risk adjustment for Medicaid recipients with disabilities
Period: August 1996-July 1998.
Funding: $50,000.
Grantee: University of California, San Diego, 9500 Gilman
Drive, La Jolla, CA 92093.
Investigator: Richard Kronick, Ph.D.
The objective of this project is to develop a
diagnostically based, risk-adjusted payment system that may be
used by State Medicaid programs when contracting on a capitated
basis with health plans for Medicaid recipients with
disabilities. The project will use data from three States
(California, Georgia, and Tennessee). In addition to developing
a risk adjustor payment system, the authors will identify
solutions to implementation problems that States are likely to
encounter. Tape-to-tape data from California, Georgia, and
Tennessee have been ordered. Once these data are received, the
analysis phase of the project will begin.
National recurring data set project: Ongoing national state-by-state
data collection and policy/impact analysis on residential
services for persons with development disabilities
Period: October 1996-September 1997.
Funding: $35,000.
Award: Interagency Agreement.
Grantee: University of Minnesota, Institute of Community
Integration, 150 Pillsbury Drive, SE., Minneapolis, MN 55455.
Investigator: Charlie Lakin, Ph.D.
This interagency agreement will support secondary data
analyses and the production of a report that describes and
updates the status of persons with mental retardation and
related conditions (MR/RC) in institutional care facilities for
the mentally retarded (ICF-MRs), Medicaid waiver programs, and
nursing homes funded under the Medicaid program to assist in
the evaluation of Medicaid services for persons with MR/RCs and
to point out areas in need of reform. The report will include
the following:
Background description of key Medicaid programs of
interest;
State-by-state and national statistics on ICF-MRs,
Medicaid home and community-based services, and nursing
home use;
Description of the characteristics of ICF-MRs and
their residents, with comparative statistics for
noncertified facilities.
The University of Minnesota continues to collect data to
produce its annual report on the status of the Medicaid
programs that serve the developmentally disabled.
Long-term care survey
Period: September 1990-February 1993.
Funding: Interagency Agreement.
Awardee: National Institute on Aging, 9000 Rockville Pike,
Bethesda, MD 20892.
Investigator: Richard Sussman.
The Office of the Assistant Secretary for Planning and
Evaluation and the Health Care Financing Administration agree
to transfer funds to the National Institute on Aging (NIA) to
support an existing NIA grant to Duke University, Center for
Demographic Studies. This grant is entitled Functional and
Health Changes of the Elderly, 1982-89. The National Long-Term
Care Survey (NLTCS) is a detailed household survey of persons
65 years of age or over who have some chronic functional
impairment (90 days or more). The survey has been administered
3 times. The first, conducted in 1982, was devised as a cross-
sectional survey. The second, conducted in 1984, added a
longitudinal component to the sample design. The third,
administered in 1989, used the cohorts from the previous
surveys in addition to persons becoming 65 years of age to form
a nationally representative sample of impaired elderly persons.
To facilitate the use of the database, these tasks related to
the 1982, 1984, and 1989 surveys were performed under this
agreement:
File linkage over the entire period 1982-89;
Derivation of new longitudinal sample weights;
Linkage of Medicare administrative records;
Improvement of coding by checking consistency of
survey items;
Improvement in survey documentation;
Seminars and education
The public use version can be obtained from Michigan
Archives by calling (313) 763-5011. The files are currently
being matched with the HCFA administrative data to verify
status (i.e., Medicare status and mortality). NIA is planning
to repeat this study in 1999.
Long-Term care program and market characteristics
Period: February 1992-December 1995.
Funding: $808,047.
Grantee: University of California at San Francisco, Office
of Research Affairs, 3333 California Street, Suite 11, San
Francisco, CA 94143-0962.
Investigator: Charlene Harrington, Ph.D.
This project will collect data on and study the effects of
nursing home and home health care characteristics and markets
on Medicare and Medicaid services in the 50 States. Primary and
secondary data for the 1990-94 period will be collected to
update earlier data on previous studies for the 1978-89 period.
Through surveys, data will be collected on licensed nursing
home bed supply and occupancy rates, State certificate of need
programs, State pre-admission screening programs, and Medicaid
nursing home and home health reimbursement. Data also are being
collected on Medicaid waiver programs, Boren amendment
litigation, provider characteristics, resident characteristics,
and deficiencies of nursing homes. Analysis will provide
detailed information on each State's current methodology for
determining nursing home capital costs, the impact of proposed
case-mix reimbursement on operating income, reimbursement
methodology for freestanding subacute units, and Medicaid
methodology used to reimburse for care provided in board and
care homes, geriatric day care centers, and intermediate care
facilities for the mentally retarded. A publicly accessible
database will be developed that will provide a complete set of
demonstration data for the period 1978-94.
This project has been completed. The second State data book
presenting data on the long-term-care program and market
characteristics across the 50 States and the District of
Columbia has been published by the Health Care Financing
Administration as State Data Book on Long-Term Care Program and
Market Characteristics, 1993 Health Care Financing Extramural
Report, HCFA Pub. No. 03366. U.S. Government Printing Office
Washington, D.C. February 1995. The public use data base and
documentation have been received and are being reviewed.
National Health Interview Survey Disability Supplement: 1994-95
Period: June 1993-June 1994.
Award: Interagency Agreement.
Awardee: Centers for Disease Control, National Center for
Health Statistics, 6325 Belcrest Road, Room 850, Hyattsville,
MD 20782.
Investigator: Owen Thornberry.
The Health Care Financing Administration (HCFA) transferred
funds to the National Center for Health Statistics to support
the implementation of the 1994/1995 disability survey as a
supplement to the National Health Interview Survey. Although
HCFA provides extensive support for the disabled through the
Medicare and Medicaid programs, very little is known about this
population. The National Health Interview Survey Disability
Supplement (NHISDS) will be thefirst survey on the disabled in
15 years. The NHISDS will be conducted during calendar years 1994 and
1995, with approximately 250,000 people of the 96,000 sampled
households. The survey will consist of two phases:
Phase I will screen the relevant populations and will
collect basic descriptive information;
Phase II will obtain information on all house-hold
members who experience limitations caused by a health
condition.
Data from Phase I will be used to make estimates of the
prevalence of disability and to determine eligibility for Phase
II questionnaires. In Phase II, separate questionnaires will be
given to adult and child respondents. This survey will be the
first source of information to determine the size,
characteristics, service use, and out-of-pocket costs for
individuals will mental retardation and related conditions. The
survey of children will provide information on the number,
characteristics, severity, and effects on families of children
with disabilities. This survey will collect information on
income and assets, along with basic disability information, to
better understand the characteristics of actual and potential
Supplemental Security Income recipients. The information
gathered from the NHISDS will be crucial for addressing a broad
number of HCFA policy concerns affecting persons with
disabilities.
Questionnaires for the disability supplement have been
revised. Phase I interviews began in January 1994 and Phase II
adult and children interviews began during Summer 1994. The
first wave of data from Phase I is available.
future directions for long term care
During 1996, HCFA devoted substantial resources to the
further development and implementation of demonstrations to
develop, implement and evaluate new coordinated systems of care
for beneficiaries with disabilities, develop more consumer
centered and controlled services, develop outcome oriented
quality measures to improve the quality of care and to test the
cost effectiveness of prospective payment systems for nursing
homes and home health agencies.
We will continue our efforts to develop, operate and
evaluate coordinated care systems for the frail elderly, as
well as younger persons with disabilities in need of long term
care, including the Program of All-inclusive Care for the
Elderly demonstration, the Social Health Maintenance
Organization demonstration, the Community Nursing Organization
demonstration, the EverCare demonstration, the Minnesota Senior
Health Options demonstration, and the Health Services for
Children with Special Needs demonstration. We will also
continue to work with States who are developing innovative
service delivery and payment interventions for dually eligible
demonstrations. We plan to release a grants announcement to
select States interested in reforming service delivery for
dually eligible individuals along areas of interest of
importance to HCFA.
HCFA will continue to test alternative payment methods for
long term care services through the continuation of the Home
Health Agency Prospective Payment demonstration and the
MultiState Nursing Home Case Mix and Quality demonstration.
We will also continue our development of models of care
that provider beneficiaries with more direction and control of
long term services. We plan to release a grants announcement to
select providers to participate in the Consumer Directed
Durable Medical Equipment demonstration. We will be working
closely with the Assistant Secretary for Planning and
Evaluation to further develop and implement the 4-State Cash
and Counseling demonstration.
HCFA will continue the development and testing of outcome
oriented measures of quality for nursing home and home health
services, as well as long term care services of persons with
developmental disabilities. We will also continue our efforts
to develop a quality assurance system for the PACE program.
An important new area of research and demonstration
activity will build from our post acute care research to
develop and test more integrated, flexible systems of post
acute care that construct services and payment around
beneficiaries' health care needs and preferences. Work focused
on assessment tools, payment methodologies, care management
systems and outcomes measures will be initiated.
Another important area that will continue to be explored is
alternative financing mechanisms for long term care. Although
the majority of the elderly are covered by both Medicare and
supplemental insurance, a large portion of long term care
services remain uncovered. Medicaid covers long term nursing
care, but only after elderly individuals have depleted their
resources. Research is continuing that will identify the
sources of financing for long term care at various points
throughout institutionalization. This research will further
examine characteristics of individuals who come to rely upon
Medicaid for payment for their care. By identifying the risks
associated with nursing home use, we hope to be able to propose
improved methods of paying for this care.
We will continue to support data collection and data
analyses from projects that gather detailed data from national
and State data bases. Research is continuing on estimating
future acute and long term care need and utilization based on
available surveys. We will continue our efforts to improve our
understanding of the characteristics, health care needs and
service use of individuals eligible for both Medicare and
Medicaid, drawing upon the Medicare Current Beneficiary Survey
as well as developing new State data bases that link Medicare
and Medicaid data. We will continue initiatives to make data
bases available for research and analyses, including State
Medicaid data, the Medicare Current Beneficiary Survey, and the
National Recurring Data Set. We plan to expand the data
gathered under the Long Term Care Program and Market
Characteristics data base to capture additional State data
related to States' community-based care system infrastructure.
OFFICE OF INSPECTOR GENERAL
Introduction
The Inspector General Act establishes the statutory
authority and responsibilities for the OIG. The OIG's mission
is to: (1) protect the integrity of departmental programs and
the health and welfare of program beneficiaries; (2) promote
the economy, efficiency, and effectiveness of departmental
programs and operations; and (3) prevent and detect fraud,
waste and abuse in departmental programs and operations.
This mission is accomplished by conducting independent and
objective audits, evaluations, and investigations, designed to
reach all organizational levels of the Department and provide
timely, useful, and reliable information and advice to
Departmental officials, the Administration, the Congress and
the public. OIG's goal is to detect and prevent fraud and
abuse, and to ensure that beneficiaries receive high-quality,
necessary services at appropriate payment levels.
Within the Department, the OIG is an independent
organization, reporting to the Secretary and communicating
directly with the Congress on significant issues. The OIG is
comprised of the following components:
The Office of Audits Services (OAS) performs audit
activities which include: conducting and overseeing audits of
HHS programs, operations, grantees and contractors; identifying
systemic weaknesses that give rise to opportunities for fraud
and abuse; and making recommendations to prevent their
recurrence. OIG auditors also perform financial statement
audits near the Chief Financial Officer (CFO) Act of 1990 and
the Government Management Reform Act (GMRA) OF 1994.
The Office of Investigations (OI) develops cases concerning
fraud, waste, abuse, and mismanagement which occur within the
Department's programs. Working with Federal and State law
enforcement agencies, OIG investigators seek criminal, civil
actions and exclusions against those who commit fraud or who
thwart the effective administration of HHS programs. OIG
investigations focus on: the providers of services and supplies
under Medicare and Medicaid; program applicants and grantees;
beneficiaries and other recipients of Federal funds; and HHS
employees.
The Office of Evaluation and Inspections (OEI) conducts
short-term program evaluations (called inspections) that focus
on issues of concern to the Department, the Congress, and the
public, such as Medicare services, device and drug approvals/
removals, child support enforcement programs, and Medicare
client satisfaction. The results of this work generate rapid
and reliable information on how well HHS programs are operating
and offer recommendations to improve their efficiency and
effectiveness.
The Office of Enforcement and Compliance (OEC) is
responsible for the imposition of those mandatory and
permissive program exclusions and civil money penalty (CMP) and
assessment actions not handled by the Office of Counsel to the
Inspector General (OCIG), Civil Recoveries Branch. The office
serves as a liaison with HCFA, State Licensing Boards and other
outside organizations and entities with regard to exclusion,
compliance and enforcement activities. It develops models for
corporate integrity, compliance and enforcement programs;
monitors ongoing compliance, exclusion, enforcement activities
and HCFA suspension agreements; and promotes industry awareness
of corporate integrity and enforcement agreements developed by
the OIG.
The Office of Counsel to the Inspector General is
responsible for providing all legal service and advice to the
Inspector General, Principal Deputy Inspector General and all
the subordinate components of the Office of Inspector General,
in connection with OIG operations and administration. OIG fraud
and abuse enforcement activities, and OIG activities designed
to promote efficiency and economy in the Department's programs
and operations. The OCIG is also responsible for litigating
civil money penalty (CMP) and program exclusion cases within
the jurisdiction of the OIG, for the coordination and
disposition of False Claims Act qui tam and criminal, civil and
administrative matters involving the Department of Justice
(DoJ), and for the resolution of voluntary disclosure and
program compliance activities.
The Office of Management and Policy (OMP) provides support
services to OIG, including congressional relations, legislative
and regulatory review and public affairs, strategic planning
and budgeting, financial and information management, resources
management, and preparation of the OIG's semiannual and other
reports.
Accomplishments
Within HHS OIG we are continuing to streamline our
operations while maintaining our vigorous pursuit of fraud,
waste and abuse. As examples of our streamlining efforts, we
completed early outs and buyout programs targeted at reducing
management positions (SES through GS-13) and closed 17 out of
65 field offices. On March 31, 1995, the Social Security
Administration became an independent agency with its own OIG
formed of staff from the HHS OIG. With the departure, OIG has
had to reexamine its use of resources in order to concentrate
its work more fully in areas of health and welfare. Our total
savings for fiscal years 1995 and 1996 total $14.9 Billion. Our
accomplishments included the second largest health care fraud
settlement ever, against a health care corporation for
kickbacks and fraud in its home infusion, oncology, hemophilia
and human growth hormone businesses. The company agreed to
plead guilty and pay approximately $161 million in criminal
fines, civil restitution and damages. The settlement included a
corporate compliance plan.
Health Care
In May 1995, The President announced a 2-year partnership
of Federal and State agencies working together to prevent and
detect health care fraud in specific industries. This Operation
Restore Trust initially targets five States which together
account for 40 percent of the Nation's Medicare and Medicaid
beneficiaries. Operation Restore Trust, led by HHS OIG working
jointly with the Health Care Financing Administration (HCFA)
and the Administration on Aging (AoA),represents one of the
largest and most complex efforts against health care fraud ever
undertaken. The project is designed to share resources and collaborate
with numerous entities to prevent and detect fraud and abuse in three
rapidly growing sectors of the health care industry: home health
agencies, nursing facilities and durable medical equipment suppliers.
Operation Restore Trust also prompted a new OIG fraud hotline, 1 800-
HHS-TIPS, and a voluntary disclosure program that encourages health
care entities to come forward with fraud they discover for themselves.
During this period we marked the 1-year anniversary of
Operation Restore Trust. In the first year, 32 criminal
convictions, 10 civil judgments and 18 indictments were
obtained. Twenty-eight criminal convictions, 9 civil
settlements and 18 indictments involved nursing facilities and
related medical services cases, and 4 convictions and 1
settlements concerned home health agencies. In addition, OIG
has identified more than $37 million in fines, recoveries,
settlements and civil monetary penalties during this same
period. Thirty-six exclusions of ORT providers from the
Medicare and Medicaid programs for convictions of health care
fraud have been processed.
The new hotline received more than 23,600 calls and letter,
of which well over 6,600 were related to Department programs.
Of the 780 calls or letter related to ORT during this time
period, about 560 were related to nursing homes and related
medical services, and 2220 to home health agencies.
Medicare Patient Transfers: This report is the result of
OIG's review of transfer recovery projects undertaken jointly
by OIG, HCFA and Medicare Fiscal Intermediaries. The projects
identified overpayments that occurred because transfer of
patients between PPS hospitals were erroneously reported and
paid as discharges. In total, these projects resulted in
Medicare Part A trust fund recoveries totaling $219 million and
annual savings totaling $8 million. In addition, it is
estimated that $22 million will be recovered by FIs from
transfer transactions that warrant further resolution. The HCFA
concurred with our recommendations that it place a high
priority on recovering the remaining overpayments, including
those over 4 years old, and that it inform OIG of the final
resolution of the remaining unresolved cases.
Hospital Reporting to the National Practitioner Data Bank:
The OIG conducted this inspection in response to a PHS request
to determine how hospitals are responding to their legal
obligation to report adverse actions to the National
Practitioner Data Bank. The report noted that about 75 percent
of all hospitals in the United States have never reported an
adverse action taken against practitioners to the data bank,
and that there has been considerable State-by-State variation
in reporting rates.
OIG recommended that PHS support further inquiry to foster
a better understanding of the factors influencing hospital
reporting to the data bank and sponsor a conference to focus
attention on issues influencing such reporting. Further, OIG
proposed that PHS work with the Health Care Financing
Administration (HCFA) to ensure that the Joint Commission on
Accreditation of Healthcare Organizations assesses more fully
hospitals' compliance with the law. The PHS and HCFA agreed to
prepare a joint letter that will be sent to the Joint
Commission urging it to devote greater attention to hospital
compliance with the data bank law.
NATIONAL INSTITUTES OF HEALTH
The National Institutes of Health (NIH) is the principal
biomedical research arm of the Federal Government. This report
highlights a number of research advances conducted or supported
during 1995 and 1996 by NIH. Part of the NIH, the National
Institute on Aging (NIA), is the primary sponsor of aging
research in the United States.
Section 1 of this report outlines NIA's key advances for
1995. Section 2 outlines NIA's key advances for 1996. Other NIH
components also conduct or support aging research. They are the
National Cancer Institute; the National Center for Research
Resources; the National Eye Institute; the National Heart,
Lung, and Blood Institute; the National Institute of Nursing
Research; the National Institute of Arthritis and
Musculoskeletal and Skin Diseases; the National Institute of
Dental Research; the National Institute of Diabetes and
Digestive and Kidney Diseases; the National Institute of Mental
Health; the National Institute on Alcohol Abuse and Alcoholism;
the National Institute of Environmental Health Sciences; and
the National Institute on Deafness and Other Communication
Disorders. Section 3 provides selected findings from these
other NIH institutes.
Section 1
1995 introduction
NIH was created in 1974 to conduct and support research on
aging processes with a focus on diseases and other special
problems of older people. The remarkable life span that has
been realized during this century now presents Americans with
three important and related challenges: how to maintain quality
of life with advanced age, how to provide cost-effective health
care, and how best to divide adult life into working years and
retirement years.
The ``graying of America,'' that is, those demographic
changes that will occur as the post-World War II baby-boom
generation ages, is markedly raising the median age of
America's population. The aging of our society will impact
health care costs, regardless of the means by which these costs
are covered. The over-85 age group is the fastest growing
segment of the American population and is often referred to as
the ``oldest old.''
Even with the hope of major advances in the treatment and
prevention of debilitating disease, the demand for long-term
care is expected to expand dramatically in our society.
Research will be pursued on many different aspects of long-term
care in general and particularly on new and evolving forms of
care. NIA supports research on preventing the need for long-
term care or institutionalization, enhancing the quality and
efficiency of such care, easing the burden of care, and
forecasting the requirements for care.
Alzheimer's disease continues to be a top research priority
for NIA. This disease currently affects as many as four million
older Americans and their families, causes enormous personal
suffering, and costs the nation at least $90 billion each year.
Without the development of new treatments, cures, or preventive
approaches to this dreaded disease, the number of individuals
and families devastated by Alzheimer's disease will likely
increase up to five-fold within the next 50 years.
In addition to Alzheimer's disease, priority initiatives
include research on the biology of the aging process and on
physical disabilities such as osteoporosis and cardiovascular
disease. These initiatives are wide-ranging and can be based on
cutting-edge laboratory technologies or upon simple by highly
effective strategies such as exercise or behavioral
interventions. The goal of NIA-supported research is to
understand the basic mechanisms of normal aging and age-
associated disease and disability and to translate this basic
knowledge into treatment and prevention strategies.
Basic research
NIA funded basic research is a prerequisite for the
rational development of treatment and prevention strategies.
Because of the advances from basic aging-related science made
possible by NIA support, real hope exists for true increases in
independence and active life expectancy, helping to stem the
rising cost of health care expenditures. To prevent or cure
diseases associated with age such as cancer, cardiovascular
disease, osteoporosis, and Alzheimer's disease, we need to
continue extensive basic research into their underlying causes
as well as to better understand the aging process itself.
For example, research will continue on antioxidants to
discover their role and protective action against the damaging
effects of naturally occurring ``free radicals'' on subcellular
components. There is increasing evidence that certain
nutrients, including vitamin C, vitamin E, and betacarotene,
serve as agents of free radical capture and otherwise augment
the body's natural protective mechanisms. Any preventive
effects of antioxidants would have extraordinary potential for
forestalling a wide range of degenerative diseases. With the
escalating costs of medical treatment and care for an aging
population, simple preventive therapies involving dietary
supplementation may have tremendous benefits.
Molecular genetic studies are developing evidence that
longevity and cellular senescence (loss of a cell's ability to
divide and reproduce itself) are, in part, under genetic
control. Characterization of the specific genes which promote
longevity and postpone aging and cellular senescence are
central to discovering the mechanisms which govern longevity
and aging in humans. Knowledge of these fundamental mechanisms
will guide and hasten the development of effective prevention
and intervention strategies to extend human longevity and
health span.
Major breakthroughs have recently occurred in Alzheimer's
disease (AD) research that promise to yield definitive results
in the near future. Most recently, NIA-supported researchers at
Duke University found that a variation of the apolipoprotein E
(ApoE) gene, ApoE4, is associated with an unexpectedly high
number of AD cases and is probably a major risk factor to
developing AD. It is not yet clear how APoE4 affects cellular
function. Depending on the results of this research, new
diagnostic tests may identify those persons at risk for AD and
lead to protective therapies and better outcomes.
Since 60 percent of U.S. deaths are due to vascular
disease, NIA has a prime interest in supporting research on
age-associated vascular disease. During atherosclerosis, some
of the vascular smooth muscle cells (VSMC) begin to multiply
and produce proteins which they secrete into their environment.
Intramural researchers have discovered that VSMC, when placed
in an environment that simulates arterial injury, not only
proliferate, but invade membranes and proteins that normally
surround the VSMC and the inner lining of blood vessels. Thus,
therapeutic measures to prevent this invasion may reduce the
extent of the atherosclerotic process, with a significant
reduction in vascular disease and in health care costs.
Applied/Clinical research
NIA supports pre-clinical and clinical treatment research
on AD, made possible by past investments in basic laboratory
studies. Tacrine, recently approved by the FDA for use in
Alzheimer's patients, was tested several years ago in a major
clinical trial and found to have an effect in delaying the
progress of disease in some patients. However, it provides only
temporary relief, and NIA continues its work towards developing
and testing new treatments that will allow patients to continue
to function independently. NIA is currently testing the drug
Deprenyl in combination with the antioxidant vitamin E in a
clinical trial. Preliminary results are due by early 1995.
NIA is supporting a number of major clinical initiatives
which address the problems of physical frailty and loss of
independence that are associated with older persons. Physical
frailty is a major cause of long-term care needs and imposes
annual costs of at least $54 billion. Results from ongoing NIA-
supported studies have provided convincing evidence of the
benefits of exercise for maintaining independent function in
older persons. FICSIT (Frailty and Injuries: Cooperative
Studies of Intervention Techniques) is a set of clinical
trials; some interventions have shown more than a 30 percent
reduction in fall rates, which could markedly lower the rate of
disabling injuries such as hip fractures.
Osteoporosis affects over 25 million Americans, mainly
women, and is a serious public health problem since associated
fractures are a major cause of disability in older people:
costs associated with hip fractures exceed an estimated $7
billion annually. NIA-supported research into new therapies and
interventions would impact a very large percentage of the older
population and save billions of dollars in health care costs.
Recently, attention has focused on treating degenerative
conditions such as osteoporosis, osteoarthritis, and muscle
atrophy through replacement therapy with ``trophic'' factors.
These factors promote growth and maintenance of tissues such as
bone, muscle, and cartilage.
NIA has a keen interest in research particularly relevant
to older women. There are many questions surrounding the health
implications of menopause and hormonal changes in women and
will continue support for a major initiative, the Women's
Health and Aging Study, to determine what diseases and other
events cause and influence disability in women age 65 years and
older. NIA is also committed to research which focuses upon
minority subpopulations and the similarities and differences
which exist between them and non-minority populations, such as
their relative use of long term care services.
These and other initiatives described in the following
pages are representative of NIA's broad research portfolio. As
we approach the next century, it will be through the continued
support of this research that we can develop the means to
prevent or cure the major causes of costly disease and
disability to maintain good health and independence for older
Americans.
extramural research
Alzheimer's disease
Recent genetic discoveries have shed new light on the
causes and biological mechanisms which result in the
development of Alzheimer's disease (AD). Among the potential
causes of AD, genetic factors have been implicated to a much
greater extent than was previously suspected. It is now known
that mutations in the amyloid precursor protein (APP) gene and
in a gene localized to a small region of chromosome 14 account
for most inheritance of early onset AD. Late onset AD has been
more difficult to trace, but linkage to chromosome 19 was
reported in some late onset families. Recently, ApoE4, whose
gene is located on chromosome 19, has been shown to be
associated with greater increased risk of AD. This may account
for the chromosome 19 linkage reported earlier. More
significantly, the ApoE4/AD association has been found not just
in late onset families but also in the general population. The
increased risk associated with ApoE4 could account for many AD
cases previously designated ``sporadic.''
Larger epidemiological studies are necessary to confirm the
association of ApoE4 with AD. Should ApoE4 be found to be a
major factor in determining AD susceptibility, modification of
ApoE4 activity would become an attractive target for
development of therapeutics. Ultimately, the elucidation of the
complete molecular pathway which results in the development of
AD will allow the design of optimal pharmacological treatment
and prevention strategies.
Risk factors associated with AD
One of the long range goals of AD research is to determine
the full range of risk factors for AD which will lead to a more
complete understanding of its etiology. A major theme of
epidemiological research in Alzheimer's disease is to address
specific biomedical problems in minority and other distinct
population groups in an effort to extend knowledge about age-
specific incidence, prevalence rates, and risk factors for the
onset of AD. Three studies have recently been initiated in
African-American populations. The major purpose is to identify
and clarify the risk factors for Alzheimer's disease and multi-
infarct dementia (MID) in three groups of patients--those with
Alzheimer's disease, those with MID, and those with multiple
strokes but without evident cognitive dysfunction. The
investigation will provide important new information about risk
and protective factors for cognitive and functional decline in
older African-Americans. NIA also supports the Honolulu
Dementia Study. The objectives of this study are to determine
rates and risk factors for Alzheimer's disease and vascular
dementia in aging Japanese-American men.
Sleep
As many as half of the older population suffer from chronic
sleep disturbance, a condition that frequently leads to
problematic use of sedative medication, reduced quality of
life, and increased morbidity and mortality. NIA supported
studies on sleep disorders, such as the multi-center
``Established Populations for the Epidemiologic Study of the
Elderly'' (EPESE), provide support for the effective detection,
treatment, and prevention of sleep disorders. Data generated
from EPESE have shown that sleep disorders are often associated
with poorer self-perceived health, increased depressive
symptoms, physical disability, respiratory symptoms, and over-
the-counter medication use. Treatment and prevention of sleep
disorders can result in savings in health expenditures as well
as enhancing the quality of life of older persons.
Control of cell proliferation in aging and cancer
Regulation of cell proliferation is required to maintain
the human body's equilibrium. NIA research has provided a
greater understanding not only of normal cell proliferation but
also the causes and effects resulting from cell senescence--the
loss of proliferation capacity--or the opposite, uncontrolled
proliferation seen in cancer. Understanding these biological
mechanisms will further our knowledge of normal aging and
cancer at the cellular level and promises to provide key
contributions to unravelling the fundamental mechanisms
underlying the aging process and other age-related diseases in
the near future.
Research progress is currently being made in several areas.
Two NIA-funded laboratories have independently obtained
evidence that p53, a tumor suppressor proteins, induces
expression of another protein which binds to kinases, a class
of enzyme, and inhibits their function. The activity of these
kinases is essential for replication. Further research will
reveal the mechanisms of these reactions with the ultimate goal
of designing drugs which can restore this tumor suppressive
property.
A second protein of interest to both aging and cancer
research is a protein known as bcl-2, which inhibits a natural
process known as programmed cell death. If this programmed
death is inhibited the result will be overpopulation of cells,
as in cancer. This is also thought to be one explanation for
benign prostatic hypertrophy. The mechanism for controlling
bcl-2 expression needs to be elucidated, opening up the
possibility of interventions to regulate bcl-2 when needed.
A third area of interest to both aging and cancer research
is the role of telomere shortening in controlling cell
proliferation. Telomeres are repeated DNA sequences found at
the ends of chromosomes that shorten each time a cell divides.
A very recent working hypothesis is that telomeres shorten
because of the ``end-replication problem,'' and that continued
proliferation requires some, as yet undefined, minimal telomere
length. The implications of this research are that both
senescence and cancer could be regulated by developing
interventions which either prevent telomere shortening or
inhibit telomerase activity.
Role of oxidative damage in aging
``Free oxygen radical'' damage has long been believed to be
a risk factor for the degenerative processes which accompany
aging. These compounds can damage DNA, proteins, and lipids.
The resulting damage can lead to cancers or dysfunctional
proteins and damaged membranes which lessen a cell's ability to
carry out its proper function. There is increasing evidence
that certain micro-nutrients, including vitamins C and E, serve
as agents of free radical capture or ``antioxidants,'' and
augment the body's protective mechanisms. The preventive
effects of antioxidants have potential for forestalling a range
of degenerative diseases. There appears to be a role for
dietary antioxidants in the prevention of some cancers, senile
dementias, and cardiovascular diseases. Simple preventive
schemes involving dietary supplementation could lead to
significant savings in the costs associated with medical
treatment.
Biology of aging muscle
A decrease in mass and functional capability of skeletal
muscle contributes substantially to the impairment of
locomotive performance that accompanies human aging and is a
significant risk factor for physical frailty. NIA continues to
support basic research into the molecular basis of skeletal
muscle growth, age-related muscle degeneration, and selective
fiber atrophy. The development of effective intervention
strategies to retard or prevent age-related muscle degeneration
is dependent on basic research to delineate the underlying
mechanisms. Such interventions would be expected to
significantly extend human health span, reduce frailty, and
increase independence and quality of life for older adults.
Protein structure and function
NIA is also focusing efforts on determining the structures
of proteins which have undergone non-hereditary changes to
their amino acids. For many years it has been clear that
``modified proteins'' accumulate during aging and may interfere
with normal cellular processes. These unstable proteins lead to
such age-related problems as cataracts, interrupted blood flow
to the heart and brain, failure of the immune system, impaired
ability to heal wounds, and loss of cognitive function. NIA is
attempting to discover the mechanisms by which modification of
proteins occur, why they accumulate in aging, and the
physiological consequence of these changes. Understanding these
mechanisms may ultimately lead to effective treatment and
prevention strategies.
Treatment of Alzheimer's disease (AD)
The primary manifestation of AD dementia is intellectual/
cognitive deterioration and the sole FDA approved drug for the
treatment of AD currently on the market, Tacrine, provides only
temporary relief for treatment of AD. In FY 1991, the Drug
Discovery Groups in AD program was initiated to facilitate the
pre-clinic development of new compounds for treating
Alzheimer's disease by expanding the range of approaches to
drug treatment beyond the current focus. The research
activities of three of the Groups deal with attempts to
circumvent the blood brain barrier's ability to keep out
peripherally administered peptides and proteins. This is
important because one potential treatment for AD would be to
raise the concentration in the brain of neurotrophic factors
which promote the health and well being of neurons. Since
neuron death and dysfunction is a major problem in AD, these
factors may be effective in delaying or reversing cognitive and
behavioral symptoms of AD.
Behavioral aspects of AD
NIA also supports research aimed at ameliorating those
alterations in behavior, mood, and function associated with AD
that cause the greatest stress for family members, and
difficulties for both professionals and family members in
providing optimal care. It is important to provide tools for
families and nursing homes which will replace physical and
pharmacological restraints. The goal is to reduce the severity
and frequency of disruptive behavior, to allow patients to live
in the least restrictive environmental and manner, to maximize
dignity and independence, and to retain or reestablish self-
care practices.
NIA supports several research projects examining the
extent, causes, and consequences of caring for people with AD
and related dementias. These include ten coordinated research
projects to examine the nature and outcomes of special care
units for persons with dementia. Other activities include
initiatives in family caregiving and health services, burdens
of care research in special populations, specifically minority
family caregivers; supportive environments and everyday
functioning; and demographic and economic aspects of
Alzheimer's disease.
In 1991, the NIA, in conjunction with the National
Institute for Nursing Research and the Alzheimer's Association,
began fourteen pilot feasibility studies for new and innovative
methods for managing the behavioral symptoms associated with
AD. The symptoms of special concern included wandering,
disturbed sleep, pacing, agitation, feeding and dressing
difficulties, incontinence and toileting difficulties,
screaming and other vocalizations, aggression and violence, and
inappropriate sexual behavior. Studies were specifically sought
for strategies to enhance AD patients' self-care abilities and
activities of daily living. These feasibility studies will lay
the scientific and clinical groundwork that may lead to large-
scale clinical studies/trials on the assessment and
nonpharmacologic management of secondary symptoms and
disabilities.
Language, attention and cognition
Cognitive dysfunction in aging is defined by the changes in
neural and psychological processes that control or regulate
attention, memory, thought, communication, spatial competence,
decision making, and other cognitive processes. Ongoing studies
are being conducted to explore the range of normal and abnormal
cognitive processing. A particularly exciting development is
the use of neuroimaging techniques that permit researchers to
image the brain while cognitive processing occurs. These
techniques hold great promise for isolating brain structures
which control various aspects of cognitive function and for
determining what parts of the brain are controlling age-related
changes in cognitive function.
Frailty and physical functional independence
Physical frailty is a major cause of long-term care needs
and afflicts over 3.25 million older Americans. Epidemiologic
studies have shown a relationship between impairment and
strength, endurance, gait, and the occurrence of loss of
independence. FICSIT (Frailty and Injuries: Cooperative Studies
of Intervention Techniques) is an NIA supported set of clinical
trials which have demonstrated that fall rates in moderately
frail older persons can be reduced significantly by
intervention targeted to individuals' specific fall risk
factors. Other findings show that balance, strength, and
endurance training can markedly improve physical performance
abilities in a wide variety of older populations ranging from
relatively healthy community-dwelling persons to very frail
nursing home residents. Other research has demonstrated that
the administration of growth hormone has been associated with
arresting or reversing degenerative tissue changes which
decrease strength and mobility.
Claude D. Pepper Older Americans Independence Centers
The NIA added one new Claude D. Pepper Older Americans
Independent Center (OAIC) in fiscal year 1993 and plans to add
at least one additional center in fiscal year1994. The OAICs
were authorized by Congress to promote research on interventions that
can help older people live independently, and avoid
institutionalization or prolonged hospitalization. Besides testing
specific ways to prevent disability, the OAICs train additional
researchers capable of doing such studies and disseminate information
on successful interventions to clinicians and the general public.
Cardiovascular disease
Cardiovascular diseases and stroke account for more deaths
in the population 75-84 years old than the next nine leading
causes of death together. Cardiovascular diseases associated
with aging include hypertension, stroke, ischemic heart
disease, heart failure, peripheral vascular disease, cardiac
arrhythmias, and impairments in blood pressure regulation which
cause intermittent hypotension. The incidence and prevalence of
these conditions rise with age.
NIA supported investigators at the Claude Pepper Center at
Harvard have shown that a reduction in overall heart rate
variability is associated with aging, congestive heart failure,
coronary artery disease, sudden death syndromes, and after-meal
low blood pressure. Although the average heart rate did not
differ between the age groups or sexes, heart rate variability
was greater in women than men at all ages. The increase in
heart rate variability in women compared to men may be related
to lower cardiovascular disease risk and greater longevity in
women. Future studies are needed to gain a better understanding
of this and other mechanisms by which age and gender
contributes to cardiovascular diseases. NIA plans a significant
research initiative in this area for fiscal year 1994.
Osteoporosis and bone quality
The progressive loss of bone, which is universal after
middle age, very commonly leads to osteoporosis, a condition
characterized by increased skeletal fragility. NIA supports a
range of research into the causes and treatment of
osteoporosis. Research aimed at identifying markers and risk
factors that predict changes in bone mass, bone competence, and
fracture susceptibility is of vital importance in identifying
individuals at risk and evaluating the effectiveness of
treatment strategies.
For example, while diabetes has been hypothesized to be a
risk factor for bone loss and osteoporosis, recent research has
shown that some diabetic women actually had increased bone mass
compared to non-diabetic women. This distinction did not appear
among men. This gender-related difference suggests that certain
hormonal agents would play a potentially important role as risk
factors and/or in a therapeutic strategy to preserve bone mass.
Additional research has uncovered a link between cigarette
smoking and reduced bone mass on the hip. These findings are
particularly important, not only in light of the public health
implications, but because they also apply to men, in whom the
need for research on risk factors for osteoporosis has received
little attention.
The decrease in estrogen levels which follows the onset of
menopause frequently results in rapid bone loss which often
precedes osteoporosis. Recent research has discovered the
osteoclasts (cells that break down and remove bone) are target
cells for estrogen, and that estrogen directly inhibits the
breakdown of bones by osteoclastic cells. This finding will
encourage the development of new approaches which will be
effective in halting bone breakdown and hence preventing
osteoporosis.
Menopause and post-menopausal problems
Menopause is a universal event in female aging and is also
associated with an acceleration in the rate of bone loss.
However, it is unclear whether osteoporosis in old age is
greater in women who had a relatively early menopause compared
to those whose menopause was later. Recently, a study has shown
that the total number of reproductive years may be a
significantly more sensitive index for identifying women at
increased risk of osteoporosis. In order to gain an increased
understanding of the inner-relationship between menopause and
osteoporosis and other problems associated with menopause, NIA
began a major initiative in this area in fiscal year 1994.
Because the menopausal experience in minority women has been
particularly neglected, special emphasis in minority
populations is an integral part of this initiative.
NIA also continues to support the NIH Women's Health
Initiative, which includes 70,000 post-menopausal women ages
50-79. This study is intended to assess the long term benefits
and risk of hormone therapy as it relates to cardiovascular
disease, osteoporosis, and breast and uterine cancer. Related
to this effort, NIA began the Women's Health and Aging Study
which is exploring the causes and course of physical disability
in women aged 65 and older. The study will also provide
important information on how the disease-disability
relationship is modified by cognitive functioning; on
psychological factors; and on social, economic, and medical
resources of older women.
Failure to thrive and malnutrition
The ``failure to thrive'' syndrome consists of weight loss,
decreased appetite, poor nutrition, and inactivity. It is often
accompanied by dehydration, depressive symptoms, impaired
immune function, and low serum cholesterol. NIA actively
encourages research to develop interventions designed at
preventing, arresting, or reversing the failure to thrive
syndrome. NIA is also interested in research on a variety of
dietary disorders in older persons, especially malnutrition and
the role of nutrition in overall health status in old age.
There is a great deal of conflicting information on dietary
recommendations for older people, leading to inappropriate use
of dietary supplements and potentially harmful eating habits.
Research in this area can lead to the development of
scientifically sound guidelines for older people, particularly
those relating to medications or to diseases that may require
dietary changes to maintain functioning.
Improving long term care for the elderly
Recent discussions of health care reform emphasize research
in regard to long-term care needs. Identifying factors that
subsequently lead to placement in nursing homes (NH) is of
particular importance for recognizing those at risk and then
developing interventions that can minimize, if not eliminate,
associated risks. NIA research provides valuable information
for predicting NH placement and mortality. These analyses
confirmed the predictability of several key sociomedical risk
factors--living alone, having fewer non-kin social supports,
low sense of personal control, and other functional
limitations.
The NIA Special Care Initiative Study predicts, examines,
and evaluates the use of long term care services and practices,
and identifies strategies for modifying and improving services
for those in need. The idea behind a Special Care Unit (SCU) is
that people with dementia might benefit from specially designed
programs or environments that are different from those provided
in a traditional nursing home setting. While special care units
have proliferated across the country in recent years, very
little is known about their effectiveness in caring for
Alzheimer's patients, in relieving burdens of care for the
patient's family, or how these programs compare to traditional
nursing home care in terms of cost and effectiveness. The NIA
Special Care Unit Initiative projects are designed to evaluate
the impact of these new care units on people with Alzheimer's
disease, their families, and nursing home staff. These studies
will provide the public, nursing home facilities personnel, and
policy makers with the first comprehensive look at how special
care units work.
Self-care refers to a broad range of activities undertaken
by an individual to maintain or promote health, as well as to
detect, prevent and treat common health problems and
conditions. Research being conducted in this area seeks to
assess the extent and nature of self-care practiced by older
adults, the strategies used to maintain independence, the
relationship between self-care and other forms of care, and the
subsequent use and costs of health care.
Economic and health status of the elderly
The well-being of America's elderly clearly depends on
their economic and health security. The reciprocal and
multidimensional relationship between income and health in
adult life is poorly understood; almost nothing is known about
the effects of these transitions at advanced ages.
Two major new NIA-supported studies aim to clarify how
people experience and evaluate their health and economic status
from immediate pre-retirement years to very old age. The Health
and Retirement Study (HRS) follows transitions in reliance on
earned income, private pensions, Social Security, Medicare
benefits, etc. in an initial sample of over 12,000 persons aged
51-61 years. An emerging portrait of this population depicts
sharp contrasts between desires for gradual retirement and
actual departure from the work force. The role of health and
disability in the timing of retirement, and of retirement in
the health and economic well-being of this cohort, are also
being examined. An auxiliary study, Asset and Health Dynamics
of the Oldest-Old (AHEAD), follows 7,300 persons aged 70 years
and over--almost a third of them over age 80--to examine how
late-life changes in physical and cognitive health affect, and
are affected by, patterns of saving and income flows.
NIA also plans to support up to six Demographic Centers on
Population Aging which apply state-of-the art demographic,
economic, and mathematical methods to analyses of these and
other new databases, providing timely reports on national
public policy issues. The centers will include outreach
activities that benefit researchers at many institutions across
the nation.
Aging and family life
Family based research identifies how health, illness, and
disability in later life are affected by intergenerational
exchanges, informal caregiving for frail elders, and cultural/
ethnic diversity in family relationships. These relationships
are pivotal to the health and health care of older people. This
research contributes to an understanding of adequacy of
informal care for frail elders and of the factors that
determine the use of health care services by older people and
their caregivers. In advancing basic social science research,
family aging studies seeks an understanding of interpersonal
relationships in physical and emotional health and illness
across the life span.
Special populations
The NIA continues to be committed to minority populations,
women, and rural older populations. Most recently, the
Institute began a research effort to establish Exploratory
Centers for Research on Health Promotion in Older Minority
Populations. These centers will conduct pilot research and plan
for a program of medical, behavioral, and social research;
medical and psychosocial interventions; and programs of health
education and community outreach aimed at improving the health
status of older ethnic minority populations.
NIA is vigorously expanding its minority research focus and
minority participation in all of its research initiatives. For
example, investigators are testing intervention strategies to
prevent frailty in older black and Hispanic-American
populations and focusing on health conditions such as
hypertension, diabetes, and prostate cancer, which are
disproportionately prevalent in older Americans. NIA also
supports four rural health centers established to explore the
special health needs of older rural Americans, including access
to and results of health care services.
The long-term goals of the NIA intramural research program
(IRP) are: (1) to conduct basic research relevant to
understanding aging processes and age-associated disabilities.
The IRP conducts the landmark Baltimore Longitudinal Study of
Aging and is a major setting for post-doctoral training of
promising investigators.
INTRAMURAL RESEARCH
Intervening in aging processes
The causes of aging are complex and involved both internal
and environmental factors that damage molecules, cells, and
tissues as well as the ability of the host to resist and repair
such damage. IRP scientists, using the latest techniques of
molecular and cellular biology, continue to search for the
causes of aging and ways to retard and reverse age-associated
deficits before they progress to disease, disability, and
institutionalization. Current projects include: (1)
investigations of DNA repair in genes including those with
implications in malignancy and longevity; (2) research on the
mechanisms by which the death of cells is increased with age
and diseases such as Alzheimer's disease and osteoarthritis;
(3) studies on the loss of host defense to aging; and (4) the
potential use of gender therapy to prevent or reverse age
deficits or diseases.
Regarding the immune system, it is well known that many
older individuals show an impaired immune response that puts
them at greater risk of infections. NIA and National Cancer
Institute scientists have defined a novel cell surface protein
that is essential for immune activation. Better definition of
the molecular components in the immune response offers new
possibilities for enhancing appropriate and suppressing
inappropriate immunologic reactions.
Baltimore Longitudinal Study of Aging (BLSA)
The BLSA, begun in 1958, seeks to understand how and why we
age. The study panel is a group of over 1,100 highly dedicated
women and men, from 20 to 97 years of age, who have volunteered
to come to Baltimore every two years for intensive study to
establish their physiologic and psychologic status. Over 160
new participants have been recruited as part of a multi-year
strategy to enroll 350 more women and minorities, meeting
specific health criteria, for major initiatives with hypotheses
about gender and racial differences. Biologic samples are
collected from participants at sequential visits and banked
which, with the extensive health and behavioral data assembled
over time, allows ``instantaneous longitudinal studies'' to be
conducted. These studies would otherwise take a decade or more
to complete and cost millions of dollars. Initial research
projects using a newly established DNA bank include studies of
age-associated changes in DNA repair and preferential DNA
repair in breast cancer. A vascular initiative is examining
age, race, and gender differences in blood pressure, arterial
stiffness, thickening of the heart muscle and the relationship
of these parameters to heart and vascular disease. The BLSA
Perimenopausal Study is characterizing the biological and
psychosocial antecedents of the menopausal transition in 200
women.
Alzheimer's Disease (AD)
The IRP has a focused research program on the etiology,
diagnosis, and treatment of AD. The distinctive aspect involves
applying and refining sophisticated technologies--positron
emission tomography, magnetic resonance imaging, and
spectroscopy--to study patients throughout the disease course
to yield new insights. For example, NIA scientists have devised
new ways to evaluate drug efficacy using only a few patients by
studying the longitudinal ``trajectory'' of function and
pathology in individual patients. These are being applied in
studies to evaluate sites and mechanisms of action in AD. NIA
scientists have hypothesized that early functional and
metabolic deficits in AD reflect reversible failure of nerve
impulse transmission. Research will continue to study the use
of drugs on the course of AD to delay development of morbidity
and hospitalization. NIA scientists have also shown that
biopterin, a natural compound that regulates many fundamental
brain mechanisms, is reduced in the cerebrospinal fluid of
certain AD patients. A clinical trial has been initiated to
study the possible role of biopterin in the pathophysiology of
AD and of its potential as a therapeutic agent.
Vascular disease
A major ongoing intramural program studies age-associated
vascular disease such as atherosclerosis, hypertension, and
stroke. NIA studies show that older men and women with higher
fitness levels generally have arteries which are less stiff
than those of less fit individuals. These results suggest that
the age-associated increase of arterial stiffness may be slowed
by aerobic exercise; longitudinal follow-up is underway.
Researchers have found that, with age, vascular smooth muscle
cells become highly motile and invasive and produce degradative
enzymes that destroy normal blood vessel architecture and
weaken the blood vessels. Various compounds have been found to
stabilize the dedifferentiation of the smooth muscle cells and
further research will continue on these prototype drugs. Other
opportunities that are being pursued include: (1) the use of
gene therapy as a potential new approach to the treatment of
coronary artery disease; (2) studies of the relationship
between hypertension associated with stress and high sodium
intake, particularly in minorities; and (3) insights into the
basic cellular and molecular mechanisms contributing to
renarrowing of an artery following balloon dilation.
Frailty, osteoporosis, hormone replacement therapy and women's health
Issues of women's health and well-being command special
attention within the IRP and include the following emphases:
First, a decline in growth hormone (GH) levels parallels the
loss of muscle as well as the development of frailty. Recent
intramural studies show that a natural stimulator of growth
hormone production, growth hormone releasing hormone, restores
the normal pattern and level of GH in older individuals.
Significant increases in muscle strength were apparent after
six weeks of treatment suggesting that such factors could be
utilized to reverse certain age-associated diseases and
disabilities. If successful, this therapeutic approach could
speed recovery and reduce bed days and hospital costs. Also, a
collaborative trial is underway comparing the effects of
replacement of GH and a gender appropriate sex steroid in 160
women and men. This will enable the effects of hormone therapy
on a wide variety of relevant health variables to be compared
in women versus men. A National Institute for Nursing Research
and NIA collaborative intramural program will continue to
examine post-operative complications from hip fracture and
devise behavioral nursing interventions to enhance outcomes.
Diabetes and other age associated metabolic defects
NIA conducts a multifaceted research effort to develop new
therapies that are safe and specific for the control of blood
glucose in older diabetic patients to prevent the disease's
late complications. Significant progress has been made in
defining and modifying the regulatory signals controlling
pancreatic insulin secretion. INA scientists have found that
the action of insulin can be enhanced and prolonged by
preventing the removal of phosphate from the activated form of
the insulin receptor. These results are being aggressively
pursued given their promise for opening new avenues in the
treatment of diabetes associated with aging.
Longitudinal studies of prostate disease and PSA
Collaborative studies will continue to investigate
potential uses of rates of change in prostate-specific antigen
(PSA) levels to improve clinical detection of prostate cancer
and benign prostatic hyperplasia (BPH). Recent findings suggest
that: (1) rates of change of PSA are significantly more
accurate than the traditional single measure for the early
detection of prostate cancer; (2) certain PSA criteria now in
use may lead to many unnecessary prostate biopsies and should
be dropped from clinical practice; and (3) PSA tests may be
useful in guiding optimal treatment decisions for BPH.
Section 2
1996 introduction
Congress created the NIA in 1974 as part of the NIH. At
that time, aging research was just in the early stages of
developing ways to explore the fundamentals of the aging
process. Now, over 20 years later, the science base has grown
in depth, breadth, and detail. And with this growth have come
new insights into the processes and the experience of aging.
Driving an increasing interest in aging research is a
projected dramatic increase in the older population. People
over 65, who were four percent of the U.S. population in 1900,
will constitute approximately 13 percent in the year 2000 and
20 percent by the year 2025. The over-85 age group is the
fastest growing segment of the American population and is often
referred to as the ``oldest old''. This boom in the population
of older Americans will have a profound impact on the Nation's
health, social, and economic institutions.
Research in aging over the last two decades has contributed
to the realization that aging should not be equated with
inevitable decline and disease. Consider Alzheimer's disease
(AD): This form of dementia has now been linked to alterations
in specific proteins and has been shown to affect specific
regions of the brain. As a result, it is no longer possible to
think of AD as ``senile dementia,'' an old and discredited term
which implied that losing one's memory was simply part of
growing older. Part of this new perspective has its roots in
the use of new technologies to explore the fundamental biology
of aging. Where researchers once theorized about the causes of
growing old, they now have the means--in recombinant DNA
techniques and nuclear magnetic resonance, for instance--to
track down the actual mechanisms of aging in cells and tissues.
Once the mechanisms of aging are understood, the interactions
between aging and disease will yield to preventive measures and
treatments for the disorders that often accompany aging.
Fueling the growth of this science are increasingly
important links between aging research and other areas of
biomedical and behavioral investigation. For example, the study
of aging cells now overlaps substantially with research on the
cellular mechanisms of cancer and cardiovascular disease.
Similarly, the study of the aging brain now has numerous
intersections with basic neurobiology and research on brain
disease. Increasingly, research on aging has become an integral
part of mainstream health research.
Even with the hope of major advances in the treatment and
prevention of debilitating diseases, the demand for long-term
care is expected to expand in our society. Research will be
conducted on many aspects of long-term care, particularly on
new and evolving forms of care. NIA supports research on
preventing the need for long-term care or institutionalization,
enhancing the quality and efficiency of such care, easing the
burden of long-term care, and forecasting the requirements for
long-term care.
Alzheimer's disease is a top research priority for NIA. It
currently affects as many as four million older Americans and
their families, causes enormous personal suffering, and costs
the nation billions of dollars each year. Without the
development of new treatments, cures, or preventive approaches
to this dreaded disease, the number of individuals and families
devastated by Alzheimer's disease will likely increase up to
five-fold within the next 50 years. In addition to Alzheimer's
disease, priority initiatives include research on the biology
of the aging process and on physical disabilities such as
osteoporosis and cardiovascular disease. These initiatives are
wide-ranging and can be based on cutting-edge laboratory
technologies or upon simple but highly effective strategies
such as exercise or behavioral interventions. The goal of NIA-
supported research is to understand the basic mechanisms of
normal aging and age-associated disease and disability and to
translate this basic knowledge into treatment and prevention
strategies.
basic research
Caloric restriction and biomarkers of aging
As aging becomes more and more a topic of public concern,
interest in interventions to delay or eliminate the
consequences of aging has grown enormously. Although the
molecular processes that must be responsible for species-
specific rates of aging are poorly understood, the gross
physical and physiological manifestations of aging are well
characterized in many species. The differences in these aging
changes within and between species suggest that aging is a
multi-process phenomenon. As a result, chronological age is not
a good predictor of physiological or functional age. Better
measures of physiological or functional age are known as
``biomarkers of aging.'' The NIA is currently in the seventh
year of a ten year initiative to develop a set of biomarkers of
aging which could be used as measures of aging-related
biological changes in experimental systems and in human beings.
It has been known since early this century that caloric
restriction extends the lifespan of rodents; useful biomarkers
of aging might predict the life extension that results from
caloric restriction. Studies conducted so far show that caloric
restriction retards the development of virtually all age-
related lesions and tumors, reduces oxidative damage to neurons
and slows the decline in the immune system associated with
aging. An understanding of how caloric restriction produces
this effect would provide important insights into preventive
measures and therapies to retard and/or alleviate the effects
of aging. The NIA and the Food and Drug Administration (FDA)
have sponsored more than 30 groups to conduct research on
biomarkers and caloric restriction. Currently, they are in the
final stages of testing in rodent models prior to considering
their translation to human studies.
The roles of oxidative damage and programmed cell death in aging
Oxidative damage to critical cell components is chronic and
ubiquitous in living cells. Although extensive repair systems
exist in these cells, repair is never 100 percent complete. The
purpose of this initiative is to determine: (1) what factors
regulate the amount of damage incurred by cells, (2) what
factors regulate the repair of this damage, (3) whether
unrepaired damage contributes to aging, (4) the role of ``cell
suicide'' in eliminating damaged cells, and (5) whether
interventions can be developed to retard aging. Recent research
results by NIA grantees include the following:
long-lived nematode (round worm) mutants express
increased levels of antioxidant defense enzymes, and
higher levels of antioxidant enzymes in fruit flies
extend maximum life span.
when ``-amyloid'' protein, which accumulates
in the brains of patients with Alzheimer's disease, is
placed in solution it generates reactive oxygen capable
of killing neurons through oxidative damage.
mice carrying one or more extra copies of the
antioxidant defense enzyme ``superoxide dismutase'' are
more resistant to oxidative stress compounds which
induces diabetes in animal models.
When oxidative stress overwhelms the cellular defense and
repair systems, an alternative protective strategy for the
organism is for the damaged cell to actually commit suicide.
Whereas this may be the best way to eliminate a heavily damaged
and potentially cancerous liver cell, the elimination of a
neuron has more serious consequences because of the inability
to replace lost neurons. Thus, an understanding of how cell
death is regulated may be crucial not only in preventing
cancer, but also in preventing neurodegenerative disease.
Recent research results of NIA grantees include the
identification of several genes required for induction of the
programmed cell death pathway.
Cellular senescence
It is possible that specific genes determine how many times
a cell divides or proliferates and that the end of cell
division, known as senescence, helps determine certain aspects
of aging. Most cells are limited in the amount of times they
can divide; a built-in barrier to unlimited growth. This limit
is higher in longer-lived species, such as humans, than in
shorter-lived species. Hence, human cells can proliferate more
times than mouse cells. This and other observations have led to
speculation that life spans and aging may be linked to the
limit on cell division.
Cellular senescence intrigues researchers for another
reason: While on one hand it limits life span, it may also
prevent cancer. When the limit on cell division is removed, as
it is for presently unknown reasons in cancer cells, the cells
continue growing indefinitely. If cell senescence is indeed one
of the fundamental mechanisms of aging, as some biologists
speculate, then aging itself may be the flip side of the cancer
coin, the byproduct of a mechanism that prevents cells from
growing into tumors. Whatever the ``purpose'' or end result of
cell senescence, the genes that regulate it are the focus of
intense study. NIA-supported scientists in several laboratories
have already isolated genes that seem to promote cell
proliferation--called oncogenes--and other genes that seem to
stop proliferation, often referred to as tumor suppressor
genes. Understanding why and how these genes are ``turned on''
or expressed may uncover new pathways for understanding both
aging and cancer.
It has been found, for example, that each time human or
animal cells divide, there is a loss of DNA from the ends of
each chromosome. The ends of chromosomes are called
``telomeres''. When telomeres have shortened beyond a critical
point, cells can no longer divide and are senescent. This
mechanism would limit the amount of cell division that any cell
can undergo, potentially limiting life span but also providing
protection against the uncontrolled cell division that occurs
in cancer. Recent analysis, however, has shown that an enzyme
called telomerase can reverse telomere shortening in some
normal cells such as sperm cells, as well as in cancer cells
where telomerase allows cancer cells to continue uncontrolled
division. Further molecular and genetic studies of telomeres
and telomerase are therefore of potential importance for the
understanding of both aging and cancer, and will be supported
by NIA.
Gene therapy
Whereas aging results from both genetic and environmental
factors, appropriately designed genetic interventions may be
able to slow aging due to both kinds of factors. For example,
increased expression of genes for antioxidant enzymes might be
effective in reducing damage due to oxidative stress in
specific tissues. If specific age-related degenerative changes
can be delayed by genetic intervention, high quality of life
can be maintained, and health care costs can be delayed until
later in life. This will be of particular benefit if the period
of time ultimately spent in ill health can be shortened, and if
the severity of the loss of function can be attenuated, thus
reducing overall health costs.
For example, it is well known that would healing declines
with age. An NIA grantee is carrying out basic studies to
determine what factors are limiting wound healing in aged
animals. He has developed a protocol to test whether treatment
of tissue with transforming growth factor by injection along
the line of the incision prior to surgery improves wound
healing. Preliminary results with another cytokine show a
temporary increase in wound strength. Such studies offer great
potential if they could be applied to the elderly undergoing
elective surgery. This research is also attempting to develop a
safe and effective method for introduction of the gene coding
for cytokine DNA into the tissue around wounds.
Mechanisms of neuronal cell dysfunction
Understanding why brain cells become dysfunctional and die
in older persons is of primary concern to NIA; elucidating the
underlying causes could lead to new therapeutic strategies to
delay, correct, or prevent the loss of these vital cells and
the resulting neurological deficits. Research into mechanisms
of nerve cell death and the compensatory response of central
nervous system cells has been recently stimulated by NIA.
Critical to an understanding of some of the neurodegenerative
diseases may be the link that impaired energy metabolism could
have with nerve cell death. NIA will also encourage research on
protein transport and signal transduction at the nerve cell
membrane. Study of the components essential for membrane
function will provide information on how the specialization of
nerve cell surface is constructed, but even more importantly,
will show how it may change leading to a variety of
neurodegenerative diseases as well as the conditions such as
cognitive decline normally associated with aging.
Sensory and sensory-motor dysfunction
Visual and hearing impairments are present in respectively
about 10 and 32 percent of American adults aged 65 years and
older. The somatosensory areas of touch, temperature, pain, and
motion are also important to successful aging but have received
even less attention than studies of visual and hearing
dysfunction. All too often older individuals have more than one
sensory impairment. Because individual researchers tend to
focus work on the study of one sense or another, questions
about neural mechanisms that may be common to sensory
processing and/or sensory dysfunction have not been explored
adequately. The NIA stimulates multimodal sensory research,
addressing questions such as the contribution of sensory
processes to the control of balance, posture, and locomotion,
areas of importance because impairments can severely compromise
the mobility for older adults. Falls in older adults, which
account for almost all of the 250,000 hip fractures occurring
annually and commonly result in long-term disability, may be
due in large part to impairments in these sensory systems.
alzheimer's disease
Alzheimer's disease will reach critical proportions in the
U.S. and other countries as the population ages. We are now
faced with a major public health crisis if something is not
done to halt the progress of this dreaded disease. Since the
prevalence of Alzheimer's disease increases dramatically with
age after about 65 years, delay of the onset of Alzheimer's
disease by five years would substantially reduce the number of
cases, and a delay of ten years would largely eliminate the
disease in the normal human lifespan. Several exciting recent
genetic discoveries have shed new light on the etiology and
pathogenesis of Alzheimer's disease. Recently, apolipoprotein
E4 (ApoE4), a blood protein whose gene is located on chromosome
19, has been shown to be associated with greatly increased risk
of Alzheimer's disease. This extremely important observation
has been confirmed in a number of laboratories and is the first
report of a major biological risk factor of the disease. In
addition, there are many laboratories currently involved with
trying to identify the gene on chromosome 14 associated with
early-onset familial Alzheimer's disease. Other important
studies in the etiology area include extensive analysis of the
cellular, genetic, and molecular parameters of nerve cell
function in health and in disease. Such basic research will
provide a necessary understanding of the molecular
underpinnings of Alzheimer's disease. Alzheimer's disease
research has been of paramount importance at NIA since the
Institute came into existence. To conquer the disease and to
bring urgently needed support to patients, families, and
researchers, NIA has built a nationwide framework for research
and assistance. The structure includes:
Alzheimer's Disease Centers (ADCs).--Located at major
medical institutions around the country, the 28 ADCs are
collecting and studying longitudinal data on the disease;
working to translate research advances into clinical services;
and educating and training professionals. Satellite centers in
rural and remote communities are recruiting minority
participants into the Centers' programs.
Drug Discovery Groups.--Located at six research centers,
these groups are designing, developing, and testing new drugs
aimed at delaying, halting, or reversing the progress of
Alzheimer's disease. These groups focus on drugs at the pre-
clinical stage, before testing in people.
Cooperative Study Units.--These 32 research sites are
conducting cooperative clinical studies (i.e., in people) of
drugs developed by the Drug Discovery Groups and other
projects. The first study to assess the effectiveness of
Deprenyl plus Vitamin E in slowing the course of the disease
began in October, 1992. Another study, for drug and behavioral
treatment of agitation began in June, 1994, and a study of the
anti-inflammatory drug prednisone for treatment of Alzheimer's
disease began in November, 1994. A conference was held in 1994
to evaluate the state-of-the-art in behavioral management in
Alzheimer's disease, and to discuss the possibility of
initiating larger-scale studies.
Alzheimer's Disease Education and Referral Center
(ADEAR).--This clearinghouse with its toll-free number (800-
438-4380) is a central source of information on all aspects of
the disease. During calendar year 1994, 82,022 calls were
received.
Consortium to Establish a Registry for Alzheimer's
Disease.--This network is working to establish uniform
standards for diagnosis to facilitate early and accurate
detection of the disease and support research.
National Cell Repository.--This growing repository of blood
samples from Alzheimer's disease patients facilitates the study
of genetic defects associated with the disease.
A major theme in Alzheimer's disease is to extend knowledge
about the age incidence, prevalence rates, and risk factors.
The search for risk factors in minority and other distinct
population groups could lead to better understanding of the
pathophysiology of Alzheimer's disease and novel treatments.
Thee ideas have been the underlying themes for three sets of
studies that have been completed over the past year. One group
of researchers conducted an incidence study of dementia in
relation to education and occupation and found that the risk
was greatest for individuals with both low education and low
lifetime occupational attainment. A study by another group,
done in pairs of older twins, has indicated an apparent inverse
relationship of Alzheimer's disease with sustained exposure to
steroidal and, possibly, non-steroidal anti-inflammatory drugs,
suggesting that these agents may prevent or delay the symptoms
of Alzheimer's disease. A third study found that the risk of
developing Alzheimer's disease decreased significantly with
increasing dose and duration of estrogen replacement therapy,
suggesting that estrogen deficiency may be one of the factors
that elevates a woman's risk of developing the disease.
Estrogen replacement therapy may be useful for both symptomatic
treatment and preventing or delaying the onset of dementia in
susceptible postmenopausal women. After further preliminary
research, clinical trials of anti-inflammatory drugs and
estrogen may be initiated.
The clinical diagnosis of Alzheimer's disease has improved
as the result of work of many investigators. In specialized
research facilities, clinical diagnosis by research
neurologists and psychiatrists now approaches 90 percent
concordance with the subsequent neuropathological diagnosis.
However, there remain important questions and gaps in
knowledge. A major area in the development of new noninvasive
diagnostic procedures has been that of imaging using Positron
Emission Tomography (PET), Single Photon Emission Computed
Tomography (SPECT), Magnetic Resonance Imaging (MRI), and
Magnetic Resonance Spectroscopy Imaging (RSI), These kinds of
techniques hold the promise of early diagnosis of Alzheimer's
disease and the ability to monitor, non-invasively, the course
of the illness.
CLINICAL, APPLIED, AND BEHAVIORAL RESEARCH
Influenza vaccine
Influenza, commonly known as the flu, can be a very serious
and often life-threatening illness in older persons. An NIA-
supported study demonstrated the efficacy of an improved
influenza vaccine in approximately 400 nursing home residents.
Half of the participants received the commercially available
influenza vaccine (HA) and the other half received an influenza
vaccine against the same flue strains, but which was linked to
another vaccine component, diphtheria toxoid. Clinical
surveillance of all participants for respiratory illness was
performed twice weekly for 5 months. During an outbreak of
influenza, fewer diphtheria-toxoid-linked vaccine recipients
than HA vaccine recipients had laboratory-confirmed infection.
Of these recipients, fewer of the diphtheria-toxoid-linked
vaccine-treated participants had bronchial and lung infections.
The investigators concluded that the toxoid-linked vaccine
produced greater protection from influenza infection for
institutionalized elderly recipients. NIA will continue to
support studies of basic cellular and molecular immunology in
order to better understand the changes in immune function that
occur with aging as well as clinical research because of the
potential of improving vaccines for a variety of infections in
older persons.
Physical frailty
NIA is supporting a number of major clinical initiatives
that address the problems of physical frailty and loss of
independence associated with older persons. Physical frailty is
a major cause of need for long-term care and imposes annual
costs of billions of dollars. Results from ongoing studies
provided convincing evidence of the benefits of exercise for
maintaining independent function in older persons. Some
interventions from a clinical trial of frailty and injuries
have shown more than a 30 percent reduction in fall rates,
which could markedly lower the rate of disabling injuries such
as some hip fractures. Tow studies have demonstrated efficacy
of interventions to prevent falls and improve strength in frail
order persons. Both have received widespread attention from
health care providers and the public and have begun to
influence health care practices for older persons.
One study employed a ``targeted intervention'' strategy for
frail community-dwelling subjects with a variety of risk
factors for falls. The subjects received individualized
treatment for their particular risk factors including
medication adjustments, strength and balance training,
instruction on safe practices to avoid lightheadedness and
environmental hazards, and raining in specific activities such
as getting in and out of the bathtub. Over a one-year follow-up
period, the treated subjects had 44 percent fewer falls per
year than the control group who received social visits only.
In another controlled study of frail nursing home
residents, it was found that a ten-week resistance exercise
program approximately doubled leg strength, increased walking
speed by 11 percent, improved stair-climbing power by 28
percent, and led to increased spontaneous physical activity.
This study also found that supplementing the diet with protein
and calories had no effect alone and no significant additional
effect when combined exercise.
Menopause and aging
There is little consensus on the significance of menopause
in healthy aging or on its role in the chronic diseases/
disorders of old age such as cardiovascular disease,
osteoporosis and urinary incontinence. Not surprisingly,
considerable controversy exists over the scope of the
physiological changes surrounding menopause or that appear
later in life that are attributable to reduce ovarian function
per se. Menopause is a universal phenomenon; however, the
manifestations of menopause are not. Cross-cultural research
demonstrates considerable variability between populations in
symptom presentation and associated psychosocial and
physiological effects of those symptoms.
In order to gain an increased understanding of the inter-
relationship between menopause and disorders such as
osteoporosis, cardiovascular disease, and the other chronic
diseases and disorders of old age, NIA began a major research
initiative in this area in 1994. Future success in preventing
and managing diseases and disorders which impact on post-
menopausal women will require a substantially improved
knowledge base to differentiate the contribution of ``hormone
deficiency'' from that of aging. Advances can do much to
clarify ambiguities in the presentation of age-related disease,
improve diagnosis and treatment, and ultimately reduce health
care costs. Similar considerations also apply to age-related
changes in other endocrine factors, such as growth hormone and
testosterone.
NIA also continues to support the NIH Women's Health
Initiative, which includes 70,000 post-menopausal women ages
50-79. This study is intended to assess the long term benefits
and risk of hormone therapy as it relates to cardiovascular
disease, osteoporosis, and breast and uterine cancer. Related
to this effort is NIA's Women's Health and Aging Study which is
exploring the cases and course of physical disability in women
aged 65 and older. The study will provide important information
on how the disease-disability relationship is modified by
cognitive functioning; on psychological factors; and on social,
economic, and medical resources of older women.
Osteoporosis
Osteoporosis and its consequences, particularly vertebral
and hip fractures, are a significant cause of frailty,
morbidity, and even mortality in old age. NIA-supported
osteoporosis research includes clinical studies of age-related
bone loss and fracture epidemiology, intervention trials to
prevent or reverse bone loss, studies of skeletal biology and
the effects of sex steroids and growth factors on bone cell
function. Five clinical studies recently funded will conduct
prospective longitudinal studies to determine the contributions
of age and ovarian hormone status to changes in bone mass as
women approach and cross menopause. Some studies will explore
underlying mechanisms whereby menopause-related changes
accelerate bone remodelling and adversely impact on bone
mineral metabolism.
Future progress in the prevention and treatment of
osteoporosis clearly requires an expanded knowledge of the
pathophysiology of this disorder. In particular, NIA will seek
research studies to determine the most appropriate methods for
studying the biology of the aging human skeleton. Such an
approach will permit us to understand the nature of the age-
and menopause-related changes that lead to bone loss. In
addition, it will facilitate the identification of risk factors
for, and specific markers of, the occurrence or reversal of
bone loss, which will be valuable in identifying the potential
of response to treatment, and/or monitoring the course of
treatment.
Biology of age-related muscle weakness (Sarcopenia)
Although a number of studies have noted correlations of
age-related changes in muscle properties will disability and
metabolic impairments, considerable gaps in our knowledge are
still present. With respect to outcomes, muscle weakness in the
extremities contributes to loss of functional independence and
falls. However, we still know little about (1) which age-
related changes in specific muscle properties (e.g., mass,
isometric strength, isokinetic strength, rate of torque
development, fiber type distribution, fatiguability)
significantly affect function and performance of specific tasks
(walking, maintaining balance, etc.), and (2) what level of
changes in muscle properties is required to significantly
affect function.
Age-related changes in muscle properties may also
contribute to non-insulin dependent diabetes mellitus,
osteoporosis, risk for fracture, impaired fracture healing
rates, and risk for hypo- and hyperthermia. Clarifying these
relationships, including their quantitative aspects, would
reveal much about the pathologic significance of these changes
in muscle and their overall health impact.
Self-care and aging
NIA is currently supporting research on the nature, extent,
and outcomes of self-care behaviors in diverse populations of
older people in order to develop social and behavioral
interventions for encouraging health and effective functioning
in later life. While health surveys have indicated that most
older people engage in some form of self-care behavior, there
has been a lack of specification in these prior surveys. NIA is
now documenting the wide variability in older people's self-
care practices, specifying factors associated with engaging in
particular self-care behaviors (e.g., self-management for
chronic health conditions and self-care practices to compensate
for functional limitations affecting routine activities of
everyday living). Such specifications are important for
documenting the links between particular self-care practices
and illness or disability.
Inappropriate self-care can lead to delays in seeking
needed care or conversely, overutilization of the medical care
system for trivial symptoms. Recent NIA studies on medical
self-care dispel myths that suggest older people are incapable
of recognizing the significant of illness symptoms and that
they are more prone than younger persons to use inappropriate
strategies that could exacerbate conditions. While most older
people have a good knowledge of symptoms and risks, NIA studies
show there is a need for greater health education regarding the
causes and consequences of common non-specific symptoms (such
as fatigue, sleep difficulties, headache, an stomach pain),
which are often erroneously attributed to age or stressful
situations. Future research initiatives are being planned to
develop a better understanding of complex processes involved in
care-seeking and to suggest ways to better interpret symptoms
and self-treatment.
Minority aging and long-term care
Dramatic increases are expected in the number of non-
minority older people, 92 percent by the year 2030; but the
projected growth in the older minority population--over 250
percent by 2030--points to a need for research on aging in
minority populations. Recent comparisons show that with
comparable levels of frailty, African-Americans are less likely
to enter nursing homes or enter at older ages than non-
minorities. Other findings are that family care is more common
than the use of formal care for all minorities, and that recent
immigrants are least likely to be institutionalized. Future
studies, however are challenged by the need to disentangle the
influence of cultural preferences for home or institutional
care from the effect of socioeconomic differences for the
largely disadvantaged older minority population. Understanding
these and other ethnic variations in long term care has
significant implications for structuring of formal services and
assisting the possibly cost-effective alternative of continued
family care.
Cognitive factors in everyday functioning of older people
NIA supports research on social, behavioral, and biological
factors affecting cognitive functioning as people age. More
recently, effects are being directed at the implications of
declines in cognitive functioning for older people's ability to
perform daily tasks, such as driving, decision-making, and
understanding and following medical instructions. Of particular
importance for such tasks are changes in ``attentional
resources''--the ability to identify and process relevant
information simultaneously from multiple sources. While older
people perform less well in general on tasks requiring divided
attention, expertise in or familiarity with the task
considerable lessens older people's disadvantage. Research has
confirmed that older people have greater difficulty than
younger people in understanding written medical instructions.
However, how the information is presented can have a
significant impact upon comprehension. For example, older
people can more easily understand instructions presented as a
list as opposed to paragraphs. Taken together, these and other
research projects highlight the practical implications of basic
cognitive research for the daily lives of older people. For
example, those older people who suffer deficits in visual
attention are at greater risk for automobile accidents. NIA
research has shown that through proper training and practice,
these deficits can be overcome or lessened.
Demography of population aging
Population aging will become one of the most important
social phenomena of the next half century, especially when the
babyboom generation becomes eligible for Social Security and
Medicare. How this nation and its institutions accommodate
themselves to the dramatic demographic age-shift will have a
significant effect on the quality of life in the twenty-fist
century. NIA-supported research in the field of demography of
aging can be characterized by an orientation towards
intergenerational relations, especially within the family; and
a focus on the characteristics and behaviors of older people
themselves, especially in he critical areas of economics and
health. To further these goals, NIA recently funded nine
Demography Centers to promote the use of data from national
surveys of health, retirement, and long-term care by the larger
research and policy-making communities. The field of
``biodemography'' is emerging, which integrates biological and
genetic research with demographic methods, and which should
enable a better understanding of how to forecast life and
health expectancies.
Research progress in the demography of aging is currently
being made in several areas. According to NIA-funded studies,
it is evident that the rate of increase in human mortality
slows after age 95; possibly even declining after age of 110,
and thatcentenarians are the fastest growing age group. The
findings emerging from this body of research are increasingly being
used to inform actuarial estimates for the Social Security and Medicare
Trust Funds. One interesting study of a small group of nuns suggests
that persons who earn college degrees and constantly challenge their
minds, are likely to live longer and suffer less from dementia. One
hypotheses explaining this finding is that education builds a greater
``brain reserve capacity'' which can better compensate for the affects
of neurological disorders.
The Health and Retirement Study (HRS), which follows
persons aged 51-61, has completed the second interview wave.
The HRS will be used to study topics such as the influence of
health and private pensions on retirement, the impact of
changing Social Security's age of eligibility provisions, and
the impact of the Americans with Disabilities Act. The Asset
and Health Dynamics of the Oldest-Old study, which follows
persons age 70 years and over to examine the interplay of
family and economic resources and late life health transitions,
has completed the first wave of data collection; analysis is
underway.
intramural research
The Intramural Research Program (IRP) supports research
conducted by government scientists in Baltimore, Maryland and
at the NIH Clinical Center, as well as the operation of NIA's
Epidemiology, Demography, and Biometry Program and also
supports the post-doctoral training of promising investigators
in the intramural laboratories.
Intervening in aging processes
The causes of aging are complex and involve both
environmental and internal factors that damage molecules,
cells, and tissues and the ability of the host to resist and
repair such damage. NIA scientists, using the latest techniques
of molecular and cellular biology, are making significant
progress in elucidating mechanisms that underlie aging
processes and in devising ways to retard and reverse age
associated deficits. Findings and related opportunities include
the following. (1) A commonly occurring mineral has been shown
to inhibit programmed cell death (apoptosis) of endothelial
cells following removal of growth factors and to improve the
angiogenic response in aged animals. This may be a useful
strategy to restore the growth of blood vessels in degenerative
diseases of aging. (2) Chondrocytes (cells responsible for
production of cartilage) can be induced to divide in culture by
treatment with growth factors and then stimulated to reform
cartilage when injected back into mice. This lays the
foundation for cell-based repair of cartilage defects that are
common in age associated disease of cartilage. (3) NIA
scientists developed techniques to measure DNA damage and its
repair in the telomeres (end regions of chromosomes that decay
with aging) and recently demonstrated that repair declines with
age. (4) The isolation of factors from old animals that inhibit
blood vessel formation and tumor growth is ongoing. Analysis of
spontaneous rat breast tumor cells may yield insights into the
loss of suppressor gene function in the progression of breast
cancer.
Baltimore Longitudinal Study of Aging (BLSA)
The BLSA, begun in 1958, seeks to understand how and why we
age. At this stage of its evolution, health outcomes are
accumulating and participants, now numbering over 1,170, have
been followed for significant segments of their lives. A BLSA
DNA bank is being established; enabling protocols on apoE risk
and protective factors in cognitive aging and on preferential
DNA repair in breast cancer to proceed. BLSA studies also
explore the role of risk factors for health and longevity, such
as obesity, glucose and insulin metabolism, and plasma
cholesterol. Each of these has been shown to continue to play a
role into very old age, but the definition of ``normality'' for
each must be age-specific. Prevention efforts depend upon
accurate definition of risk, and such data are becoming
uniquely available through the BLSA. A ten year BLSA study of
the causes and natural history of prostate cancer, benign
prostatic hyperplasia (BPH) and normal prostatic growth in
Caucasian and African-American men continues. The BLSA
perimenopausal study is an intensive evaluation of 100
Caucasian and 100 African-American women who will be seen four
times each year until menses have ceased for two years or
hormone replacement is begun. Age-matched men, premenopausal
women and older postmenopausal women already enrolled in the
BLSA provide contrast groups to assess the separate effects of
sex and estrogen status on normal aging.
Alzheimer's disease (AD)
The IRP has a focused research program on the etiology,
diagnosis and treatment of AD. Scientists have shown that
overexpression of mutant forms of the amyloid precursor protein
(APP), which have been implicated in AD, correlates with a
reduced rate of capillary tube formation when cells are grown
in culture and leads to enhanced cell death in differentiated
neuronal cells. These results suggest new approaches for AD
treatment involving reducing the expression of APP and
intervening in the cell death pathway induced by APP. Also,
recent studies suggest that apolipoprotein E (ApoE) is a risk
factor for AD and that the ApoE4 gene is more frequent in AD
patients. IRP scientists are relating ApoE4 genotypes of BLSA
participants to repeated cognitive assessments made over the
past 30 years. As this research continues, ApoE genotypes will
be related to normal and pathological rates of cognitive
changes, especially risks for developing AD.
Vascular disease
The ongoing intramural research on age associated vascular
disease will continue to capitalize on recent advances. These
include the finding that the injury-transformed vascular smooth
muscle cell, which is largely responsible for the vascular
blockage in restenosis--renarrowing of an artery following
angioplasty or balloon dilation--is critically dependent on
intact microtubule function. Intramural scientists have found
that taxol, a potent microtubule stabilizing agent, prevents
this vascular narrowing by 70-80 percent in an animal model
without significant toxicity. Others are investigating the
potential utility of gene therapy to induce the formation of
new blood vessels and enhance collateral blood flow to
compromised or damaged heart tissues and to prevent restenosis
after coronary artery angioplasty. ``Advanced glycation
endproducts'' (AGE) are proteins that accumulate in the blood
stream and blood vessels of diabetic patients and older
individuals; these products interact with specific receptors
present on circulating blood and blood vessel cells. Intramural
scientists, in concert with extramural colleagues, have made a
number of recent discoveries that have fueled a growing
excitement about the potential role of this system as a novel
therapeutic target for preventing and alleviating vascular
disease. These include observations suggesting that the
signalling pathway activated by this receptor plays an
important role in the progression of all vascular disease and
that activation of these receptors leads to increased
intracellular oxidant stress.
Frailty, osteoporosis, hormone replacement and women's health
Issues of women's health and well-being command special
attention within the intramural program. Studies are ongoing
with models of postmenopausal osteoporosis to determine the
efficacy of an analog of the common antibiotic tetracycline in
preventing accelerated bone loss. A collaborative clinical
trial comparing the effects of growth hormone, sex steroid
replacement, and growth hormone combined with sex steroid in
men and women over 65 continues; it is expected to provide
important new data on the risk benefit ratio of such treatments
in older people. Women aged 65-75, treated for two years with
constant oral estrogen/low dose daily protestin, showed
improved bone mineral density, decreased biochemical evidence
of bone resorption, a decrease in percent body fat, increases
in lean body mass, and improved cholesterol profiles compared
with BLSA controls. A new study of the interactions of
treatment with growth hormone releasing hormone with and
without estrogen replacement therapy on bone biochemistry and
microanatomy in osteoporotic women 55-75 years of age has
begun. A National Institute for Nursing Research and NIA study
of elderly patients hospitalized with hip fracture suggests
that an aggressive nursing intervention during the acute period
of hospitalization could improve function and increase
independence at discharge.
Diabetes and other age associated metabolic defects
Metabolic abnormalities, including type II diabetes, are
extremely common in the older population. A major intramural
initiative is underway to develop new therapies that are safe
and specific for the control of blood glucose in older diabetic
patients to prevent the disease's late complications. Molecular
approaches are being used to address the factors responsible
for type II diabetes--an impaired ability of the beta cells of
the pancreas to respond to blood glucose and a decreased
insulin responsivity at target tissues--and to elucidate
underlying mechanisms. Intramural studies have shown that
specific gut hormones can restore beta cell responsiveness in
conjunction with glucose and also increase insulin effects on
insulin sensitive tissues. To investigate potential therapeutic
strategies, studies of the effects of acute and chronic
treatments of the pancreatic beta cells with these hormones and
their effects on skeletal muscle, a major site of insulin
resistance, are being pursued. Emphasis is directed to defining
further a region of the insulin receptor that is essential for
its activation status to prolong insulin's action. These
advances are being aggressively pursued given their promise for
opening new therapeutic avenues.
Section 3
research advances on aging supported and conducted by other nih
institutes
National Center for Research Resources
Old age is often a slow decline into frailty and
dependence. Researchers studying the aging process find that
muscles--or lack of them--play an important role in determining
quality of life. Physical impairment is a major cause of
institutionalization in nursing homes, costing this country
billions of dollars each year. An insidious condition called
sarcopenia--loss of muscle tissue--seems to be a strong
contributor to physical deterioration. Only recently has it
become apparent that muscle loss begins as early as age 35 and
is much greater than previously thought. Sarcopenia, largely
masked by increases in fat, leads to loss of strength, balance,
mobility, and ultimately independence.
Dr. William J. Evans of the Knoll Physiological Research
Center at Pennsylvania State University, supported by the
National Institute on Aging and the National Center for
Research Resources, has shown that strength training with
exercise machines and free weights in men and women 60 to 98
years old--some in nursing homes--in many cases doubled or
tripled the muscle mass. Although walking, biking, and swimming
are healthy exercises, ``the way one prevents or reverses
sarcopenia is through resistance exercise, or strength
training,'' Dr. Evans emphasizes.
National Institute of Neurological Disorders and Stroke
The National Institute of Neurological Disorders and Stroke
(NINDS) is the lead institute for research on a number of
nervous system disorders--such as Parkinson's disease and
stroke--that occur with greater frequency in older people. The
institute also conducts and supports research on a number of
other diseases that occur more commonly in older people, such
as Alzheimer's disease.
Parkinson's disease
In 1995, Congress encouraged the NIH to sponsor a research
planning workshop on Parkinson's disease. This debilitating
disease affects more than 500,000 Americans and causes
progressive symptoms including tremor, muscle rigidity, and
immobility that ultimately lead to total disability and death.
Because the disease most commonly affects people in later life,
the number of people with Parkinson's disease and the
associated costs will grow as the average age of the American
population increases.
In response to this Congressional directive, the
Parkinson's Research Planning Workshop, co-sponsored by NINDS,
NIA, NIEHS, and NIMH, took place August 28-30, 1995. The
workshop's purpose was to bring together key Parkinson's
disease researchers and experts from other fields to foster new
ideas and research directions that might lead to rapid advances
in the understanding and treatment of the disease.
The workshop discussions centered upon several major
themes. Chief among these was the recognition that both genetic
and environmental factors are important in understanding
Parkinson's disease. Many participants also emphasized a need
to identify biological traits, or biomarkers, that would allow
researchers to identify people at risk fordeveloping
Parkinson's disease, allow earlier diagnosis of the disease, and mark
its progression. Participants encouraged collaboration between basic
and clinical scientists. In recognition of the common themes emerging
from research on different diseases, they also called for collaboration
with scientists outside the Parkinson's field.
The discussions highlighted several key areas for
productive investigation, but Parkinson's is a complex disease
and there is no definitive cure on the immediate horizon.
Improved understanding of the underlying biology of the disease
will lead to better ways of relieving the symptoms of
Parkinson's patients and ultimately halting the underlying
degeneration of brain cells.
Efforts to locate a gene responsible for some cases of
Parkinson's disease intensified after the August 1995 workshop.
In the fall of 1996, scientists from the NINDS and the NCHGR
(now the NHGRI), in collaboration with researchers from the
UMDNJ-Robert Wood Johnson Medical School in New Brunswick, New
Jersey, and the Istituto de Scienze Neurologiche in Naples,
Italy, pinpointed the location of such a gene. Previously, most
scientists believed the disease was due almost exclusively to
environmental factors such as drugs on toxic chemicals,
although in most cases, no environmental cause has been
identified. But many people appear to have an inherited
susceptibility to the disease. The significance of the NIDS/
NHGRI finding is that scientists now believe that a single gene
alteration can cause Parkinson's disease. The next step will be
to find and identify the specific gene involved, which is
located somewhere within a region of DNA on the long arm of
chromosome 4. Learning the gene's exact location and isolating
it may eventually lead to genetic testing that will enable
early diagnosis and treatment for all forms of Parkinson's
disease--not only inherited cases, but also those with no
familial link. It may also help researchers discover how the
disease occurs and how to develop methods of preventing or
curing it.
Stroke
In 1995, about 500,000 Americans suffered a stroke. Of
these strokes, about 80 percent were ischemic, caused by a
blood clot that reduces blood flow to the brain. The remaining
20 percent were hemorrhagic strokes, caused by bleeding into
the brain. Stroke ranks as the third leading cause of death in
the country after heart disease and cancer, killing about
150,000 Americans each year. The overall cost of stroke to the
nation is estimated to be $30 billion each year.
In December 1995, NINDS-funded investigators published the
results of a 5-year clinical trial demonstrating that treatment
with the clot-dissolving drug t-PA is an effective emergency
treatment for acute ischemic stroke despite some risk from
bleeding. The trial found that carefully selected stroke
patients who received t-PA treatment within 3 hours of their
initial stroke symptoms were at least 30 percent more likely
than untreated patients to recover from their stroke with
little or no disability after 3 months. The nationwide study
included more than 600 stroke patients.
The drug t-PA works by dissolving the blood clots that
block brain arteries. Although it had been proven effective in
the treatment of heart attack, t-PA's potential as a treatment
for stroke had been unclear because of an increased risk of
brain hemorrhage. Bleeding into the brain within 36 hours of
treatment worsened strokes in 6.4 percent of those patients in
the NINDS trial who received t-PA compared to 0.6 percent of
those who received placebo. Overall, however, there were
greater numbers of stroke survivors who were able to live
normal lives in the t-PA treated group, leading the
investigators to conclude that the use of t-PA for stroke is
beneficial. Furthermore, the NINDS trial showed lower levels of
brain hemorrhage than previously published stroke trials
involving clot-dissolving drugs.
The investigators agree that substantial efforts by the
health care community will be necessary before t-PA can be used
on a widespread basis. These efforts include intensive public
education about the signs of stroke and the importance of
immediate treatment, the organization and training of medical
personnel to evaluate and treat stroke patients, as well as
planning for the rapid transport of patients to treatment
centers through emergency medical services.
National Institute on Nursing Research
Americans expect to live longer than earlier generations,
but these additional years should be lived well--with health
and independence intact for as long as possible. Nursing
researchers are exploring interventions with this goal in mind
in order to preserve cognition and the ability to function, and
to maintain or improve quality of life.
The National Institute of Nursing Research (NINR) supports
studies that address these and other health issues of the older
population, including prevention of illness and disability;
health promotion strategies; management of the symptoms of
chronic diseases, including pain; interventions for family
caregivers to help them maintain their own health as well as
that of their ill relatives; and end-of-life care to promote a
comfortable death with dignity.
Among the findings of FY 1995-96 are two that hold promise
to improve older people's recovery from the effects of
immobility and illness.
Immobility is frequently associated with more serious
chronic illnesses, and a preventable secondary effect, pressure
ulcers, still occurs too often. These ulcers are caused by
constant pressure on the body's bony areas, which results in
damage and death of skin, muscle and bone tissues. The care of
these wounds is quite costly, estimated to the $737 million
nationally. Nursing home populations have benefited from an
assessment scale developed by nurse researchers that identifies
patients most likely to develop pressure ulcers within a few
days of their entering a nursing home, thus alerting the staff
to the need for immediate preventive action. The assessment
scale has been adapted for use in routine clinical practice and
has been incorporated into the ``Guidelines on Pressure
Ulcers'' published by the Agency for Health Care Policy and
Research.
Stroke patients usually have low endurance for exercise,
although physical activity is thought to be important in the
recovery process. When patients with moderate hemiparesis used
an exercise bicycle regularly for 30 minutes 3 times a week for
10 weeks, they improved not only their aerobic capacity, but
also their sensorimotor function, as measured by such factors
as sensation, balance and awareness of body position. The
exercise training also significantly improved systolic blood
pressure. The nursing research findings indicate that patients
who have a propensity for increased blood pressure during
activity could benefit from an aerobic exercise program to
lower their systolic pressure, thereby reducing their risk of a
future stroke.
National Institute of Environmental Health Sciences
The incidence, prevalence, and severity of many chronic
conditions increase with age. As the elderly segment of the
U.S. population increases, it will be important to understand
which conditions are an inevitable consequence of aging and
which are due to cumulative effects of low-dose environmental
exposures that could be prevented. Scientists already know that
cancer initiation and progression is influenced by
environmental exposures. It is only beginning to be appreciated
that other disease states--cardiovascular disease, respiratory
problems, kidney function impairment--can also be influenced by
involuntary, environmental exposures.
These research needs are being pursued by the National
Institute of Environmental Health Sciences (NIEHS). It is the
mission of the NIEHS to define (1) how environmental exposures
affect our health, (2) how individuals differ in their
susceptibility to these exposures, and (3) how these
susceptibilities change with age. Some of the important work at
the NIEHS on the environmental components of aging-related
disorders is described below.
Cancer. An environmental component for many cancers is
clearly established. Since its inception, the NIEHS has
supported work exploring the connection between environmental
exposures and cancer risks. This work continues in ongoing
investigations into the risks of lung cancer from household
radon exposures and the risks of breast cancer from a variety
of exposures including pesticides, polychlorinated biphenyls,
and other estrogenic compounds. Some of the most exciting work
is being done in linking environmental risk factors to
underlying individual vulnerabilities, such as defective
genetic repair mechanisms or inadequate detoxification
mechanisms. This work includes:
Breast Cancer: Isolation to two breast cancer
susceptibility genes, BRCA1 and BRCA2, by NIEHS scientists
working with non-Institute research teams.
Prostate Cancer: Studies of a vitamin D receptor gene
variant that showed an association with increased prostate
cancer risk.
Urinary Bladder Cancer: An epidemiologic study that showed
a 70% increased risk for bladder cancer development in
individuals lacking the gene that codes for the carcinogen
detoxification enzyme, glutathione transferase M1.
Senescence (``Aging'') Gene: NIEHS scientists are
interested in understanding the processes governing cellular
aging, or senescence. An NIEHS laboratory identified the first
senescence gene, a finding with important implication in
understanding the molecular basis of cancer.
Impaired Kidney Function and Lead Exposure: NIEHS-supported
scientists discovered a link between lead exposure and impaired
kidney function. This study showed that even low blood lead
levels, a measure of lead exposure, correlated with significant
reductions in kidney function as measured by serum creatine
concentration. Environmental sources of lead include old
paints, lead solder, some ceramic glazes, and dusts and soils
that were contaminated by automobile exhausts from leaded
gasoline. These studies give further support to the need to
continue these environmental programs and also provide
clinicians with an important diagnostic tool for determining
causes for reduced renal functions in patients.
Hypertension and Lead Exposure: High blood pressure, or
hypertension, is a leading risk factor for heart disease. A new
NIEHS-supported study identified a potentially important
environmental component of this disease--long-term lead
exposure. This finding is particularly important because lead
is an environmental agent whose exposure can be controlled.
Neurodegenerative Disorders: Neurodegenerative disorders
such as Alzheimer's and Parkinson's might well prove to be the
consequence of long-term, low-level exposures to environmental
compounds. Understanding the environmental components of these
diseases is complicated by the fact that individuals probably
differ in their susceptibility to these effects and that there
is probably a long latency period between exposure and disease
expression. The NIEHS is investigating the environmental causes
of these diseases, with particular emphasis on neurotoxic
compounds such as metals and solvents.
Osteoporosis: Osteoporosis is a crippling bone disorder
that worsens with age and, in women, accelerates after
menopause. NIEHS-supported scientists are investigating
environmental agents that could play a role in increasing
(e.g., cadmium) or reducing (e.g., natural plant estrogens)
disease risks. Additionally, work has led to a reevaluation of
current air quality standards to assess their ability to
protect the public's health. Asthma, a frequently fatal
condition that can persist from childhood, is being intensely
studied by NIEHS-funded scientists who are examining the role
of indoor exposures, including cockroach and dust mite
allergens, and the efficacy of allergen control strategies in
reducing asthma attacks.
Environmental Justice: Those least likely to enjoy a long
and healthy life are those who inhabit the bottom rungs of the
socio-economic ladder. A critical research need is to determine
if their health problems are due solely to low income or due in
part to the environmental consequences of low income. These
consequences would include hazardous jobs, lead-contaminated
homes, living in neighborhoods near hazardous waste sites, and
water sources contaminated by pollutants leaching from
landfills. The NIEHS has provided vigorous leadership in the
area of environmental justice and continues to reach out to
disadvantaged communities to understand what unique
environmental risks that might face that could affect their
health.
National Institute of Mental Health
In elderly people, major depression may be chronic or recur
frequently, and, while their depressive episodes can be treated
successfully, elderly people are more prone to relapse during
continuation therapy than are younger patients. NIMH is
conducting a study of elderly outpatients susceptible to
recurrent depression who are on maintenancetreatment after
having been successfully treated for a depressive episode, with the
objective of learning how to identify which patients will benefit from
a particular form of maintenance psychotherapy after discontinuation of
antidepressant medications. Researchers assessed the subjective sleep
quality that patients had achieved early in their continuation
treatment phase and found that a high percentage of patients who report
good subjective sleep quality at this point remained well over the next
year, provided they also received maintenance psychotherapy once a
month.
The efficiency of vascular function in the brain is
increasingly commanding the attention of researchers interested
in diverse facets of health and illness in older people. Now,
and NIMH-funded investigator has reported that a particular
gene product the E-4 type of apolipoprotein, which is a known
risk factor for coronary artery disease, cerebral
atherosclerosis, and Alzheimer's disease also is more commonly
associated with the occurrence of depression in advanced old
age as opposed to depression with an earlier onset among older
patients. This finding sparks particular interest in light of
the fact that depressed, elderly cardiac patients have much
higher rates of mortality than do comparably aged patients who
are not depressed. Further information about apolipoprotein
variants as correlates of, and possibly risk factors for mental
disorders in late life may prove to have implications for
tailoring pharmacologic treatments with an eye toward
maximizing treatment effects and minimizing side effects, or
even preventing symptom development. The potential import of
the finding is buttressed by a separate NIMH-funded study in
which researchers have described a specific clinical profile of
elderly patients with what appears to be a subtype of
depression associated with cerebrovascular disease. This
subtype of depression describes patients whose lack of
depressive thought patterns marks a departure from an otherwise
``classic'' presentation of depressive symptoms. If the
syndrome of vascular depression is validated, it may have
direct treatment implications. Animal studies suggest that some
antidepressant promote neurological recovery after
cerebrovascular incidents, but others inhibit recovery.
Research has shown that the apolipoprotein E4 (ApoE4)
allele is a genetic risk factor for both familial and sporadic
Alzheimer's disease, and it is estimated that up to 65 percent
of patients carry this allele, compared to only 24-31 percent
of healthy controls. In studies with a group of Alzheimer's
disease patients, NIMH-supported researchers found that there
is no correlation between the ApoE4 ``dosage'' (number of these
alleles in a patient's DNA) and the rate of cognitive decline.
In a related study, these researchers also found that this
ApoE4 risk factor is associated with increased behavioral
disturbances in Alzheimer's disease.
National Institute on Deafness and other communication disorders
PSP, Parkinson's, and Alzheimer's
Errors in differentiating the diagnosis of individuals with
various neurodegenerative diseases can have serious medical
consequences. For example, progressive supranuclear palsy
(PSP), a rare disease, is often misdiagnosed as the more
prevalent Parkinson's disease because the two diseases share
many motor symptoms and signs. Because PSP does not respond to
medications for Parkinson's disease, the misdiagnosis can delay
appropriate intervention. Research has revealed that testing of
the sense of smell may be useful in the differential diagnosis
of individuals in the early stages of PSP. PSP patients perform
well on smell identification tests, whereas Parkinson's disease
patients perform poorly. Further, the applications of
contemporary imaging and molecular biologic techniques to
biopsies of olfactory sensory tissue may prove useful in the
early diagnosis of brain diseases, such as Alzheimer's disease,
in which the olfactory neurons are the only affected neural
tissue that can be readily obtained from living patients.
Hearing aid developments
National Institute of Deafness and Communication Disorder
(NIDCD) scientists funded through the Small Business Innovation
Research program have made progress in alleviating ringing
``feedback,'' a common complaint of many hearing aid users. By
physically delivering sound deeper into the ear canal via
improved hearing aid shell designs, hearing aid users
experience less feedback and reduced occlusion effects, a
common complaint of hearing aid users described as
``hollowness'' or a feeling of ``talking inside a barrel.''
Voice Disorders Associated with Parkinson's Disease
Of the 1.5 million individuals with the progressive
neurogenic disorder Parkinson's disease, at least 89% have a
breakdown in their ability to speak. The long-term goals of one
study are to evaluate the efficacy of a model of behavioral
voice treatment for these patients and to examine the
physiologic and neural mechanisms underlying voice and speech
changes that occur during treatment or with progression of the
disease. Preliminary analysis indicates beneficial increases in
movement of the vocal folds and improved stability of the voice
accompanying treatment. To further assess the underlying
changes associated with successful treatment, a number of
patients with Parkinson's disease are being evaluated for
variables in speech physiology such as vocal loudness, voice
quality, and speech intelligibility. All of these measures
improve significantly after treatment that focused on the
voice. In most cases, these posttreatment improvements were
maintained for one to two years without additional treatment.
After voice treatment, patients reported that they spoke more
often and had more confidence because people could now
understand them. These findings document that Parkinson's
disease patients can make changes in their speech production in
response to voice treatment; they also suggest that stimulating
improved phonation may be a key to improving their overall
speech production.
Collaborative efforts to improve hearing aids
The NIDCD continues an innovative collaboration with the
Department of Veterans Affairs (VA) in an effort to support the
development of better hearing aids. Five initiatives have been
developed and are in various stages of implementation. These
initiatives include a call to the research community for the
submission of grant proposals to determine how hearing aids
affect speech understanding, in quiet and in noise, published
in January 1994. There was also a call for research to
determine ways to measure the benefit received from hearing
aids by persons who are hearing impaired, also published in
1994. A contract for a program of device development for
hearing aids will begin in the near future. This will support
the design and evaluation of creative new technologies and
strategies for hearing aids. The protocol for a first clinical
trial has been developed and is expected to begin in Fiscal
Year 1995 through an interagency agreement with the VA. The
clinical trials will identify specific subgroups of individuals
who benefit most from the existing and newly developed hearing
aid technologies. A hearing aid research and development
conference, scheduled for September 1995, will be a national
forum for the presentation of research relevant to hearing
aids. This collaborative effort between the NIDCD and the VA is
facilitating progress towards the improved use of existing
devices, as well as stimulating research to develop new
technologies and devices.
Century auditory processing in elderly people
Early diagnosis of certain dementias is now being
facilitated by a battery of central auditory tests with elderly
patients. One disease known to cause deterioration of neuronal
circuits is a form of Alzheimer's disease called ``Mild Senile
Dementia of the Alzheimer's type.'' These patients also suffer
from hearing loss. Using an extensive audiologic testing
battery, it was demonstrated that all measures of pure-tone
hearing and recognition of simple words were similar between
subjects with neurodegenerative disease and otherwise normal
elderly subjects. However, when presented with complex sentence
tests specifically designed to assess the processing
capabilities of the higher level auditory structures, patients
with mild neurodegenerative disease could not perform the test.
Mild neurodegenerative diseases appear to affect central
auditory processing and thus the ability to process more
complex acoustic signals.
Cochlear implant technology
The NIDCD, together with the Office of Medical Applications
of Research, convened a NIH Consensus Development Conference on
Cochlear Implants in Adults and children on May 15-17, 1995.
Co-sponsored by NIA, NICHD, NINDS, and the Department of
Veterans Affairs, the conference summarized current knowledge
about the range of benefits and limitations of cochlear
implantation. One of the major conclusions of the panel
addressed the auditory criteria for adult implant candidacy.
Previously, only adults with profound hearing impairment were
candidates for implantation, and individuals receiving marginal
benefit from hearing aids were not considered implant
candidates. However, recent data show that most marginally
successful hearing aid users will have improved speech
perception performance with a cochlear implant. The panel
therefore concluded that it is reasonable to extend cochlear
implants to postlingualy hearing-impaired adults currently
obtaining marginal benefits from other amplification systems,
increasing the number of Americans to some one million who may
benefit from a cochlear implant.
Hearing loss and its effect on older women
Projections based on figures from the National Center for
Health Statistics estimate that by the year 2030, at least 21
million Americans beyond 65 years of age will be classified as
hearing impaired. Age-related hearing loss (presbycusis) is a
seemingly complex disorder developed in senior years, typically
characterized by a decrease in speech understanding, though not
necessarily a parallel decrease in sensitivity to simple tones.
The functional consequences of hearing loss in senior citizens,
as evidenced by its impact upon psycholosocial well-being, can
be substantial. This is particularly true for elderly women
since during their later years an increased susceptibility to a
variety of conditions of aging seems only to further the
functional impact of the hearing loss. To gain a better
understanding of gender-specific presbycusis, NIDCD-supported
investigators are exploring the pathophysiologic factors
potentially related to hearing capabilities in older women, to
include the relation between incidence of hearing loss and
cardiovascular risk factors.
National Institute on Alcohol Abuse and Alcoholism
Problems of alcohol abuse and alcoholism among the elderly
remain a priority at the National Institute on Alcohol Abuse
and Alcoholism (NIAAA). In fact, one of NIAAA's 14 Alcohol
Research Centers focuses exclusively on understanding the brain
changes that result from both chronic and acute alcohol uses,
characterizing the clinical manifestations of these phenomena,
and developing and evaluating methods for screening and
intervention among elderly alcohol-abusing and alcoholic
patients.
Major objectives at the Alcohol Research Center on Aging
include characterizing how alcohol interacts with aging to
produce central nervous system abnormalities; developing
strategies for early diagnosis and treatment of alcoholism in
older individuals; and understanding how aging interacts with
alcohol consumption in interfering with complex motor
activities, such as driving.
Investigators use state-of-the-art noninvasive brain
imaging technologies (i.e., positron emission tomography and
magnetic resonance imaging) to better characterize the
mechanisms underlying alcohol-induced central nervous system
changes in the elderly. Investigators also conduct detailed
electroencephalographic studies of sleep physiology in alcohol-
dependent and nonalcohol-dependent elderly subjects and use
computer simulation of driving performance to assess changes in
performance under conditions of intoxication. Ongoing NIAAA
research projects investigate:
Combined effects of alcohol abuse and the aging
process on alterations of brain metabolism, brain
receptor binding, and neuropsychological functioning;
The interactions of chronic alcohol use, sleep apnea,
sleep disruption, and aging;
The effects of alcohol on complex driving skills in
the elderly, including the effects of sleep deprivation
on driving performance;
The effectiveness and acceptability of brief
intervention strategies on drinking problems in older
adults;
The role of alternations in serotonin on the clinical
features and pharmacotherapy of alcoholism among the
elderly,
As the proportion of the U.S. population reaching old age
continues to grow, the relevance and importance of alcohol use
and abuse in this age segment increases.
ITEM 7--DEPARTMENT OF HOUSING AND URBAN DEVELOPMENT
----------
U.S. HOUSING FOR THE ELDERLY--CALENDAR YEAR 1995 AND 1996
The Department of Housing and Urban Development is
committed to providing America's elderly with decent affordable
housing appropriate to their needs. The Department's goal is to
provide a variety of approaches so that older Americans may be
able to maintain their independence, remain as part of the
community, have access to supportive services, and live their
lives with dignity and grace.
I. HOUSING
a. section 202--capital advances for supportive housing for the elderly
and section 811 supportive housing for persons with disabilities
The National Affordable Housing Act of 1990 authorized a
restructured Section 202 program while separating out and
creating the new Section 811 program for Housing for Persons
with Disabilities. Funding for both programs is provided by a
combination of interest-free capital advances and project
rental assistance. Project rental assistance replaces Section 8
rent subsidies. The annual project rental assistance contract
amount is based on the cost of operating the project. The 30
percent maximum tenant contribution remains unchanged.
Since the passage of the National Affordable Housing Act of
1990, there have been 43,357 units approved under the Section
202 program and 13,041 units approved under the Section 811
program. Of those amounts 8,669 Section 202 units and 1,971
Section 811 were approved in Fiscal Year 1996.
b. section 231--mortgage insurance for housing for the elderly
Section 231 of the National Housing Act authorized HUD to
insure lenders against losses on mortgages used for
construction or rehabilitation of market rate rental
accommodations for persons age 62 years or older, married or
single. Nonprofit as well as profit-motivated sponsors are
eligible under this program. The program is largely inactive
since most sponsors and lenders prefer to use the Section
221(d)(3) and 221(d)(4) programs instead.
c. section 221(d) (3) and (4)--mortgage insurance program for
multifamily housing
Sections 221(d)(3) and (4) authorized the Department to
provide insurance to finance the construction or rehabilitation
of market rate rental or cooperative projects. The programs are
available to non-profit and profit-motivated mortgagors as
alternatives to the Section 231 program. While most projects
under the programs have been developed for families, projects
insured under Section 221 may be designed for occupancy wholly
or partially for the elderly, and the mobility impaired of any
age.
d. section 232--mortgage insurance for nursing homes, intermediate care
facilities, and board and care homes, and assisted living facilities
The Section 232 program assists and promotes the
construction and rehabilitation (or purchase or refinance of
existing projects) of nursing homes, intermediate care
facilities, board and care homes, and assisted living
facilities by providing mortgage insurance to finance these
facilities. The vast majority of the residents of such
facilities are the frail elderly. In FY 1996, HUD insured 156
projects containing 20,608 units and worth $1 billion.
e. section 8--new construction
The Section 8 program sponsored the new construction of
housing for families and for the elderly by attaching subsidy
to the units being developed. That way the landlord was
guaranteed a stream of income that would facilitate finding
financing and that would guarantee the ability to make payments
and operate the developments. The new construction program was
active from 1974 until the mid-1980s. There are 1.4 million
private, project-based Section 8 units, about 47 percent of
which serve elderly households. About 193,000 of these 658,000
units were built under the Section 202 program before the
restructuring of that program in 1990. That means that about
465,000 units developed with Section 8 project-based assistance
serve elderly households. The Section 8 new construction
program is no longer in operation.
f. service coordinators
The National Affordable Housing Act authorized funding for
service coordinators under the Section 202 program in 1990.
Eligibility was expanded to cover Sections 8, 221(d)(3), and
236 projects in 1992. A service coordinator is a social service
staff person who is part of the project's management team. That
individual is responsible for ensuring that the residents of
the project are linked with the supportive services they need
from agencies in the community to assure that they can remain
independently in their homes and avoid premature and
unnecessary institutionalization as long as possible.
In FY 1995, HUD awarded $19.5 million to 179 projects,
almost all of which were Section 202 projects; another $5
million was awarded to 34 Section 202 projects in 1996.
g. the congregate housing services program
The Congregate Housing Services Program (CHSP), initially
authorized in 1978 and revised in 1990, provides direct grants
to States, Indian tribes, units of general local government and
local non-profit housing sponsors to provide case management,
meals, personal assistance, housekeeping, and other appropriate
supportive services to frail elderly and non-elderly disabled
residents of HUD public and assisted housing, and for the
residents of Section 515/8 projects under the Department of
Agriculture's Rural Housing and Community Department Service.
In 1995 HUD made one grant for $252,595 to serve an
estimated 20 additional non-elderly disabled residents of
eligible housing. The program covers 111 grantees, which serve
about 5,000 people.
h. flexible subsidy and loan management set aside (lmsa) funding
The Flexible Subsidy Program provides funding to correct
the financial and physical health of HUD subsidized properties,
including those which house the elderly. Flexible Subsidy
provides funds for projects insured under Section 221(d)(3),
Section 236, and funding under the 202 program (once they have
reached 15 years old).
The Loan Management Set Aside (LMSA) Program provides
Project-based Section 8 funding to HUD-insured and HUD-held
projects and projects funded under the 202 Program, which need
additional financial assistance to preserve the long term
fiscal health of the project.
i. manufactured home parks
The Housing and Urban-Rural Recovery Act (HURRA) of 1983
amended Section 207 of the National Housing Act to permit
mortgage insurance for manufactured home parks exclusively for
the elderly. The program has been operational since the March
1984 publication of a final rule implementing the legislation,
although HUD insures very few manufactured home parks.
j. title i property improvement loan insurance
Title I of the National Housing Act authorizes HUD to
insure lenders against loss on property improvement loans made
from their own funds to creditworthy borrowers. The loan
proceeds are to be used to make alterations and repairs that
substantially protect or improved the basic livability or
utility of the property. There are no age or income
requirements to qualify for a Title I loan.
k. title i manufactured home loan insurance
Title I of the National Housing Act authorizes HUD to
insure lenders against loss on manufactured home loans made
from their own funds to creditworthy borrowers. The loan
proceeds may be used to purchase or refinance a manufactured
home, a developed lot on which to place a manufactured home, or
a manufactured home and lot in combination. The home must be
used as the principal residence of the borrower. There are no
age or income requirements to qualify for a Title I loan.
l. home equity conversion mortgage insurance program
The Department has implemented a program to insure Home
Equity Conversion Mortgages (HECM), commonly known as ``reverse
mortgages.'' The program is designed to enable persons aged 62
years or older to convert the equity in their homes to monthly
streams of income and/or lines of credit.
As of September 30, 1996, the cumulative number of active
insured loans reached 20,321. Two hundred and thirty-two
lenders in 49 states participate in the program. The volume of
loans increased significantly during the 1990's, from 151 in
1990 to 4,083 in 1995 as more lenders and the general
population become more aware of the HECM program. For that
reason, the Department is planning program changes that will
offer consumer protection against excessive fees.
II. PUBLIC AND INDIAN HOUSING
a. section 8 rental certificates and rental vouchers
Section 8 of the U.S. Housing Act of 1937 authorizes
housing assistance payments to aid low-income families in
renting decent, safe, and sanitary housing that is available in
the existing housing market.
About 16 percent of Section 8 certificate and voucher
recipients are elderly. This represents 224,000 units.
b. elderly/disabled service coordinators
Section 673 of the Housing and Community Development Act of
1992 authorized the Department to fund services coordinators in
public housing developments to assure the elderly and non-
elderly disabled residents have access to the services they
need to live independently. The Department awarded $60 million
in FY 1994 and 1995 funds for public housing authorities to
hire services coordinators for their elderly and non-elderly
disabled residents to provide case management and link these
needy residents to other supportive services.
c. tenant opportunity program
Section 20 of the U.S. Housing Act of 1937 authorized the
Tenant Opportunity Program. This program provides training and
technical assistance to resident entities to organize their
communities and to establish various resident managed
initiatives. The program began in 1988 and to date has funded
about 900 resident groups. Public andIndian housing
developments with elderly residents are eligible to participate and we
would estimate a small portion, perhaps 5 percent are in fact primarily
elderly grantees.
d. public housing development program
The Public Housing Development Program was authorized by
Sections 5 and 23 of the United States Housing Act of 1937 to
provide adequate shelter in a decent environment for families
that cannot afford such housing in the private market.
In 1995, 208 additional units of public housing for the
elderly were reserved, 469 were under construction, and 514
became available for occupancy. In 1996 another 43 were
reserved, 272 were under construction, and 233 became available
for occupancy. The following statistics are provided for the
elderly low income population of public and Indian housing:
Public housing residents...................................... 360,000
Indian housing................................................ 11,400
--------------------------------------------------------------
____________________________________________________
Total Public and Indian Housing........................... 371,400
e. set-asides
The Department is currently conducting a demonstration
program called HOPE for Elderly Independence which was created
in 1992. The purpose of the demonstration is to test the
effectiveness of providing rental voucher and supportive
services to frail elderly people who are living in the general
community and require this combined assistance to continue
living independently and to avoid premature or unnecessary
institutionalization.
Hope for Elderly Independence grants worth $7.7 million
made in FY 94. Hope for Elderly Independence vouchers worth
$32.1 million (11,186 units) were assigned in FY 94 and another
$990,805 (150 units) were assigned in FY 1995.
III. COMMUNITY PLANNING AND DEVELOPMENT
a. community development block grant (cdbg) entitlement communities
program
The CDBG Entitlement Communities Program is HUD's major
source of funding to large cities and urban counties for a wide
range of community development activities. These activities
primarily help low- and moderate-income persons and households,
however, they can also be used to help eliminate slums and
blight or meet other urgent community development needs.
The Department normally does not ask grantees to report
program beneficiaries by age. Despite this, grantees did report
on their 1994 Grantee Performance Report (the most recent
performance report for which the Department has reliable
information) that they spent about 1.1 percent of their program
funds (over $34 million) that year for public services that
were specifically targeted to senior citizens and about 0.7
percent of their funds (over $22 million) for public facilities
for senior citizens. In addition, HUD staff are aware that
senior citizens frequently benefit from local housing
rehabilitation programs that are funded by CDBG. What is not
known is how many of those benefiting from rehabilitation
projects are elderly. It has been the experience of the
Department that the percentage of CDBG funds spent on these
activities by grantees has not varied much from year to year.
No further information is available at this time.
b. cdbg state-administered and hud-administered small cities programs
The CDBG State-administered program and the HUD-
administered Small Cities program for the States of New York
and Hawaii are HUD's principal vehicles for assisting
communities with under 50,000 population that are not central
cities of metropolitan areas. States and small cities/counties
use the CDBG funds to undertake a broad range of activities and
structure their programs to give priority to eligible
activities that they wish to emphasize. As is also true with
the Entitlement Communities program, these activities must
primarily help low- and moderate-income persons and households,
however they can also be used to help eliminate slums and
blight or meet other urgent community development needs.
The Department has no specific information on the extent of
benefit from these programs for the elderly, however HUD staff
are aware that elderly persons and households who live in these
small cities and counties are benefiting from CDBG-funded
activities.
No further information is available at this time.
c. home investment partnership
The HOME Program provides funds by formula to States and
local governments for acquisition, rehabilitation, and
construction of affordable housing for rent or homeownership.
As of September 1996, the program, which was first funded in
1992, had assisted 21,500 elderly households. Over 80 percent
of these households had incomes at or below 50 percent of the
area median income. Most assistance was provided to existing
homeowners (15,200) to rehabilitate their homes. HOME provided
rental units for 3,200 elderly households, tenant based rental
assistance to 2,300 elderly households, and assistance to
purchase homes to 750 elderly households. The publication, Home
Repair/Modification Programs for Elderly Homeowners, is
designed to assist jurisdictions in designing programs using
HOME funds specifically to meet the needs of the elderly.
d. emergency shelter grants program
The Emergency Shelter Grants Program provides funds to
States, metropolitan cities, urban counties, Indian tribes, and
territories to improve the quality of emergency shelters, make
available additional shelters, meet the cost of operating
shelters, provide essential social services to homeless
individuals, and help prevent homelessness.
No further information is available at this time.
e. supportive housing demonstration program
The Supportive Housing Demonstration Program (SHDP) has two
components, Transitional Housing and Permanent Housing for the
Handicapped Homeless. The Transitional Housing Program is
designed to provide short-term housing and support services
that facilitate the transition of homeless persons to
independent living. The Permanent Housing for the Handicapped
Homeless Program assists States in developing community-based,
long-term housing and supportive services for handicapped
persons who are homeless.
No other information is available at this time.
IV. FAIR HOUSING AND EQUAL OPPORTUNITY (FHEO)
a. the fair housing act
The Fair Housing Act prohibits discrimination in housing
based on race, color, religion, sex, national origin, handicap,
or familial status. The Act exempts from its provisions against
discrimination based on familial status ``housing for older
persons.'' which is defined as housing intended and operated
for occupancy by elderly persons. The statutory exemption of
``housing for older persons'' comprises three categories of
housing: (1) housing provided under any State or Federal
Program that the Secretary of HUD determines is specifically
designated and operated to assist elderly persons; (2) housing
intended for and solely occupied by residents 62 years of age
and older; and (3) housing intended for and solely occupied by,
at least one person 55 years of age or older per unit, provided
various other criteria are met.
b. the housing for elderly persons act of 1995
The Housing for Older Persons Act (HOPA) of 1995 named the
``55 and older'' senior housing exemption to the Fair Housing
Act's prohibition against discrimination based on familial
status. HOPA eliminates the requirement that ``housing for
older persons'' have significant services and facilities for
its elderly residents and establishes a good faith reliance
defense from monetary damages based on a legitimate belief that
the housing was entitled to an exemption. In order to qualify
for the ``55 and over housing'' exemption a housing community
or facility must: (1) have at least 80 percent of its occupied
units occupied by at least one person 55 years of age or older;
(2) adhere to policies and procedures which demonstrate an
intent by the owner or manager to provide housing for persons
55 and older; and (3) verify the age of its residents through
reliable surveys and affidavits.
c. age discrimination act
During Fiscal Year 1995, the Department received five
complaints alleging age discrimination in federally-assisted
programs. It appears that three of these complaints were filed
by persons over 62 years of age. (Age discrimination complaints
may be filed by persons of any age.) In Fiscal Year 1996, there
were 10 such complaints, 6 of which were filed by elderly
persons.
d. designated housing
The 1992 Housing and Community Development Act authorized
HUD to approve Public Housing Authority plans to designate
mixed population housing units (serving elderly and persons
with disabilities) for elderly families only, if the plans met
certain statutory requirements. The Housing Opportunities
Program Extension Act of 1996 simplified and streamlined those
requirements, but continued to require HUD to review and
approve or disapprove designate housing plans.
As of December 1996, 38 housing authorities had received
approval to designate four units for elderly families only.
V. OFFICE OF POLICY DEVELOPMENT AND RESEARCH
a. american housing survey
The American Housing Survey for the United States, Current
Housing Reports H. 150 for the year 1995 contains special
tabulations on the housing situations of elderly households in
the United States. (Data for 1997 will be available in Fall
1998.) Chapter 7 of the regular report provides detailed
demographic and economic characteristics of elderly households,
detailed physical and quality characteristics of their housing
units and neighborhoods and the previous housing of recent
movers, and their opinions about their house and neighborhood.
The data are displayed for the four census regions, and for
central cities, suburbs, and non metropolitan areas, and by
urban and rural classification. The non-elderly chapters (total
occupied, owner, renter, Black, Hispanic, central cities,
suburbs, and outside MSAs) as well as the publications for the
44 largest metropolitanareas individually surveyed over a 4-
year cycle, Current Housing Reports H. 170, also contain data on the
elderly.
An elderly household is defined as one where the
householder, who may live alone or head a larger household, is
aged 65 years or more. Special information in these
publications is provided on households in physically inadequate
housing or with excessive cost burden, and on households in
poverty.
b. evaluation of the hope for elderly independence demonstration
program
The program was conceived as an alternative to the
Congregate Housing Services Program (CHSP). The major
difference between the two programs is that HOPE IV is a
tenant-based program implemented by the PHAs. Beyond specifying
minimum age, level of frailty and income requirements, HUD has
allowed considerable flexibility in local implementation of the
HOPE IV coordinator, obtain matching funds for its share of the
cost of services, and serve as a contractor for service
delivery.
The second interim report was published in August 1996.
This report describes the baseline characteristics of the
program participants and those of a comparison group composed
of frail elderly recipients of Section 8 rental assistance who
are not receiving HOPE IV supportive services. It also presents
the HOPE IV participants' initial view of the program and it's
services.
The PHAs have had to work very hard to get the HOPE IV
program fully operational.--Most HOPE IV grantees have had to
modify their normal Section 8 operating procedures and initiate
an array of new linkages with other agencies in the community
to recruit participants, help them relocate, and meet the
special challenges of serving the very frail elderly. Two years
into the program, the PHAs continue to have difficulties
finding candidates not in assisted housing who are sufficiently
frail. After two-years, only one-third of the projected slots
have been filled. The grantees have had to help the
participants find new housing (almost 25 percent of the
eligible candidates) to be eligible for the program and
physically move. This was unexpected, but many homes did not
meet Section 8 housing quality standards and the landlords were
unwilling to upgrade them; in other cases the sponsoring PHA
chose a program design option that permitted targeting services
to a specific neighborhood so applicants had to move to
participate. Some of the eligible participants could not make
the transition into new housing and they were lost to the
program. The comparison group survey shows that there are frail
elderly receiving Section 8 assistance who need the program's
services, but these elderly people are not eligible for HOPE IV
services because HUD opted to selected participants from the
waiting list, not from current recipients.
Even though the HOPE IV participants are considered very
frail, over 20 percent of the participants do not meet the
required level of frailty by HOPE IV program standards.--There
are explanations for this disparity. First, the grantees had
considerable difficulty interpreting the eligibility criteria
regarding ADL deficiency as defined by the program. The
professional assessment instruments available for measuring
frailty are not perfectly suited for assessing frailty required
by HOPE IV. Second, prior research in measuring ADL difficulty
shows self-reports (which these are) tend to be inaccurate
because the person has either compensated for the failure by
changing how they approach an activity they have trouble
performing or because they are unaware that they are
functionally declining.
Even though not all HOPE IV participants meet the minimum
ADL criteria for eligibility, the HOPE IV program appears to
appropriately targeted to those at risk of being
institutionalized.--The HOPE IV participants are much frailer
than non-institutionalized elderly persons in the general
population. However, they are less frail than persons in
community based programs for nursing home eligible persons or
than persons in nursing homes.
Even though most HOPE IV participants are considered very
frail, with many adverse health conditions, they actively
participate in activities outside the home and enjoy social
contact.--Over half of the participants report they are
satisfied with their lives, like their neighborhoods and living
arrangements, have good appetites, have control over their
activities, and have few worries. Almost all say that the HOPE
IV program is integral to keeping them independent.
c. evaluation of the congregate housing services program (chsp)
The New Congregate Housing services program was authorized
under the National Affordable Housing Act of 1990 and amended
by the Housing and Community Development Act of 1992.
The (CHSP) combines project-based rental assistance with
community-based supportive services to help low-income frail
elderly and non-elderly persons with disabilities maintain
independence and avoid institutionalization. In addition to
rental assistance, HUD pays 40 percent of the supportive
services cost, the grantees pay 50 percent of the cost, and the
participants pay 10 percent, if they are able. To be eligible
for the program, residents must need assistance with at least
three activities of daily living (ADL) as defined by HUD or, if
they are non-elderly, they must have temporary or permanent
disabilities.
The second interim report of the CHSP evaluation project
was published October 1996.
The third interim report describes the characteristics of
the program participants, their functional status, the services
received, the cost of the program and the impact of the
program.
The CHSP appears to be targeted to those at risk of being
institutionalized and who are likely to be appropriately served
by community-based options.--CHSP participants are older and
much frailer (in terms of ADL criteria) than elderly persons in
the general population, but they are somewhat similar to
residents of more restrictive environments such as board and
care homes, and in some cases, nursing homes.
Although overall the program participants include a
substantial proportion of very old people (75 years or older)
most of whom have six or more ADL impairments, about 22 percent
of the program participants report having fewer than three
ADLs.--This is for the same reasons as in the HOPE for Elderly
Independence program: difficulty interpreting the eligibility
criteria regarding ADL deficiency; problems with the
professional assessment instruments available for measuring
frailty; and inaccuracy of self reports.
About half of the original baseline participants have left
the program.--Because the CHSP participants are so frail and
old, a high number are not able to continue to live
independently, even with CHSP services. An overwhelming
majority (71 percent) of those who left the program moved to a
more restrictive environment or died. Of those remaining in the
program, 45 percent of the participants report more ADL
limitations than at baseline, 31 percent fewer, and 24 percent
report the same number.
Comparison of HOPE IV and CHSP
Both programs appear to be targeted to those at risk of
being institutionalized and who are likely to be appropriately
served by community-based options.--The two populations are
very similar in most reports, except that the HOPE IV
participants are frailer at a younger age. In general, elderly
participants in both programs are much frailer (in terms of ADL
criteria) than elderly persons in the same age range in the
general population, even though about 20 percent of the
participants currently in each of the programs do not meet the
strict level of frailty required by the program standards.
In many cases, coordinated service delivery is new to the
persons in these programs, particularly the HOPE IV elderly.
This coordination has resulted in individual participants
receiving greater total amounts of assistance than before
participation. However, the level of assistance necessary to
maintain independence with these populations corresponds to the
level of frailty and impairment of the participants.--Most
participants receiving services say they are satisfied with the
program, especially HOPE IV participants, 86 percent of which
say they are very satisfied. However, around one-fourth of the
elderly in these programs say that they need more services to
remain independent.
d. service coordinator program evaluation
The Office of Policy Development and Research completed an
evaluation of the Service Coordinator Program (SCP) in early
1996. The major goal of study was to assess the effectiveness
of the SCP, which pays the cost of a service coordinator who
arranges to bring the needed supportive services to the elderly
and persons with disabilities so that they may continue to live
independently; the program does not pay for the cost of the
services. The evaluation objectives were to describe early
implementation experiences of SCPs; ongoing program operations;
and resident satisfaction with the program.
There are several policy relevant findings:
The study provides evidence that the program worked
effectively. Across the 18 study sites, residents were very
satisfied with the program and the service coordinator. Even
residents who believed that they did not currently need any
help from the service coordinator indicated that they liked
knowing that assistance was available should they need it.
Property managers and service coordinators believed that
the SCP had prevented early institutionalization of some
residents. Their estimates of the number of residents able to
continue living independently as a result of the SCP ranged
from 3 to 30 per project, or about 12 percent of residents on
average across projects.
The flexibility of the program allowed service coordinators
to address the myriad of supportive service needs of their
residents, which ranged from coordinating transportation to
medical-related services.
ITEM 8--DEPARTMENT OF THE INTERIOR
----------
Departmental Office for Equal Opportunity
In 1995 and 1996, the Departmental Office for Equal
Opportunity (OEO) civil rights mission was to ensure compliance
with the various Federal laws and regulations that prohibit
discrimination on the bases of race, color, national origin,
age, and disability in programs and activities that received
Federal financial assistance. The Office also served as the
focal point for all equal opportunity functions in the
Department of the Interior. During the period, the Departmental
OEO provided technical assistance on age discrimination matters
to bureaus and offices of the Department and to entities of
State and local governments. The Office developed policies and
programs relating to age discrimination compliance and
enforcement matters. Work force data based on age and other
factors were collected and analyzed for the purpose of
identifying illegal equal employment trends. Age discrimination
complaints were adjudicated. In instances where age
discrimination complaints were filed against the Department,
the Departmental OEO routinely issued final agency decisions in
response to such cases. In 1996, the Department's civil rights
and Federal equal employment programs were the focus of
``reinvention'' laboratories which were associated with the
Administration's National Performance Review Initiative. These
laboratories served to improve customer service with respect to
identifying instances of age discrimination; investigating and
resolving civil rights complaints including ones that allege
age discrimination; and, reengineering complaint processing
practices that proved costly and inefficient. On March 4, 1996,
the Interior Management Council formed a ``Diversity Task
Force'' to review the affirmative employment issues regarding
under-representation in the Department of the Interior. The
Task Force looked at, among other concerns, age discrimination
issues affecting the Department in such areas as recruitment,
retention and employee development, and performance management
standards. Age factors were considered by the Task Force in
studying these issues. During the period, an electronic home
page was developed on the ``Internet.'' The home page described
the Department's nondiscrimination policies and the procedures
for filing complaints including those based upon age. Also,
civil rights training was conducted for all bureaus and offices
of the Department on the requirements of the Age Discrimination
Act of 1975. In addition, the Departmental OEO oversaw the
conduct of complaint investigations and compliance reviews and
the resolution of accessibility problems in areas where
federally assisted and federally conducted program areas. These
activities also included people with disabilities who were
predominantly senior citizens.
Office of Surface Mining Reclamation and Enforcement
The Office of Surface Mining Reclamation and Enforcement
(OSM) is committed to ensuring that persons are provided equal
opportunity in all employment matters. During calendar years
1995 and 1996, a policy statement from the Director of OSM was
in effect which stated that discrimination based on age (40
years of age and older) will not be tolerated. In addition,
during calendar year 1995, a diversity policy statement was
issued committing OSM to creating and maintaining a diverse
work force that would be inclusive of elderly persons. Older
workers are represented in most of OSM's occupational series.
During Calendar year 1995, OSM's work force shrank from 874 to
640 employees due to a ``Reduction-In-Force'' and retirements.
The bureau recognized that these types of situations could
cause some older workers to experience work changes or stress.
In order to help all its workers deal with these situations,
OSM sponsored a number of seminars on ``change.'' These
seminars were designed to assist individuals in the transition
from work to retirement or from one occupation to another.
Older workers were also given the opportunity to attend various
retirement seminars. Also, awards for 25, 30, and 35 years of
service were given to many OSM employees in calendar years 1995
and 1996.
U.S. Fish and Wildlife Service
The U.S. Fish and Wildlife Service (Service) recognizes its
responsibility for providing opportunities to all citizens
throughout its system and strives to ensure that aging citizens
are fully utilized and supported through special programs,
volunteerism, employment opportunities and the modification of
facilities to improve accessibility.
In 1995, the Service employed a total of 7,242 persons. Of
that number, 4,764 employees were 40 years of age and older.
This represented 66 percent of the total work force. Of the
4,764 employees, 269 were 60 years and older and worked various
schedules in a wide variety of occupations with the majority
employed in the biological sciences positions. The following
occupational categories are reflective of that group:
2,179 (46%) were in Professional positions with 86
(4%) of them over the age of 60;
926 (19%) were in Administrative positions with 40
(4%) of them over the age of 60;
627 (13%) were in Technical positions with 48 (8%) of
them over the age of 60;
466 (10%) were in Clerical positions with 37 (8%) of
them over the age of 60;
14 (.3% were in Other positions with (7%) of them
over the age of 60; and
552 (12%) were in Wage Grade positions with 57 (10%)
of them over the age of 60.
Through its Office of Human Resources, the Service provided
training and technical assistance to managers, supervisors and
equal employment opportunity counselors on the regulations and
guidelines governing age discrimination to sensitize them to
the rights of employees who were 40 and older. In 1995, there
were a total of 60 employment related discrimination complaints
filed Service wide. Of these, 16 (26.7%) were filed alleging
discrimination on the basis of age (40 and above). The Service
investigated a total of 45 federally assisted program related
complaints, of which 5 (11.1%) were filed alleging
discrimination on the basis of age (40 and above). The Service
increased its efforts in making programs, activities and
facilities more accessible to persons with disabilities and to
meet the needs of older employees and citizens. There were more
than 23,000 volunteers Service-wide including 1,937 (8.4%)
individuals over the age of 61. The Service sponsored
recreational and environmental education programs in which
senior citizens volunteered at National Wildlife Refuges, Fish
Hatcheries, and Ecological Services Field Stations. The seniors
conducted tours of Service facilities and answered questions
about camping, fishing, hiking, and wildlife viewing. The
Service entered into cooperative agreements; such as, Sullys
Hill Visitor Center and the Devils Lake Retired Senior
Volunteer Program (RSVP) and the ``Serendipity'' Club at the
Salvation Army Senior Citizen Center, in Anchorage, Alaska.
In 1996, the Service employed a total of 6,997 persons. Of
that number, 4,331 employees were 40 years of age and older.
This represents 62 percent of the total work force. Of the
4,331 employees, 148 were 60 years and older and worked various
schedules in a wide variety of occupations with the majority
employed in the biological sciences positions.
The following occupational categories are reflective of
that group:
1,972 (46%) were in Professional positions with 43
(2%) of them over the age of 60;
873 (20%) were in Administrative positions with 25
(3%) of them over the age of 60;
585 (14%) were in Technical positions with 27 (5%) of
them over the age of 60;
387 (9%) were in Clerical positions with 19 (5%) of
them over the age of 60;
13 (.3%) were in Other positions with 0 of them over
the age of 60; and
501 (12%) were in Wage Grade positions with 34 (7%)
of them over the age of 60.
There were more than 25,000 volunteers Service-wide
including 3,542 (14.2% individuals over the age of 61. The
Service sponsored recreational and environmental education
programs inwhich senior citizens volunteered at National
Wildlife Refuges, Fish Hatcheries, and Ecological Service Field
Stations. The seniors conducted tours of Service facilities and
answered questions about camping, fishing, hiking, and wildlife
viewing. The Service received a significant portion of written and
telephonic inquiries from retired individuals who were interested in
natural resource oriented issues, especially concerning endangered
species and non-game birds and animals. The Service's publication unit
made available educational materials and provided practical methods and
techniques to enhance fish and wildlife habitats to the public. The
Service continued its involvement in cooperative agreements with
various Senior Centers and Organizations.
The Service's Office of Human Resources provided training
and technical assistance to Service managers, supervisors and
equal employment opportunity counselors on the regulations and
guidelines governing age discrimination. This training enhanced
their skills by enabling them to informally resolve complaints
and sensitizing them to the rights of employees who were 40 and
older. In 1996, there were a total of 45 employment related
discrimination complaints filed Service wide. Of these, 16
(35.6%) were filed alleging discrimination on the basis of age
(40 and above). Additionally, the Service investigated a total
of 34 Federally Assisted Program related complaints, of which 3
(8.8%) were filed alleging discrimination on the basis of age
(40 and above).
National Park Service
The National Park Service (NPS) continues to ensure that a
broad range of services and activities are provided to the
visiting public including senior citizens. The NPS hosts the
``Senior Community Service Employment Program (SCSEP).'' This
activity is carried out in cooperation with the U.S. Forest
Service and Voyageurs National Park. Program participants must
possess a valid State driver's license; be at least 55 years of
age; pass a physical examination and live in or near Voyageurs
National Park. Under SCSEP, Voyageurs National Park employed
four senior citizens, i.e., three maintenance workers and one
receptionist. The program seeks to provide supplemental income
to seniors in general and to rural communities in particular.
It provides invaluable work experience to older Americans. This
employment program has worked very well at Voyageurs. The NPS
also offers the ``Volunteers-in-Parks Program'' which operates
at Voyageurs and other national parks. The program serves a
variety of older couples who work at various park sites during
the summer.
The George Washington National Monument serves as a
worksite for older Americans who are employed by the Area
Agency on Aging. The Agency on Aging pays the salary and the
park provides work projects, supervision and training for
program participants. Participants usually work part-time (20
hours per week).
The Golden Age Passport, for persons 62 and older, is a
lifetime entrance pass to most national parks monuments,
historic sites, recreation areas, and national wildlife refuges
that charge an entrance fee. The passport admits the pass
holder and any accompanying passengers in private automobiles.
The Golden Age Passport also provides a 50% discount on fees
charged for park services, facilities and services such as
parking, boat launching, swimming, camping, and cave tours.
The NPS continues to ensure nondiscrimination on the basis
of age in its workforce. For example, in 1996, out of 288
issues raised in complaints of alleged discrimination, in 40
instances, allegations of age discrimination were raised. The
NPS processed a total of 26 complaints of alleged age
discrimination out of a total of 99 complaints received during
the period.
The NPS Accessibility Office is an office that is staffed
by experienced park and recreation professionals who have
provided park and recreation services to special populations
including the elderly and people with disabilities. A primary
goal of the office is to develop and implement a comprehensive
and system wide approach for ensuring that the national park
system is readily accessible to all people including the
elderly and people with disabilities. Since its creation, the
office has been providing training and technical assistance to
all NPS regional offices in an effort to improve and make more
accessible park and recreation services to senior citizens and
other special populations.
U.S. Geological Survey
The U.S. Geological Survey (USGS) provides opportunities to
all individuals throughout its system and ensures that older
individuals were utilized through special programs,
volunteerism, and employment opportunities.
In 1996, USGS employed a total of 8,949 individuals. There
were, 5,700 (64%) USGS employees aged 40 and over. Of USGS
employees aged 40 and over, there were 334 (6%) employees who
were 60 years of age and older, and there was one employee over
the age of 80.
The majority of USGS' mission related occupations, which
include occupations such as hydrologists, geologists, and
cartographers, are in the professional category. Of the 5,700
USGS employees age 40 and over, there were 2,777 (49%) in
professional positions, 191 (3%) of whom were age 60 and over,
and one employee over the age of 80. Other demographic
information regarding USGS employees age 40 and over was as
follows:
855 (15%) were in the ``administrative'' positions
with 28 (3%) of them aged 60 and over;
1,645 (29%) were in ``technical'' positions with 77
(5%) of them aged 60 and over;
301 (5%) were in ``clerical'' positions with 33 (11%)
of them aged 60 and over;
12 (0.2%) were in other positions with none of them
aged 60 and over; and
110 (2%) were in the ``wage grade'' positions with 5
(5%) aged 60 and over.
In 1995, USGS employed a total of 9,220 people. There were
5,824 (63%) Survey employees aged 40 and over. Of USGS
employees aged 40 and over, there were 400 (7%) employees who
were 60 years of age and older, and four employees aged 80 and
over.
In USGS' professional occupational series, 2,883 (49%) of
the employees were aged 40 and over, 237 (8%) were aged 60 and
over, and four employees aged 80 and over. Other demographic
information regarding USGS employees age 40 and over was as
follows:
807 (14%) were in the ``administrative'' positions
with 31 (4%) of them aged 60 and over;
1,686 (29%) were in ``technical'' positions with 34
(11%) of them aged 60 and over;
316 (5%) were in ``clerical'' positions with 34 (11%)
of them aged 60 and over;
8 (0.1%) were in other positions with none of them
aged 60 and over; and
124 (2%) were in the ``wage grade'' positions with 8
(6%) aged 60 and over.
In addition to the full time employees, USGS also had many
volunteers. These individuals provided outstanding services to
USGS and the public nation-wide in a variety of capacities. The
various types of volunteer opportunities, and the number of
individuals involved, were:
------------------------------------------------------------------------
Categories 1995 1996
------------------------------------------------------------------------
USGS Retirees......................................... 50 50
Other Retirees........................................ 200 300
Docents............................................... 25 15
Scientists Emeritus................................... 252 260
-----------------
Totals.......................................... 527 625
------------------------------------------------------------------------
The USGS Scientist Emeriti are welcomed back to the USGS
after retirement to continue important scientific research. The
USGS benefits immeasurably from the accumulated knowledge,
experience, and dedication of over 250 Scientist Emeritus. For
example, Scientist Emeritus astrogeologist, Gene Shoemaker and
his wife, contributed to the understanding of our solar system
by significantly sharing in the discovery of Comet Shoemaker-
Levy.
The following are examples of some of the other activities
in which USGS' volunteers were involved:
A retired Federal government employee logged over 4,000
hours of volunteer service working in the Reston, Virginia,
Earth Science Information Center filing maps and brochures and
assisting customers. He epitomized the highest standards of
customer service recognized at the USGS.
USGS retirees served as docents in the National Visitors
Center, leading tours and providing information about the USGS
to groups from pre-school age to senior citizens.
Scores of senior citizens volunteered nationwide for the
Water Resources Division, collecting analyzing water quality
data in their communities.
Two retirees from outside the Federal sector donated their
time in Reston, Virginia, to provide critical assistance to the
development and management of the USGS Earth Science Corps, a
project that utilizes hundreds of citizens across the country
to update USGS maps. It was estimated that within the Earth
Science Corps contingent, 200 volunteers made valuable
contributions to the USGS and the Nation by providing accurate,
up-to-date geographic information about their communities.
Two retirees served as volunteers on a special project in
Alaska to investigate the movement and impact of the Bering
Glacier. Working under rugged conditions, the volunteers helped
make it possible for USGS scientists to complete numerous
studies and advance our understanding of this significant
glacier.
Senior citizens and retirees with backgrounds in
mathematics and computer science volunteered to instruct
employees on software applications, enter data and evaluate
software and hardware upgrades.
In the Water Resources Division, Volunteers aged 60 and
over contributed their services to the USGS in the following
ways:
1. Assisted in processing computer data for the
Annual Data Report;
2. Worked on surface-water and quality-water record;
3. Assisted with field trips for the National Science
Foundation and USGS Water Workshops;
4. Completed Volume VI, Water Resources Division
History, 1957-1966;
5. Reviewed sediment laboratories for the Office of
Surface Water, examining method consistencies of Water
Resources Division sediment laboratories, and providing
insight to the Sediment Action Laboratory Subcommittee;
6. Completed two models: Blaine Aquifer, Oklahoma,
and the High Plains Aquifer, Twin Platte, Nebraska;
7. Provided support and guidance to the Central
Region Hydrologist's office;
8. Provided technical support and consultation for
flood hydrology and hydraulics program;
9. Reviewed Titan reports for McConnell Air Force
Base, aquifer maps, reports, and other services as
necessary;
10. Assisted in making discharge measurements and
checking gages;
11. Assisted in the ``Extreme Storm Study'';
12. Prepared for and attended the International
Records Annual meeting in Maple Creek, Saskatchewan,
Canada;
13. Helped in selecting and monitoring wells for USGS
observation well network;
14. Worked on the South Dakota History, Volume 7;
15. Assisted with Water Resources data collection and
processing in the Data Unit;
16. Processed East Fork River bedload report and
Wyoming dye tracing report;
17. Completed reports on river sediments, Powder
River, Orinoco River, and Amazon River;
18. Revised the report entitled, Transport, Behavior,
and Fate of Volatile Organic Compounds in Streams and
Rivers;
19. Conducted laboratory work for the Nation Research
Project in Boulder, Colorado; and,
20. Consulted on sediment transport, data collection,
and interpretation of data.
Bureau of Land Management
The Bureau of Land Management (BLM) administers a multi-
faceted, multiple-use natural resource management program
intended to serve all members of the public regardless of age,
gender, national origin, race, color, religion or mental or
physical disability. It fosters an environment of equality of
opportunity through initiatives aimed at programmatic and work
force diversification. The BLM's approach incorporates broad
policies and practices which encourage participation and
inclusion among all employees, applicants for employment, users
of the public lands, and other members of the public who
support the BLM's mission.
The BLM does not routinely gather and publish information
on age groups within its nationwide work force. However, as of
September 30, 1997, the BLM employed 8,949 permanent employees,
of whom 705 individuals, or nearly 8 per cent of the work
force, were eligible for voluntary retirement. This level of
total employment is down from previous years, reflecting the
effects of voluntary retirements and Government-wide early-out
and other retirement incentive programs offered during 1995 and
1996 when the BLM, along with other Federal agencies, lost a
considerable number of older employees.
During 1996, approximately 17,000 persons through the
contiguous United States and Alaska contributed their skills
and services to the BLM's natural resource management and
protection activities as volunteers and hosted workers. Again,
while no statistics on age were maintained, an appreciable
number of individuals over the age of 65 traditionally have
participated in the BLM's volunteer programs and have received
public recognition for their contributions and dedication.
The BLM values the skills, perspectives and energy that
older Americans can bring to its programs, both as employees
and as volunteer workers. And recognizing its debt to the
efforts of previous generations, the BLM carefully monitors its
operations to ensure that older employees and volunteers can
contribute meaningfully in accordance with their talents and
interests. Finally, the BLM strives to ensure that all members
of the public have full access to BLM installations,
facilities, and programs--without discrimination or restricted
access based upon age--in order to use, enjoy, and appreciate
America's public lands.
Bureau of Indian Affairs
During the reporting period of 1995 and 1996, the Bureau of
Indian Affairs (BIA) administered initiatives and programs to
benefit older (aging) American Indians and Alaskan Natives.
More specifically, the BIA's Division of Social Services
provided and financed adults with custodial and protective care
services. These services were provided in homes, group homes,
and nursing care facilities for elderly persons who lacked the
financial, physical and mental capacity to care for themselves.
Other aging citizens have received protective and counseling
services without custodial care payments. They coordinated
intensive skill nursing care service needs for aging residents
through referrals to other Federal, State or local agencies.
This office is currently establishing standards that will
upgrade custodial care facilities making them eligible to
receive Medicare and Medicaid payments and provide better
subsequent custodial care to eligible aging Native Americans.
The BIA's Social Services Division administers a Housing
Improvement Program that makes existing housing repairs and
renovations and some new home constructions on Indian
reservations or communities. This program is a grant program
designed to improve housing standards for citizens who are not
qualified for such assistance under conventional housing
assistance programs. Program participants are selected from
weighted variables that favor low income individuals, people
with disabilities, elderly applicants. Furthermore, Tribal
governments are ``638 Contracts'' as a means for meeting the
special housing needs of elderly Native Americans.
BIA's Office of Indian Education Programs has developed and
administers a Family and Child Education (FACE) Program. FACE
is a family literacy program. The program serves all family
members including the elderly who have guardian responsibility
for minor children. The program provides for early childhood
and adult education, instructions on parenting skills. These
services are provided in homes, community centers, and schools.
These services empower elderly Native Americans to become more
proficient in caring for children that remain in their custody.
BIA's Office for Equal Employment Opportunity Programs
continues to vigorously enforce the Age Discrimination in
Employment Act which prohibits discrimination on the basis of
age in its work force. These anti-discrimination enforcement
efforts ensure that older employees may continue their careers
uninhibited.
Minerals Management Service
The Minerals Management Service (MMS) continues to work to
support programs for older Americans. MMS's work force
statistics are as follows:
Seventy-eight percent of MMS' work force is comprised
of employees aged 40 and over (1,362 or 1737);
Older employees are well represented in a variety of
occupations within MMS including accountants, auditor,
computer specialist, engineers, and physical
scientists; and,
The MMS has implemented and continues to implement
effective personnel management policies to ensure that
equal opportunity is provided to all employees and
applicants, including the aged.
The MMS continues to perform its mission-related functions
with diligence and with appreciation of the importance of its
actions. A major mission responsibility affecting large numbers
of citizens is the approval of mineral royalty payments of
various landholders, including numerous older Americans who
often depend heavily on these payments to meet their basic
human needs and rely on the ability of the MMS to effectively
discharge their financial responsibilities.
The MMS offshore mission has the ultimate objective of
increasing domestic mineral (oil and gas) production through
offshore Resources, thereby decreasing its dependence on
foreign imports. Such activities have a significant effect on
the economic well-being of all Americans, especially older
Americans. In summary, the MMS has a strong commitment to all
of its employees including older workers. Older workers are a
source of valuable knowledge and experience and a significant
factor in the success of the MMS mission.
Bureau of Reclamation
The Bureau of Reclamation (Reclamation) conducts many
activities throughout the year that affect and benefit aged
individuals. Its Personnel Offices maintain contact with and
provide services to many retirees who need advice or have
questions concerning their retirement and health benefits. In
addition, retirees and their spouses attend annual health
insurance fairs where representatives from insurance carriers
are available to discuss the provisions of, or changes to,
their respective medical plans. Several of Reclamation's
regional offices continue to mail out a monthly newsletter to
all retirees. The newsletters contain information on
Reclamation, current employees, past employees, and is highly
regarded by retirees as a way to keep in touch. Additionally,
pre-retirement briefings and seminars are held for all
interested employees who are within five years of retirement
eligibility.
Work and Family Programs.--The Bureau of Reclamation
established a Work and Family Team (WAFT) in September 1995 to
implement the President's directive on Family-Friendly Federal
Work Arrangements. The Team is comprised of representatives
from all the Regions in Reclamation. Initiatives taken on
behalf of older Americans and their families are principally
addressed in this arena. The Bureau of Reclamation maintains
family friendly workplace information in the Human Resources
Offices, located in 7 geographically dispersed regions. A Human
Resources Center is established within each office to provide
information and assistance on various Human Resources. It is a
``One Stop Shopping Center'' including job information,
References and Resources Library, Equal Employment Opportunity,
Work and Family Resources Issues (to include elder care) and,
etc. The Office of Personnel Management's Handbook on Child and
Elder Care is available as well as information from the
American Association of Retired Persons. The WAFT has developed
a Web page to provide information on Resources, topics of
interest and updates on information relating to family issues
as well as a LAN address, ``TALKTOWAFT,'' to enable employees
to send questions about work and family policies or to ask for
information. In addition, the WAFT has developed a handbook on
a variety of family-related topics. One of the sections in the
handbook addresses elder care and Resources.
Family and Medical Leave Initiatives.--Reclamation is in
the process of testing an alternative work schedule program,
which would allow employees greater flexibility in constructing
their work hours to accommodate family needs. This is in
addition to its telecommuting initiative already in place and
vigorous support of the Family and Medical Leave Acts.
Employment Opportunities.--Reemployed annuitants are hired
to perform special projects or provide assistance in
specialized technical areas of work since they are able to
offer invaluable experience and expertise to these assignments.
Our Boise, Idaho, Office has signed a Memorandum of Agreement
with the State of Idaho, Department of Health and Welfare, to
provide work opportunities for individual interested in getting
back into the work environment. The Region provides work
opportunities while the State provides the salary. The period
of time is usually 10-15 weeks. Traditionally, the individuals
have been senior citizens.
ITEM 9--DEPARTMENT OF JUSTICE
----------
INITIATIVES RELATED TO OLDER AMERICANS
Introduction
As the largest law firm in the Nation, the Department of
Justice (DOJ) serves as counsel for its citizens. It represents
them in enforcing the law in the public interest. Through its
thousands of lawyers, investigators, and agents, the Department
plays the key role in protecting against criminals and
subversion, ensuring healthy competition of business in our
free enterprise system, safeguarding the consumer, and
enforcing drug, immigration, and naturalization laws. The
Department also plays a significant role in protecting citizens
through its efforts for effective law enforcement, crime
prevention, crime detection, and prosecution and rehabilitation
of offenders.
In addition, the Department conducts all suits in the
Supreme Court in which the United States is concerned. It
represents the Government in legal matters generally, rendering
legal advice and opinions, upon request, to the President and
to the heads of the executive departments. The Attorney General
supervises and directs these activities, as well as those of
the U.S. Attorneys and U.S. Marshals in the various judicial
districts around the country.
Within the Department, two components--the Civil Rights
Division and the Office of Justice Programs--conduct
initiatives related to older Americans.
Civil Rights Division
The Civil Rights Division was established in 1957 to secure
effective Federal enforcement of civil rights. The Division is
the primary institution within the Federal Government
responsible for enforcing Federal statutes prohibiting
discrimination on the basis of race, sex, disability, religion,
and national origin.
Americans with Disabilities Act (ADA) Enforcement
The Division's Disability Rights Section enforces the ADA's
provisions prohibiting discrimination against people with
disabilities in state and local government services and places
of public accommodation. The Section has established a
comprehensive technical assistance program to educate those
with rights and responsibilities under the law. This program
includes the establishment of an ADA Information File,
containing over 70 documents, in 15,000 public libraries across
the country, a toll-free ADA Information Line, which receives
over 100,000 calls per year, and an ADA home page on the World
Wide Web, which receives over 50,000 hits per week. The
Internet address is www.usdoj.gov/crt/adahom1.htm.
Through the ADA technical assistance grant program, the
American Association of Retired Persons (AARP) has developed
materials to help older persons understand their rights and to
help businesses and agencies serving older persons understand
their obligations under the law. The AARP provides training to
service providers, advocates, and older persons throughout the
country.
Since 1992, the Division has reached voluntary agreements
with businesses and local governments in more than 600 cases
involving state and local government services and the private
sector. The resolution of these complaints has resulted in the
removal of architectural and communication barriers in a wide
variety of settings, including retail stores, restaurants,
hotels, stadiums, and town halls. A 1996 agreement with the
Cineplex Odeon Corporation, one of the Nation's largest
operators of motion picture theaters, established a model for
the industry on compliance with the ADA's requirements for
assistive listening devices used by persons who are hard-of-
hearing.
Civil Rights of Institutionalized Persons Act (CRIPA) Enforcement
The Division's Special Litigation Section has
responsibility under CRIPA to investigate conditions in
publicly operated nursing homes and to file suits where there
is a pattern or practice of violations of the constitutional or
Federal statutory rights of nursing home residents, including
the right to adequate care and treatment. In 1996, the Section
initiated investigations of several publicly operated nursing
homes.
Further information about the activities of the Civil
Rights Division is available online at www.usdoj.gov/crt or by
calling the Department of Justice's Office of Public Affairs at
202/514-2007.
Office of Justice Programs
Since 1984, the Office of Justice Programs (OJP) has
provided Federal leadership in developing the nation's capacity
to prevent and control crime and delinquency, improve the
criminal and juvenile justice systems, increase knowledge about
crime and related issues, and assist crime victims. OJP is
comprised of five program bureaus, three Crime Act program
offices, the Executive Office for Weed and Seed, the American
Indian and Alaskan Native Desk (AI/AN), and the Violence
Against Women Office (VAWO).
The Bureau of Justice Assistance (BJA) provides funding,
training, and technical assistance to state and local
governments to combat violent and drug-related crime and help
improve the criminal justice system. It also administers the
Edward Byrne Memorial State and Local Law Enforcement
Assistance Program, the Local Law Enforcement Block Grants, the
State Criminal Alien Assistance Program, the Public Safety
Officers' Benefits Program, Regional Information Sharing
Systems, and the Church Arson Prevention Grant Program.
The Bureau of Justice Statistics (BJS) is the principal
criminal justice statistical agency in the nation. BJS collects
and analyzes statistical data on crime, criminal offenders,
crime victims, and the operation of justice systems at all
levels of government. It also provides financial and technical
support to state statistical agencies and administers special
programs that aid state and local governments in improving
their criminal history records and information systems,
including grant programs that implement the Brady Handgun
Violence Prevention Act and the National Child Protection Act.
The National Institute of Justice (NIJ) is the principal
research and evaluation agency in the Department of Justice.
NIJ supports research and development programs, conducts
demonstrations of innovative approaches to improve criminal
justice, develops new criminal justice technologies, and
evaluates the effectiveness of justice programs. NIJ also
provides primary support for the National Criminal Justice
Reference Service, a clearinghouse of criminal justice-related
publications, articles, videotapes, and online information.
The Office of Juvenile Justice and Delinquency Prevention
(OJJDP) provides Federal leadership in preventing and
controlling juvenile crime and improving the juvenile justice
system at state and local levels. OJJDP also provides grants
and contracts to states to help them improve their juvenile
justice systems and sponsors innovative research,
demonstration, evaluation, statistics, replication, technical
assistance, and training programs to help improve the nation's
understanding of and response to juvenile violence and
delinquency. In addition, OJJDP administers the Missing and
Exploited Children's program and four programs funded under the
Victims of Child Abuse Act.
The Office for Victims of Crime (OVC) provides Federal
leadership in assisting victims of crime and their families.
OVC administers two grant programs created by the Victims of
Crime Act of 1984 (VOCA). The Victims Assistance Program gives
grants to states to support programs that provide direct
assistance to crime victims. State victim assistance
subgrantees reported expenditures of over $2 million for elder
abuse victims in Fiscal Year 1996 (from October 1, 1995 through
September 30, 1996). The Victims Compensation Program provides
funding to state programs that compensate crime victims for
medical and other unreimbursed expenses resulting from a
violent crime. OVC also sponsors training for Federal, state,
and local criminal justice officials and other professionals to
help improve their response to crime victims and their
families.
The three Crime Act Offices--the Violence Against Women
Grants Office (VAWGO), the Corrections Program Office (CPO),
and the Drug Courts Program Office (DCPO)--administer major
programs authorized by the 1994 Crime Act.
VAWGO administers one formula and four discretionary grant
programs. The grant programs are designed to help prevent,
detect, and stop violence against women, including domestic
violence, sexual assault and stalking.
CPO provides financial and technical assistance to state
and local governments to implement the corrections-related
programs created by the Crime Act. CPO administers two formula
and two discretionary grant programs.
DCPO administers the discretionary drug court grant program
authorized by Title V of the Crime Act. The purpose of the
grant program is to provide support for the development,
implementation, and improvement of drug courts through grants
to local or state governments, courts, and tribal governments,
as well as through technical assistance and training. A survey
of 93 drug courts by OJP's Drug Court Clearinghouse found that
1 percent of drug court participants were over age 60.
OJP's American Indian and Alaskan Native Desk (AI/AN)
improves outreach to tribal communities. AI/AN works to enhance
OJP's response to tribes by coordinating funding, training, and
technical assistance and providing information about available
OJP resources. An overview of OJP's response to preventing and
controlling crime in Indian Country is provided in the February
1997 report, Office of Justice Programs Partnership Initiatives
in Indian Country. The report is available at no cost from the
National Criminal Justice Reference Service at 1-800/851-3420
or online through OJP's home page at www.ojp.usdoj.gov.
The Executive Office for Weed and Seed (EOWS) is dedicated
to building stronger, safer communities through the Weed and
Seed strategy, a community-based, multi-disciplinary approach
to combating crime. EOWS works closely with United States
Attorneys and OJP's bureaus to implement Operation Weed and
Seed in communities throughout the country.
Also within OJP is the Violence Against Women Office
(VAWO), which coordinates the Department of Justice's
legislative and other initiatives relating to violence against
women, including intradepartmental activity. To stop violence
against older women, the VAWO Director works with organizations
such as the Older Women's League (OWL), the American
Association of Retired Persons (AARP), and the National Task
Force on Violence Against Women.
The following describes OJP's major activities on behalf of
older Americans:
Working Group on Victimization of Older Persons.--OJP leads
a Department-wide Working Group on Victimization of Older
Persons. Participants include OJP, BJA, NIJ, OVC, VAWGO, the
Department's Criminal Division, and the Executive Office for
U.S. Attorneys. The Working Group explores ways to elevate the
Department's focus on victimization of senior citizens through
new or ongoing efforts. It also coordinates related activities
among its member agencies and provides planning and other
assistance to DOJ agencies in conducting initiatives related to
older persons.
Research.--In Fiscal Year 1996, NIJ awarded a 2-year
research grant to Victim Services in New York City to conduct
(in cooperation with the New York City Police Department) an
evaluation of a program teaming community policing and social
services to respond to elder abuse. The study is examining the
effects of the project's public education efforts and home
visitations to elderly residents. Preliminary findings were
reported at the November 1996 annual meeting of the American
Society of Criminology. The study found that home visits
increased crime reporting, reduced the incidence of financial
abuse, and increased the victim's confidence to call the police
again; public education increased victims' satisfaction with
police; and victims who received the home visits and/or public
education information believed these interventions to be
helpful. The final report is expected by April 1998. For
copies, contact NIJ's National Criminal Justice Reference
Service at 1-800/851-3420 or online at www.ncjrs.org.
Safe Return Program.--At the direction of Congress, OJJDP
administers this program to facilitate the identification and
safe return of memory-impaired persons who are at risk of
wandering from their homes. Directed by the Alzheimer's Disease
and Related Disorders Association, the Safe Return Program
operates a national photographic registry of memory-impaired
persons, maintains a toll-free telephone service, provides a
Fax Alert System, conducts ``train-the-trainers'' programs for
law enforcement and emergency personnel, develops information
and educational materials, conducts public awareness campaigns,
and works to network with other ``wandering persons'' programs.
For more information, contact the Safe Return Program at 1-800/
572-1122.
Telemarketing Fraud.--In Fiscal Year 1996, with a $2
million appropriation for ``programs to assist law enforcement
in preventing and stopping marketing scams against senior
citizens,'' BJA awarded a grant to the National Association of
Attorneys General (NAAG) to develop a training curriculum for
prosecutors and investigators to help address these crimes.
NAAG is collaborating in this project with the National
District Attorneys Association and the National White-Collar
Crime Center. A small, regional pilot training course was held
in San Diego in February 1998. A larger training program is
planned in Boston, Massachusetts, in the spring of 1998. BJA
and OVC also are funding the development of education and
public awareness campaigns to address telemarketing fraud aimed
at senior citizens.
Triad.--Through a grant to the National Sheriffs'
Association, BJA and OVC support Triad. Triad programs involve
a three-way effort among a sheriff, the county police chief(s),
and members of the American Association of Retired Persons
(AARP) or other older/retired leadership in the area. These
groups agree to work together to reduce criminal victimization
of older citizens and enhance the delivery of law enforcement
services to this population. Triad provides the opportunity for
an exchange of information between law enforcement and senior
citizens. It focuses on reducing unwarranted fear of crime and
improving the quality of life for seniors.
A Triad program is tailored to meet the needs of each
community and is guided by a senior advisory council called
SALT (Seniors and Lawmen Together). More than 415 counties
participate in Triad nationwide, and efforts are under way to
encourage Native American tribal governments to initiate Triad
projects. For more information about Triad, or for help in
starting a program, contact the National Sheriffs' Association
at 1-800/424-7827.
Training and Technical Assistance.--Through its Trainers'
Bureau, OVC provides training to Federal, state, and local law
enforcement officials on issues relating to elder abuse and
financial exploitation of the elderly. For example, in November
1996, OVC staff conducted a training program on elder abuse
issues for tribal governments in Warm Springs, Oregon. The
training conference was attended by 180 people, including
representatives of 12 Native American tribes, as well as 6
tribal chiefs. Further information about OVC's Trainers' Bureau
is available from Donna Ray at 202/616-3572 or e-mail at
[email protected].
Victimization Statistics.--Through its National Crime
Victimization Survey (NCVS), the OJP's Bureau of Justice
Statistics annually collects data on crime victimization on
individuals age 12 and older in a statistically representative
sample of U.S. households. A BJS Special Report, Age Patterns
of Victims of Serious Violent Crime, released in September
1997, uses data from 1992 through 1994 to examine serious
violent crime across different age groups. Serious violent
crimes include rape and sexual assault, robbery, and aggravated
assault, as measured by NCVS, and homicide from data reported
by law enforcement agencies to the FBI.
The report found that vulnerability to violent crime
victimization varies across the age spectrum. The victimization
rate increases through the teenage years, crests at around age
20, and steadily decreases through the remaining years. This
pattern, with some exceptions, exists across all race, sex, and
ethnic groups. According to the report, persons age 50 or older
made up 30 percent of the population, 12 percent of murder
victims, and 7 percent of serious violent crime victims. Copies
of this report are available at no cost from the BJS
Clearinghouse at 1-800/732-3277 or online at www.ojp.usdoj.gov/
bjs/.
Indian Country Initiatives.--OJP's American Indian/Alaska
Native Desk is working to expand existing OJP efforts
concerning elder abuse to address problems in Indian Country.
It also is collaborating with the Indian Health Service at the
U.S. Department of Health and Human Services to explore
partnership efforts regarding elder abuse in tribal
communities.
Future Initiatives.--On March 30, 1998, BJA sponsored a
focus group on elder victims of crime to discuss issues and
plan strategies related to prevention, enforcement, and the
response of the criminal justice system and other institutions,
as well as to make recommendations to the Justice Department.
Participants included staff from the OJP components, the
Executive Office for U.S. Attorneys, the Department of
Justice's (DOJ) Criminal Division and other representatives of
the DOJ Working Group on Elder Victimization, representatives
from agencies in states with the highest senior citizen
populations, and national senior citizen organizations.
For More Information about OJP programs or activities on
behalf of older Americans, contact OJP's Office of
Congressional and Public Affairs at 202/307-0703 or access the
OJP home page at www.ojp.usdoj.gov. Funding information is
available from the Department of Justice Response Center at 1-
800/421-6770. OJP and other criminal and juvenile justice-
related publications are available from the National Criminal
Justice Reference Service by calling toll-free, 1-800/851-3420,
or online at www.ncjrs.org.
ITEM 10--DEPARTMENT OF LABOR
The welfare of our Nation's older citizens is a matter of
substantial concern to the Department of Labor. The Department
of Labor is pleased to provide this summary of the programs it
administers which can provide helpful assistance to older
citizens. These include--job training and related services,
dislocated worker services, and other employment services,
under programs administered by the Department of Labor's
Employment and Training Administration; a public information
and assistance program on matters relating to certain pension
and welfare plans under programs administered by the Pension
and Welfare Benefits Administration; the Bureau of Labor
Statistics' statistical programs providing employment and
unemployment data for older persons; protection for certain
employees to take unpaid, job-protected leave to provide care
for sick, elderly parents under a program administered by the
Employment Standards Administration; and a Clearinghouse
administered by the Women's Bureau which provides information
and resources to workers and employers interested in developing
or implementing family-friendly policies such as elder care and
child care. These programs and services are addressed more
fully in the following discussion.
EMPLOYMENT AND TRAINING ADMINISTRATION
introduction
The Department of Labor's (DOL's) Employment and Training
Administration (ETA) provided a variety of training, employment
and related services for the Nation's older individuals during
Program Years 1994 (July 1, 1994-June 30, 1995) and 1995 (July
1, 1995-June 30 1996) through the following programs and
activities: the Senior Community Service Employment Program
(SCSEP); programs authorized under the Job Training Partnership
Act (JTPA); and the Federal-State Employment Service system.
senior community service employment program
SCSEP, authorized by Title V of the Older Americans Act,
employs low-income persons age 55 or older in a wide variety of
part-time community service activities such as health care,
nutrition, home repair and weatherization, child care, and in
beautification, conservation, and restoration efforts. Program
participants work an average of 20 hours per week in schools,
hospitals, parks, community centers, and in other government
and private, non-profit facilities. Participants also receive
personal and job-related counseling, annual physical
examinations, job training, and in many cases, referral to
private sector jobs.
About 82 percent of the participants are age 60 or older,
and about 58 percent are age 65 or older. Almost three-fourths
are female; about 40 percent have not completed high school.
All participants are economically disadvantaged.
Table 1 below shows SCSEP enrollment and participant
characteristics for the program year July 1, 1994, to June 30,
1995, in Column 1 and July 1, 1995, to June 30, 1996, in Column
2.
TABLE 1.--SENIOR COMMUNITY SERVICE EMPLOYMENT PROGRAM (SCSEP): CURRENT
ENROLLMENT AND PARTICIPANT CHARACTERISTICS--PROGRAM YEARS JULY 1, 1994,
TO JUNE 30, 1995, (PY94) AND JULY 1, 1995, TO JUNE 30, 1996 (PY95).
------------------------------------------------------------------------
(PY94) (PY95
------------------------------------------------------------------------
Enrollment:
Authorized positions established.......... 67,645 64,600
Unsubsidized employment rate (Percent).... 27.7 25.7
Characteristics (Percent):
Sex:
Male.................................. 27.9 27.6
Female................................ 72.1 72.4
Educational status:
8th grade and less.................... 20.4 19.6
9th grade through 11th grade.......... 19.4 19.0
High School graduate or equivalent.... 38.1 38.8
1-3 years of college.................. 15.2 15.6
4 years of college or more............ 6.9 7.0
Veterans.................................. 13.0 13.4
Ethnic Groups: \1\
White................................. 59.4 59.4
Black................................. 24.3 24.6
Hispanic.............................. 10.1 10.0
American Indian/Alaskan Native........ 1.7 1.8
Asian/Pacific Island.................. 4.3 4.1
Economically disadvantaged................ 100.00 100.0
Poverty level or less..................... 80.7 85.4
Age groups:*
55-59................................. 18.9 17.2
60-64................................. 24.5 23.7
65-69................................. 24.4 24.8
70-74................................. 19.2 19.8
75 and over........................... 13.0 14.5
------------------------------------------------------------------------
\1\ Figures may not add to 100% due to rounding.
Source: U.S. Department of Labor, Employment and Training
Administration.
job training partnership act programs
The Job Training Partnership Act (JTPA) provides job
training and related assistance to economically disadvantaged
individuals, dislocated workers, and others who face
significant employment barriers. The ultimate goal of JTPA is
to move program participants into permanent, self-sustaining
employment. Under JTPA, Governors have the approval authority
over locally developed plans and are responsible for monitoring
local program compliance with the Act. JTPA functions through a
public/private partnership which plans, designs and delivers
training and other services. Private Industry Councils (PICs),
in partnership with local governments in each Service Delivery
Area (SDA), are responsible for providing guidance for and
oversight of job training activities in the area.
Amendments to JTPA became effective July 1, 1993. These
amendments target program services to those with serious skill
deficiencies; and individualize and intensify the quality of
services provided. Five percent of the funds appropriated for
the adult program (Title II-A) must be used by States in
partnership with SDAs for older workers. The amendments also
require Governors to ensure that services under the adult
program are provided to older workers on an equitable basis.
basic jtpa grants
Title II-A of JTPA authorizes a wide range of training
activities to prepare economically disadvantaged youth and
adults for employment. Training and training-related services
available to eligible older individuals through the basic Title
II-A grant program include vocational counseling, jobs skills
training (either in a classroom or on-the-job), literacy and
basic skill training, job search assistance, and job
development and placement. Table 2 below shows the number of
persons 55 years of age and over who terminated from the Title
II-A program during the period July 1, 1994, through June 30,
1995, and during the period July 1, 1995, through June 30,
1996. (The data do not include the 5 percent set-aside for
older individuals, which is discussed separately.)
TABLE 2--JTPA DATA JULY 1, 1994-JUNE 30, 1996
[Title II-A]
------------------------------------------------------------------------
Number Served
Item -------------------------- Percent
PY94 PY95
------------------------------------------------------------------------
Total Adult Terminees............ 237,470 224,458 100
55 years and over................ 3,831 3,485 2
------------------------------------------------------------------------
Source: U.S. Department of Labor, Employment and Training Administration
(April 1998 Data).
section 204 set-aside
The 1992 JTPA amendments require 5 percent of the Title II-
A allotment of each State to be made available for the training
and placement of older individuals in private sector jobs. Only
economically disadvantaged individuals who are 55 years of age
or older are eligible for services under this State set-aside.
Governors have wide discretion regarding use of the JTPA 5
percent set-aside. Two basic patterns have evolved. One is
adding set-aside resources to Title II-A to ensure that a
specific portion of older persons participates in the basic
Title II-A program. The other is using the resources to
establish specific projects targeted to older individuals which
operate independently of the basic job training program for
disadvantaged adults. Likewise, States are required to provide
``equitable services to older individuals throughout the State,
taking into consideration the incidence of such workers in the
population.'' Some States distribute all or part of the 5
percent set-aside by formula to local SDAs; other States retain
the resources for State administration or model programs.
Governors are expected to coordinate services as much as
possible with those provided under Title V of the Older
Americans Act--Senior Community Service Employment Program.
There are two separate provisions for older individual programs
as they relate to Title V of the Older Americans Act. First,
under the Title II-A program, up to ten percent of the
participants may be individuals who are not economically
disadvantaged, but who have a serious barrier to employment.
Second, when a JTPA grantee and Title V sponsor establish joint
projects, individuals eligible under Title V of the Older
Americans Act ``shall be deemed to satisfy the requirements''
of JTPA. These joint (JTPA-SCSEP) projects may include co-
enrollment of Title V participants in Title II-A activities.
Joint programs must have a written agreement, which may be
financial or nonfinancial in nature, and may include a broad
range of activities. For Program Year 1994 (July 1, 1994,
through June 30, 1995), 16,101 participants were enrolled in
the State set-aside program for economically disadvantaged
individuals 55 years of age and older. For Program Year 1995
(July 1, 1995, through June 30, 1996), 16,594 participants were
enrolled in the State set-aside program for economically
disadvantaged individuals 55 years of age and older.
programs for dislocated workers
Title III of JTPA authorizes a State and locally-
administered dislocated worker program that provides retraining
and readjustment assistance to workers who have been, or have
received notice that they are about to be, laid-off due to a
permanent closing of a plant or facility; laid off workers who
are unlikely to be able to return to their previous industry or
occupation; and the long-term unemployed with little prospect
for local employment or reemployment. Those older dislocated
workers eligible for the program may receive such services as
job search assistance, retraining, pre-layoff assistance and
relocation assistance. During the period July 1, 1994,through
June 30, 1995, approximately 28,257 individuals 55 years of age and
over exited the program (9 percent of the program terminations). During
the period July 1, 1995, through June 30, 1996, approximately 26,640
individuals 55 years of age and over left the program (10 percent of
the program terminations).
The Federal-State Employment Service System
The State-operated public employment service (ES) offices
offer employment assistance to all job seekers, including
middle-aged and older persons. A full range of basic labor
exchange services are provided, including counseling, testing,
job development, job search assistance and job placement. In
addition, labor market information and referral to relevant
training and employment programs are also available.
Federal reporting requirements for State employment service
agencies (SESAs) were revised effective July 1, 1992, to
capture additional information on applicant characteristics,
including data on the age of all ES applicants and those placed
in employment. During the period July 1, 1994 through June 30,
1995 over 1,219,000 ES applicants were age 55 and over.
Approximately 98,100 of the ES applicants age 55 and over were
placed in jobs during this period. During the period July 1,
1995 through June 30, 1996 over 1,191,000 ES applicants were
age 55 and over. Approximately 87,600 of the ES applicants age
55 and over were placed in jobs during this period.
Pension and Welfare Benefits Administration
Introduction
The Pension and Welfare Benefits Administration (PWBA) is
responsible for enforcing the Employee Retirement Income
Security Act (ERISA). PWBA's primary responsibilities are for
the reporting, disclosure and fiduciary provisions of the law.
Employee benefit plans maintained by employers and/or
unions generally must meet certain standards, set forth in
ERISA, designed to ensure that employees actually receive
promised benefits. Employee benefit plans exempt from ERISA
include church and Government plans.
The requirements of ERISA differ depending on whether the
benefit plan is a pension or a welfare plan. Pension plans
provide retirement benefits, and welfare plans provide a
variety of benefits, such as employment-based health insurance
and disability and death benefits. Both types of plans must
comply with provisions governing reporting and disclosure to
the Government and to participants (Title I, Part 1) and
fiduciary responsibility (Title I, Part 4). Pension plans must
comply with additional ERISA standards (contained in both Title
I, Parts 2 and 3, and Title II), which govern membership in a
plan (participation); nonforfeitability of a participant's
right to a benefit (vesting); and financing of benefits offered
under the plan (funding). Welfare plans providing medical care
must comply with ERISA continuation of coverage requirements
and medical child support orders (Title I, Part 6).
The Departments of Labor and Treasury have responsibility
for administering the provisions of Title I and Title II,
respectively, of ERISA. The Pension Benefit Guaranty
Corporation (PBGC) is responsible for administering Title IV,
which established an insurance program for certain benefits
provided by specified ERISA pension plans. On a regular basis,
PWBA meets and coordinates closely with the Internal Revenue
Service (IRS) and PBGC on matters concerning pension issues.
In FY 1996, PWBA worked to advance the Health Insurance
Portability and Accountability Act (P.L. 104-91), enacted
August 21, 1996, which amended ERISA to provide increased
access to health care benefits, to provide increased
portability of health care benefits, and to provide increased
security of health care benefits. The Newborns' and Mothers'
Health Protection Act and the Mental Health Parity Act, enacted
on September 26, 1996 (P.L. 104-204), added to ERISA mental
health parity provisions and provisions regarding minimum
mandatory hospital stays for newborns and mothers.
Implementation of these laws requires PWBA's continuing
attention.
PWBA also worked to advance the Administration's Retirement
Savings and Security Act. Many of its provisions were
incorporated in the Small Business Jobs Protection Act (P.L.
104-188) (SBJPA) enacted on August 20, 1996. The SBJPA created
a new simplified retirement plan for small businesses, and
simplified plan distribution and nondiscrimination rules.
Because of the risk of abuse or loss (e.g., from employer's
bankruptcy), many employees have raised questions about the
time period during which employers must transmit participant
contributions to employee benefit plans. To address their
concerns, PWBA issued a rule under Title I of ERISA which
substantially shortens the time period during which covered
private sector employers may hold employees' contributions to
pension plans, including 401(k) plans, before depositing the
funds in the plans. Under the new rule, for example, an
employer that sponsors a 401(k) plan must deposit its
employees' contributions in the plan as soon as the
contributions can reasonably be segregated from the employers'
general assets, but not later than 15 business days following
the month in which the employer withholds the money from
employees' paychecks, or receives employees' checks for the
amount of the contributions.
With the growth of participant-directed individual account
pension plans, more employees are directing the investment of
their pension plan assets and, thereby, assuming more
responsibility for ensuring the adequacy of their retirement
income. In order to help employers address the need of
participants for more investment information, PWBA issued an
interpretive bulletin providing guidance to plan sponsors,
fiduciaries, participants and beneficiaries concerning the
circumstances under which the provision of investment related
educational information, programs and materials to plan
participants and beneficiaries will not give rise to liability
under ERISA.
In fiscal year 1996, PWBA continued its program of research
directed toward improving the understanding of the employment-
based pension and health benefit systems. PWBA published
comprehensive data and statistics on the private retirement
income system and pension plan investments in its semiannual
``Private Pension Plan Bulletin.'' Another key component of the
research program was the project with the National Academy of
Sciences to improve retirement income modeling. Under PWBA's
small grants program, twelve new contracts were awarded and
products were received from thirteen previously awarded
projects. Studies completed included ``Does 401(k) Introduction
Affect Defined Benefit Plans?'' and ``Health Insurance Coverage
of Children of Working Parents.''
Inquiries
PWBA publishes literature and audio-visual materials which,
in some depth, explain provisions of ERISA, procedures for plan
to ensure compliance with the Act and the rights and
protections afforded participants and beneficiaries under the
law. In addition, PWBA maintains a public information and
assistance program, which responds to many inquiries from older
workers and retirees seeking assistance in collecting benefits
and obtaining information about ERISA. Among the publications
disseminated, the following are designed exclusively to assist
the public in understanding the law and how their pension and
health plans operate: Top Ten Ways to Beat the Clock and
Prepare for Retirement; Women and Pensions--What Women Need to
Know and Do; What You Should Know About Your Pension Rights;
Protect Your Pension--A Quick Reference Guide; How to File a
Claim for Your Benefits; How to Obtain ERISA Plan Documents
from the Department of Labor; Handling Inquiries on Pension and
Welfare Benefits; Guide to Summary Plan Description
Requirements; Reporting and Disclosure Guide for Employee
Benefit Plans; Trouble Shooter's Guide to Filing the ERISA
Annual Report; Exemption Procedures under Federal Pension Law;
Health Benefits under COBRA; Multiple Employer Welfare
Arrangements under ERISA (MEWAs); Customer Service Standards--
Our Commitment to Quality; How Did We Measure Up.
Bureau of Labor Statistics
The Department of Labor's Bureau of Labor Statistics (BLS)
regularly issues a wide variety of statistics on employment and
unemployment, prices and consumer expenditures, compensation
including wages and benefits, productivity, economic growth,
and occupational safety and health. Data on the labor force
status of the population, by age, are prepared and issued on a
monthly basis. Data on consumer expenditures, classified by age
groupings, are published annually. In 1994 BLS published the
first results of the redesigned survey of occupational injuries
and illnesses; these data are now available by age, race, and
gender, providing important new information on this aspect of
the labor market experiences of older Americans. In addition to
regularly recurring statistical series, BLS undertakes special
studies as resources permit. In May 1994 BLS published a report
on an experimental series that reweighted the official Consumer
Price Index using expenditure data for older Americans. This
report updated a portion of a study originally performed by BLS
in response to the Older Americans Act Amendments of 1987. BLS
continues to compute the reweighted index each month.
The Women's Bureau Clearinghouse
Established by the Women's Bureau of the U.S. Department of
Labor in 1989, the Clearinghouse is a computerized database and
resource center responsive to dependent care and women's
workplace issues. Services help employers and employees make
informed decisions about which programs and services help in
balancing work and family. The Clearinghouse offers information
in five broad option areas for child care and elder care
services: direct services, information services, financial
assistance, flexible leave policies, and public-private
partnerships. The workforce quality component of the
Clearinghouse offers information and guidance on the rights of
women workers such as age, wage discrimination, the Family and
Medical Leave Act (FMLA), pregnancy discrimination, and sexual
harassment and the agencies that enforce them. Within each of
these areas customers can be provided with model programs from
other companies, implementation guides, national and State
information sources and bibliographic references.
The Clearinghouse continues to receive requests for
information on work-site elder care program options.
Information provided included flexible work schedules, adult
day care, case management, decision making, information and
referral, respite care, and transportation services.
The Clearinghouse can be accessed through 1-800-827-5335.
Employment Standards Administration
The Family and Medical Leave Act of 1993 became effective
on August 5, 1993, for many employers. This statute provides
potential benefit to the elderly in that it empowers eligible
employees of covered employers to take up to 12 weeks of
unpaid, job-protected leave in any 12-month period to provide
care for a parent who has a serious health condition. In the
past, the employee had to make a decision in many instances of
whether or not to give up their job to provide care to a sick,
elderly parent.
ITEM 11--DEPARTMENT OF STATE
The Department is pleased to report that we continue to
expand services for aging Americans. Not only are employees
working longer (the mandatory retirement age for Foreign
Service is 65, and there is no mandatory retirement age for
Civil Service), but employee responsibilities for caring for
aging family members have grown significantly. In recognition
of this, in 1995 the Office of Medical Services, Education and
Wellness Programs, conducted a panel discussion on a variety of
topics focused on older persons. That office hosted a health
fair and offered several medical tests aimed at identifying
diseases found primarily in older persons, such as prostate,
cholesterol, and blood pressure screenings. The Office of
Medical Services also hosted a panel of experts from the
Washington metropolitan area to describe long-term care
programs in local jurisdictions. Seminars were offered on
Alzheimer's disease, living wills, osteoporosis and menopause.
The Office of Employee Consultation Services, staffed by
licensed clinical social workers, arranged support groups and
special presentations on topics such as caring for elderly
parents and dementia.
The Office of Work and Family Programs in the Bureau of
Personnel was established in 1995 as a focal point for work and
family programs. This office assists employees with questions
on locating elder care services and recently hosted a monthly
series of noontime sessions on family related topics, including
elder care. The Work and Family Program Coordinator represented
the Department on the Office of Personnel Management's
Interagency Working Group on Adult Dependent Care.
In support of the Foreign Service's employees based
overseas, the family Liaison Office continued to provide
Foreign Service families with oral and written information on
caring for elderly parents, medical insurance, and procedures
for taking an elderly relative to overseas posts. In addition,
they make referrals, upon request for information on payment
options for long-term care and legal issues.
In 1996, the Department's Work and Family Programs office
expanded its outreach efforts. They held seminars for
grandparents who are primary caretakers for their grandchildren
and repeated their most popular seminar topics, i.e. caring for
aging parents and the diseases most common in the elderly. In
addition, the Office of Employee Consultation Services hired an
additional clinical social worker who had a specialty in
geriatrics.
Thank you for your continuing interest in this issue. The
Department continues to identify ways to adapt or expand our
current elder care services to help employees balance their
work and family responsibilities.
ITEM 12--DEPARTMENT OF TRANSPORTATION
----------
SUMMARY OF ACTIVITIES TO IMPROVE TRANSPORTATION SERVICES FOR THE
ELDERLY \1\
Introduction
The following is a summary of significant actions taken by
the U.S. Department of Transportation during calendar years
1995 and 1996 to improve transportation for elderly persons.\2\
---------------------------------------------------------------------------
\1\ ``Prepared for the U.S. Senate Special Committee on Aging--
February 1998.
\2\ Many of the activities highlighted in this report are directed
toward the needs of persons with disabilities. However, one-third of
the elderly are persons with disabilities and thus will be major
beneficiaries of these activities.
---------------------------------------------------------------------------
Direct Assistance
federal railroad administration (fra)
The National Railroad Passenger Corporation (Amtrak)
continued throughout calendar years 1995 and 1996 to provide
discounted fares, accessible accommodations, and special
services, including assistance in arranging travel for disabled
and elderly passengers. These passengers continue to represent
a substantial part of Amtrak's ridership--in recent years, 28
percent of long-distance passengers were 62 or older.
Discounted Fares.--Amtrak has a systemwide policy of
offering to elderly persons and persons with disabilities a 15
percent discount on one-way ticket purchases. This 15 percent
discount cannot be combined with any other discounts.
Accessible Accommodations.--Amtrak provides accommodations
that are accessible to elderly persons and passengers with
disabilities, including those using wheelchairs, on all of its
trains. Long-distance trains include accessible sleeping rooms.
Short-distance trains, including Northeast Corridor trains,
have accessible seating and bathrooms. Many existing cars are
being modified to provide more accessible accommodations and
all new cars will provide enhanced accessibility for passengers
with mobility and other types of disabilities.
Mechanical lifts operated by train or station staff provide
passengers with access to single-level trains from stations
with low platforms and short plate ramps provide access to bi-
level equipment. An increasing number of Amtrak stations are
fully accessible, particularly key intermodal stations that
provide access to commuter trains and other forms of
transportation.
Special On-Board Services.--Amtrak continues to provide
special on-board services to elderly persons and passengers
with disabilities, including aid in boarding and deboarding,
special food service, special equipment handling, and
provisions for wheelchairs. Amtrak has also improved training
of its employees to enable them to respond better to passengers
with special needs. It is recommended that passengers advise
Amtrak of any special needs they may have in advance of their
date of departure.
Assistance in Making Travel Arrangements.--Persons may
request special services by contacting the reservations office
at 1-800-USA-Rail. This office is equipped with text telephone
(TTY) service for customers who are deaf or hard of hearing. To
ensure that passengers receive the assistance they need, Amtrak
maintains a Special Services Desk which supports its
reservations agents seven days a week. This desk has completed
successful responses to nearly 100,000 requests for special
services. Passengers may also inform their travel agent or the
station ticket agent of their assistance requirements when
making travel reservations.
federal transit administration (fta)
Under 49 USC 5310, the FTA provides assistance to private
non-profit organizations and certain public bodies for the
provision of transportation services for the elderly and
persons with disabilities. In FY 1995, $57.7 million was used
to assist 1,371 local providers purchase 1,783 vehicles, and in
FY 1996, $52 million was used to assist 1,260 local providers
purchase 1,562 vehicles for the provision of transportation
services for the elderly and individuals with disabilities.
Most of the agencies funded under this program are either
disability service organizations or elderly service
organizations, and service provided under the program is nearly
equally divided between the two. Those agencies serving the
elderly are, however, more dependent on funding from the
elderly and persons with disabilities program as 53 percent of
their vehicles are purchased with Section 5310 funds compared
to 42 percent of vehicles purchased by agencies serving the
disabled. Vehicles purchased with these funds may also be used
for meal delivery to the homebound as long as such use does not
interfere with the primary purpose of the vehicles.
Under 49 USC 5311, the FTA obligated $169.4 million in FY
1995 and $137.6 million in FY 1996. These funds were used for
capital, operating, and administrative expenditures by state
and local agencies, nonprofit organizations, and operators of
transportation systems to provide public transportation
services in rural and small urban areas (under 50,000
population). The nonurbanized area program funds are also used for
intercity bus service to link these areas to larger urban areas and
other modes of transportation. An estimated 36 percent of the ridership
in nonurbanized systems is elderly which represents nearly three times
their proportion of the rural population.
Under 49 USC 5307, the FTA obligated $3.2 billion in FY
1995 and $2.4 billion in FY 1996. These funds were used for
capital and operating expenditures by transit agencies to
provide public transportation services in urbanized areas.
while these services must be open to the general public, a
significant number of passengers served are elderly.
Under the Transportation Cooperative Research Program, FTA
provided funding in 1996 to assist the Southern Maine Area
Agency on Aging to develop and implement an operational
demonstration of the Independent Transportation Network (ITN)
in Portland, Maine. The ITN is a nonprofit, membership based
transportation service for seniors that uses cars along with
both paid and volunteer drivers to pick up seniors in and
around Portland and take them where they need to go. The goal
of the ITN is to become a financially self-sufficient
transportation program specifically designed to provide
transportation services for the elderly who own their own
vehicles but, because of diminished capacity, no longer want to
drive themselves or can no longer safely drive their own
automobiles. The ITN uses demand responsive automobiles to
match the convenience of private cars. It offers payment
options ranging from cash or transportation credits earned from
trading in unused vehicles to payment into an individual ITN
account from the elderly users or their children.
The National Easter Seal Society's Project ACTION
(Accessible Community Transportation in Our Nation) is a $2
million a year research and demonstration grant program.
National and local organizations representing public transit
operators, the transit industry, and persons with disabilities
are involved with the development and demonstration of workable
approaches to promote access to public transportation services
for persons with disabilities. A significant proportion of the
population of persons with disabilities are elderly and, as a
result, will benefit from this project. Project ACTION also
assists in the implementation of the Americans with
Disabilities Act by identifying and addressing training needs
related to accessibility in transportation. Project ACTION has
also targeted other model projects to be refined and replicated
throughout the country.
Research
federal aviation administration (faa)
The Office of Aviation Medicine's Civil Aeromedical
Institute has contributed to the following research related to
the needs and concerns of the aging population in aviation
transportation.
Cognitive Function Test.--An automated cognitive function
test (CogScreen) was developed to permit the more sensitive and
specific evaluation of pilots after brain injury and disease.
Administration of CogScreen to groups of pilots led to the
establishment of a data base that could be used to assess
fitness to perform flying duties in relation to the age of the
subject being evaluated. A report describing age-related
changes in CogScreen performance is under review.
federal highway administration (fhwa)
Beginning in 1989, a High Priority Area for research was
established to address the needs of older drivers with respect
to the roadway environment. Research under this program started
as problem identification, and quickly moved to focus on the
specific areas which cause the greatest problems for older
drivers and pedestrians. The studies described below were
ongoing during the calendar years 1995 and 1996. It should be
noted that all human factors research, including Intelligent
Transportation Systems initiatives, conducted by FHWA includes
an older driver component to ensure the system's utility for
all potential users.
Pavement Markings and Delineation for Older Drivers used
simulation and field techniques to investigate the use of
improved pavement marking and delineation systems to enhance
their value for older drivers. Findings showed that delineation
treatments that included both an edge line and an off-road
element (post-mounted delineators, chevron signs) have the best
recognition distance for both younger and older drivers. Better
recognition distances mean that the driver has more time to
preview the road ahead and to plan steering maneuvers.
Human Factors Study of Traffic Control in Construction and
Maintenance Zones is using laboratory and field studies to
evaluate the entire traffic control system, including Traffic
Control Devices (TCD) placement and layout, and operational
aspects, in construction zones. Specific problems which older
drivers encounter will be addressed, and countermeasures will
be developed and tested.
Intersection Geometric Design for Older Drivers and
Pedestrians investigated specific problems that older drivers
and pedestrians have in negotiating intersections. For example,
channelized right turns can add to the distance which
pedestrians have to cross, and because older pedestrians have
slower walking speeds, they may be put at greater risk. One
critical finding of this research was with respect to left turn
operations. The research suggests that if the right-of-way is
available, left turn lanes should be offset to the left, such
that drivers trying to turn may have unrestricted sight
distance in viewing oncoming traffic.
Investigation of Older Driver Freeway Needs and
Capabilities was a preliminary research study investigating the
problems older drivers have with freeways. Prior to this study,
it had often been assumed that older drivers avoided freeways;
however, it was found that they generally do not avoid them.
Problems identified for future older driver research included
navigation and way-finding, freeway merging and transition
areas, visual acuity and contrast sensitivity, and lane-
changing behavior.
Delineation of Hazards for Older Drivers evaluated object
markers for comprehension, conspicuity, and recognizability
under day and night conditions, both in laboratory and field
testing. It was found that all drivers tend to notice the
object being marked (e.g., tree, bridge abutment) rather than
the marker. None of the existing or experimental object markers
from this study was consistently noticed by subjects. Future
research will address this problem.
Computer-Aided Optimization and Evaluation of Candidate
Manual on Uniform Traffic Control Devices (MUTCD) Signs was a
laboratory study of recognition distance and comprehension of
13 novel or redesigned symbol signs, including lane reduction
transition, tractor crossing, and number of railroad tracks.
The results were used by the Office of Highway Safety in
selecting the best new or redesigned signs to be included in
the revised MUTCD.
Improved Traffic Control Device Design and Placement to Aid
the Older Driver is a field study which investigated issues
related to the design and placement of signs to aid older
drivers in terms of detection, comprehension, recognition
distances and response times. This study is being conducted
under the auspices of the National Cooperative Highway Research
Program (NCHRP).
Uniform Traffic Signal Displays for Protected/Permissive
Left Turn Control investigated problems with left turn control,
particularly with the variety of signs currently in use.
Problems looked at included the ``yellow trap'' and driver
confusion. This study was the first phase of an NCHRP study.
The second phase will include experimental treatments to
address specific problems.
Effect of Advanced Traveler Information Systems (ATIS)
Display Views and Age on Intersection Recognition investigated,
in a laboratory setting, the performance of younger and older
drivers in terms of speed and accuracy in using different types
of in-vehicle displays. Older drivers were slower than younger
drivers; however, the real differences in times were small.
Researchers found that older drivers using Head Up Displays
(HUDs), small windshield projected displays that present
information closer to the driver's line of sight than
instrument panel displays, performed better than those using
displays mounted next to the steering wheel, indicating the
potential benefit of HUDs for navigational assistance.
national highway traffic administration (nhtsa)
Vehicle Design for Crash Avoidance.--NHTSA's crash
avoidance research program addresses the relationship between
vehicle design and driver performance and behavior. New vehicle
technologies could help reduce older driver crashes and enhance
their mobility. For example, in-vehicle navigation systems may
allow drivers to concentrate on watching for dangerous traffic
conflicts instead of being distracted while searching for road
signs. Collision avoidance systems may alert drivers to
potential crash situations. Additional research in this area
could provide useful information regarding the acceptability of
technology-based innovations designed to help older,
functionally less able people continue to drive. The focus is
to determine how the design and function of vehicle systems
need to be adapted to the unique capabilities and needs of
older drivers.
Research was initiated to develop human factors guidelines
for consideration in developing a warning display for back up
collision warning systems. These systems sense the presence and
distance of objects behind vehicles and warn drivers through
various types of visual displays and auditory signals. Older
drivers often express difficulties when backing due in part to
restricted head movements, as well as poor vehicle visibility
to the rear. This ongoing research will help to assure that
warning information will be presented to drivers in an
understandable and timely format.
Occupant Protection.--One of the most significant reasons
for elderly drivers over-involvement in fatal crashes is the
inability of their bodies to absorb crash forces. What would be
a survivable crash for a younger person is often a fatal crash
for an older person. Current occupant-protection standards do
not specifically address the frailty of older occupants. More
information is needed to establish the feasibility of improving
the protection of older people when they are in a crash.
At people age, their vulnerability to injuries and fatality
increases dramatically. NHTSA is continuing two major
activities begun in 1993 that will better understand and
increase the survivability of older vehicle occupants who are
involved in a crash. Work is continuing under a grant awarded
to the William Lehman Injury Research Center at the Ryder
Trauma Center, Jackson Memorial Hospital in Miami, Florida.
This will develop an Automobile Trauma Care and Research
Facility, and establish an information system that will advance
both the delivery of trauma care and the detailed data for
research on automobile injuries, treatments, outcomes, and
costs. The availability of an older population of automobile
injury victims in the Miami area is providing information on
the prevention of restrained occupant injuries that will be of
increasing national importance as the population ages and the
use of occupant restraints (air bags and automatic and manual
belts) grows.
NHTSA is also continuing research with the Transportation
Systems Center using computer simulation and experimental work
to improve belt/air bag systems for vehicle occupants.
Particular attention is being paid to possible approaches to
improving alternate restraint designs or requirements for
elderly vehicle occupants. It is expected that this work will
be of particular value to older vehicle occupants and to women
who, due to their more fragile bone structure, can benefit most
from improved belt/air bag designs.
In addition, NHTSA's new side impact standard provides a
higher level of protection to older occupants in vehicles
meeting the standard. The new standard is based on a dynamic
crash test which incorporated age effects for the first time
and, thus, will provide better protection to older vehicle
occupants. Manufacturers are required to apply the standard to
100 percent of care manufactured after September 1, 1996.
Pedestrian Safety Issues.--Older pedestrians, 65 and over,
account for a smaller proportion (7.7 percent) of all
pedestrian crashes than would be expected by their numbers in
the population (12.8 percent). However, they account for almost
one-quarter (22.4 percent) of all pedestrian fatalities. In
response to this problem, NHTSA and FHWA are continuing work
aimed at preventing crashes involving older pedestrians. A
joint research initiative is ongoing in Phoenix and Chicago,
and involves a demonstration program of behavioral safety
information [public information and education materials]
combined with traffic engineering applications [installing
overhead and signal information signs, etc.] in selected zones
of the cities that have been shown to have a high incidence of
older pedestrian crashes. An impact evaluation is planned in
Phoenix.
Safe Driving Assessment.--The majority of older drivers do
not constitute a major safety problem. Research has indicated
that most older drivers adjust their driving practices to
compensate for declining capabilities. They reduce or stop
driving after dark or in bad weather and avoid rush hours, and
unfamiliar routes. Men appear to be somewhat more reluctant
than women to stop driving and consequently are at a higher
risk of crashing than women of comparable age. Conditions such
as memory loss, glaucoma, and antidepressant use appear to be
related to increased crash risk.
Some older persons are not aware of their changing
conditions; most notably, those with cognitive disorders, such
as Alzheimer's disease, and certain visual problems. These
drivers may not self regulate and, as a result, pose an
increased risk of crash involvement. Such individuals may
require outside intervention to remove them from traffic.
Unfortunately, research suggests that most family members,
social service agencies, and health care professionals are
either not sufficiently aware or choose not to provide
assistance in making driving related decisions to those who
need it. For a variety of reasons, many appear hesitant to get
involved with this issue.
Those elderly drivers who remain a problem are not easily
detected with standard licensing procedures. Further, there is
some doubt as to whether most licensing staff have the skills
necessary to detect these problem drivers, even with training
and state-of-the-art testing techniques. Diagnostic tests
currently in use have not been shown to be effective in
identifying those older drivers who are at increased crash
risk, but some recently developed tests of ``speed of
attention'' and ``visual perception'' may have such potential.
Several long-term efforts are not approaching conclusion.
These developmental projects include: (1) procedures to help
elderly drivers make better decisions about adapting their
driving to accommodate their changing abilities are being
developed in ajoint project with the Federal Highway
Administration and the Commonwealth of Pennsylvania; (2) procedures for
family members, friends, social service agencies, physicians, and other
health care providers to recognize when an older person needs to adjust
his or her driving to adapt to functional limitations; (3) model
screening and assessment procedures to aid driver licensing agencies
deal with those who do not appropriately restrict their driving; and
(4) model programs for medical and social service agencies to help
older people to make appropriate decisions about driving while
maintaining their mobility. Current efforts also include a survey to
determine societal perceptions and willingness to assist older drivers
to better regulate their driving.
Mobility Issues.--One factor that must be considered with
regard to interventions is the fact that elderly people who
give up driving often lose mobility. For many, the automobile
is their primary mode of transportation and acceptable
alternatives are simply not available. Decreased mobility is
frequently followed by decreased quality of life as elderly
people are cut off from the social events, family visits,
medical attention, and opportunities for worship that are
critical in maintaining their sense of well being. These issues
are being studied in a joint project with the Department of
Health and Human Services and in a separate project with the
Federal Transit Administration.
RESEARCH AND SPECIAL PROGRAMS ADMINISTRATION (RSPA)
RSPA played a key role in initiating an effort to develop a
Transportation Science and Technology Strategy for the Federal
Government. Staff activities in late 1996 identified
Accessibility for Aging and Transportation-Disadvantaged
Populations as one of twelve topics warranting partnership
initiatives between Federal agencies and the transportation
community. (The Strategy was subsequently released in November
1997, and development of implementation plans is continuing.)
Information Dissemination
OFFICE OF THE SECRETARY OF TRANSPORTATION (OST)
Improving Transportation for a Maturing Society discusses
the impact of postponing retirement, longer productive lives
and the growing segment of older operators will have on the
Nation's impact the transportation system. It is also available
through the Internet.
FEDERAL RAILROAD ADMINISTRATION (FRA)
Information about Amtrak accessibility is available to
senior citizens and passengers with disabilities in a brochure
entitled ``Access Amtrak'' which can be obtained by calling 1-
800-USA-RAIL. Amtrak also works directly with a number of
organizations each year on moving groups of passengers needing
assistance and traveling together.
FEDERAL HIGHWAY ADMINISTRATION (FHWA)
Synthesis of Research Findings on Older Drivers gathered
all available research and synthesized it into a report of the
major replicable findings regarding older drivers. This
research was then incorporated into an Older Driver Highway
Design Handbook which became available in January 1998. The
handbook will serve as an important resource for traffic
engineers in assuring that highways meet the needs and
capabilities of older drivers and pedestrians.
NATIONAL HIGHWAY TRAFFIC SAFETY ADMINISTRATION (NHTSA)
A Pedestrian and Bicyclist Safety and Accommodations
course, funded by NHTSA and FHWA, was completed. This course
was designed to address the pedestrian and bicyclist traffic
safety needs of highway safety specialists, police, traffic
engineers, and other professionals. A resource guide was
prepared which provides information about traffic safety
problems and ways to avoid them for all pedestrians, including
older pedestrians. Also, as a countermeasure to the hazards
that older Hispanic pedestrians face, materials are being
prepared for Hispanic senior citizens. These materials include
a report, slide show, a presenters guide, brochure, and a video
``novela.''
RESEARCH AND SPECIAL PROGRAMS ADMINISTRATION (RSPA)
RSPA's Technology Sharing Program has continued the
distribution of technical materials responding to needs and
priorities identified by state and local officials. Key
products published and distributed during 1995 and 1996
relating to the provision of transportation for special users
include the following:
Access for Persons with Disabilities to Passenger Vessels
and Shore Facilities: The Impact of the Americans with
Disabilities Act of 1990 (July 1996, DOT-T-96-20) describes
approaches to making marine passenger vessels and dockside
facilities accessible to the disabled, including the elderly.
It was developed for the Office of the Assistant Secretary for
Transportation Policy and distributed in cooperation with them.
The Effects of Age on the Driving Habits of the Elderly:
Evidence from the 1990 National Personal Transportation Study
(October 1994, DOT-T-95-12) focuses on safety-related changes
in the behavior of elderly (post-65) drivers. Six aspects are
considered: the amount of daily driving exposure, driving by
time of day, driving speed, driving by type of roadway, vehicle
size, and number of passengers carried.
Operational Strategies for Rural Transportation (March
1996, DOT-T-97-01) explores the potential of advanced
electronics for improving transit services to rural patrons,
particularly the elderly. It emphasizes trip request and
billing processes for the bus service provided.
Operator Performance Measurement: Developing Commonality
Across Transportation Modes--Proceedings of a September 1994
Workshop (November 1996, DOT-VNTSC-RSPA-95-2) describes
techniques to determine and assure the performance of vehicle
operators, including elderly persons, and to thereby assure
system safety.
Planning Intermodal and Operations Facilities for Rural and
Small Urban Transit Systems: Workshop Manual (October 1995,
DOT-T-96-08) describes how to develop transportation intermodal
terminals to suit the scale and conditions of rural and small
urban areas.
ITEM 13--DEPARTMENT OF THE TREASURY
----------
TREASURY ACTIVITIES IN 1995-96 AFFECTING OLDER AMERICANS
The Treasury Department recognizes the importance and the
special concerns of older Americans.
social security trust funds
The Secretary of the Treasury is Managing Trustee of the
Social Security trust funds. The short- and long-run financial
status of these trust funds is presented in annual reports
issued by the Trustees. The April 1997 report, covering
calendar year 1996, estimated that combined Old Age and
Survivors Insurance and Disability Insurance (OASDI) benefits
can be paid on time for about the next 31 years. The OASDI
cost-of-living increase was 2.6 percent in 1995 and 2.9 percent
in 1996. The taxable base for OASDI was increased to $61,200
for 1995 and to $62,700 for 1996. The amount a 65- to 69-year-
old beneficiary could earn before OASDI benefits were reduced
was $11,280 in 1995; in 1996 it was $12,500.
medicare trust funds
The Secretary of the Treasury is also Managing Trustee of
the Federal Hospital Insurance (HI) and Supplementary Medical
Insurance (SMI) trust funds. In their April 1997 report,
covering calendar year 1996, the Trustees estimated that the HI
trust fund would be exhausted in 2001.
personal income tax
Each year, pursuant to statute, the width of the income tax
brackets and personal exemption and standard deduction amounts
are increased to reflect the effects of inflation during the
preceding year.
The personal exemption allowed for each taxpayer and
dependent increased from $2,450 in 1994 to $2,500 in 1995, and
to $2,550 in 1996.
Taxpayers aged 65 or over (and taxpayers who are blind) are
entitled to larger standard deductions than other taxpayers.
Each single taxpayer who is at least 65 years old was entitled
to an extra $950 standard deduction in 1994 and 1995, and
$1,000 in 1996. Each married taxpayer aged 65 or over was
entitled to an extra standard deduction of $750 in 1994 and
1995, and $800 in 1996. Thus, a married couple, both of whom
were over age 65, was entitled to extra standard deduction
amounts of $1,500 in 1994 and 1995, and $1,600 in 1996.
Including the extra standard deduction amounts and the basic
standard deduction amounts, taxpayers over age 65 were entitled
to the following standard deductions for tax years 1994 through
1996:
------------------------------------------------------------------------
Filing status 1994 1995 1996
------------------------------------------------------------------------
Single................................. $4,750 $4,850 $5,000
Unmarried head of household............ 6,550 6,700 6,900
Married filing jointly:
One spouse age 65 or older......... 7,100 7,300 7,500
Both spouses age 65 or older....... 7,850 8,050 8,300
------------------------------------------------------------------------
The tax credit for the elderly (and permanently disabled)
was retained throughout the period.
The 15 percent excise tax on excess accumulations in, and
distributions from, the aggregate amount of qualified
retirement plans, tax-sheltered annuities, and IRAs was
eliminated, effective in 1997. The separate limits on
contributions and benefits applicable to each type of
retirement saving vehicle remain.
Two provisions of the Health Insurance Portability and
Accountability Act of 1996 (HIPA) are particularly relevant to
the aged. Both provisions became effective for tax year 1997.
Qualified long-term care insurance premiums and the
unreimbursed expenses for the care of a chronically ill
individual may be deductible, but only as part of the itemized
deduction for medical expenses. Employer-paid long-term care
premiums are excludable from the employee's income subject to
taxation. Long-term care premiums paid by self-employed workers
are partially deductible in the calculation of adjusted gross
income to the same extent as other health insurance premiums.
HIPA also provides that accelerated death benefits received
under a life insurance contract or from a viatical settlement
provider are generally excluded from income subject to tax.
Internal Revenue Service
The Internal Revenue Service (IRS) recognizes the
importance and special concerns of older Americans, a group
that will comprise an increasing proportion of the population
in the years ahead. Major programs and initiatives of the
Office of the Assistant Commission (Taxpayer Services) and the
Office of Strategic Planning and Communications that are of
interest to older Americans and to others are described below.
The following publications, revised on an annual basis, are
directed to older Americans:
Publication 524, Credit for the Elderly or the
Disabled, explains that individuals 65 and older may be
able to take the Credit for the Elderly or Disabled,
reducing taxes owed. In addition, individuals under 65
who retire with a permanent and total disability and
receive taxable disability income from a public or
private employer because of that disability may be
eligible for the credit.
Publication 554, Older Americans' Tax Guide, explains
the income conditions under which single taxpayers aged
65 or older, and married taxpayers filing jointly if at
least one of the spouses is 65 or older, are generally
not required to file a Federal income tax return. The
publication also advises older taxpayers about possible
eligibility for the earned income credit. The taxpayer
may be eligible for a credit based on the number of
qualifying children in the home or a smaller credit if
the taxpayer has no qualifying children.
Publication 721, Tax Guide to U.S. Civil Service
Retirement Benefits, and Publication 575, Pension and
Annuity Income, provide information on the tax
treatment of retirement income.
Publication 907, Tax Highlights for Persons with
Disabilities is a guide to issues of particular
interest to persons with handicaps or disabilities and
to taxpayers with disabled dependents.
Publication 915, Social Security Benefits and
Equivalent Railroad Retirement Benefits, assists
taxpayers in determining the taxability, if any, of
benefits received from Social Security and Tier I
Railroad Retirement.
All publications are available free of charge. They can be
obtained by using the order forms found in the tax forms
packages or by calling 1-800-TAX-FORM (1-800-829-3676.) Many
libraries, banks, and post offices stock the most frequently
requested forms, schedules, instructions and publications for
taxpayers to pick up. Also, many libraries stock a reference
set of IRS publications and a set of reproducible tax forms.
Most forms and some publications are on CD-ROM, available
in some larger libraries, and are on sale to the general public
through the Government Printing Office's Superintendent of
Documents. Information about ordering can be obtained by
calling (202) 512-1800. Over 100 forms and instructions and
about 150 tax topics are available by fax by calling 703-363-
9694.
Taxpayers may obtain most forms, instructions, publications
and other products via the IRS's Internet Web Site at
www.irs.ustreas.gov. They can also reach IRS using:
Telnet at iris.irs.ustreas.gov
File Transfer Protocol at ftp.irs.ustreas.gov
Direct Dial (by modem) at 703-321-2020, IRIS, the on-
line information service
The 1990 tax year was the first year older Americans could
use the expanded Form 1040A to report income from pensions and
annuities, as well as other items applicable to older
Americans, such as estimated tax payments and the credit for
the elderly or the disabled. More than half of the potential
filing population eligible to use this simpler, shorter form
made the switch from the much longer Form 1040.
Responding to requests from the public for such a product,
the Tax Forms and Publications Division developed large-print
versions of the Form 1040 and Form 1040A packages earmarked for
older Americans. These packages (designated as Publications
1614 and 1615, respectively) are newspaper-size and contain
both the instructions and the forms (for use only as
worksheets, with the amounts to be transferred to regular-size
forms for filing).
IRS volunteer & outreach programs
The Volunteer Income Tax Assistance (VITA) Program offers
FREE tax help to people who cannot afford paid professional
assistance. Volunteers help prepare basic tax returns for
taxpayers with special needs, including persons with
disabilities, non-English speaking persons, those with low
income, and elderly taxpayers. Assistance is provided at
community and neighborhood centers, libraries, schools,
shopping malls and other convenient locations across the
nation. Volunteers generally include college students, law
students, members of professional, business and accounting
organizations, and members of retirement, religious, military
and community groups.
In 1995, over 46,000 volunteers assisted over 1.7 million
taxpayers at nearly 8,100 sites across the nation through the
VITA Program. In 1996, over 47,000 volunteers assisted over 1.8
million taxpayers at 8,300 sites across the nation through the
VITA Program.
Banks, Post Offices, and Library (BPOL) Programs
During 1995 and 1996, the Banks, Post Offices and Library
Program (BPOL) provided approximately 46,500 libraries, banks,
post offices, and other sites with free tax preparation
materials such as tax forms and publications that can assist
older Americans in preparing Forms 1040, 1040A, 1040EZ, and
related schedules. IRS provided volunteers in some libraries to
answer tax questions and direct taxpayers to the correct tax
forms.
Small Business Tax Education Program (STEP)
The Small Business Tax Education Program (STEP) provides
information about business taxes and the responsibilities of
operating a small business. During 1995 and 1996, small
business owners and other self-employed persons had an
opportunity to learn what they needed to know about business
taxes through a partnership between IRS and approximately 2,000
community colleges, universities, and business associations.
Assistance was offered at convenient community locations and
times. Many elderly persons, such as those beginning second
careers, availed themselves of this program.
Community Outreach Tax Education Program
The Community Outreach Tax Education Program provides
individuals with group income tax return preparation assistance
and tax education seminars. IRS employees and trained
volunteers conduct these seminars which address a variety of
topics. They are tailored for groups and individuals with
common tax interest, such as groups of older Americans. These
seminars are conducted at convenient community locations.
In 1995, over 1,400 volunteers assisted over 660,000
taxpayers in over 7,200 sessions across the nation through this
program. In 1996, almost 500 volunteers assisted over 421,000
taxpayers in over 5,000 sessions. In addition, the IRS
coordinated outreach activities with the Center for Budget and
Policy Priorities that led to grassroots EITC and AEITC
information campaigns by state and local social advocacy groups
throughout the nation.
Tax Counseling for the Elderly (TCE) Program
The Tax Counseling Program was first authorized by Congress
in 1978 as part of the Revenue Act of 1978. The Revenue Act
authorizes an appropriation of special funds, in the form of
grants, to provide free income tax assistance to individuals 60
years of age or older. TCE sponsors recruit volunteers that are
trained by the Service to provide income tax assistance to
older individuals. TCE volunteer sites can be found in
retirement homes, neighborhood sites, and shopping malls.
Volunteers also travel to the private residences of the
homebound. In 1996, 33,000 volunteers assisted 1.6 million
taxpayers at nearly 11,000 sites.
Financial Management Service
The Financial Management Service (FMS) makes 700 million
Social Security, Supplemental Security Income, and Veterans
benefit payments annually. Working under the mandate of the
Debt Collection Improvement Act (DCIA) signed by President
Clinton on April 26, 1996, Federal departments and agencies are
on the fast track to convert all Federal payments to electronic
funds transfer (EFT) by January 1999. EFT significantly
improves the certainty of the payments reaching the intended
recipients on a timely basis, and improves the ability of
recipients to use those payments safely and conveniently.
Payment inquiries and claims will be significantly reduced
under EFT.
Payment by EFT has substantial benefits in terms of
reliability, safety, and security that are especially important
for the elderly. Recipients are twenty times more likely to
have a problem with a paper check than with an EFT transaction;
each year Treasury replaces over 800,000 checks that are lost,
stolen, delayed, or damaged during delivery. Waiting days for a
replacement check is an inconvenience and a burden on
recipients, especially elderly persons living on low incomes.
EFT payments are much more convenient and secure--misrouted EFT
payments are never lost, and are typically rerouted to the
correct bank account within 24 hours.
FMS is overseeing implementation of DCIA government-wide
and is working with agencies to identify and resolve the major
issues confronting stakeholders so that Treasury's formulation
of regulations and policy on EFT conversion will reflect
Federal agencies' and key stakeholders' participation in
addressing and resolving issues. During 1996 Treasury began a
major initiative to assure the successful implementation of the
EFT mandate. Treasury will ensure that individuals required to
receive payments electronically will, for that purpose, have
access to an account at a financial institution at reasonable
cost, and with the same consumer protections as other account
holders at that financial institution. In addition, the
Secretary of the Treasury is authorized to grant waivers based
on recipient hardship, for classes of checks, or where
otherwise necessary. The transition to EFT will be made with
the interests of recipients being of paramount importance, and
waiver guidelines will be liberal.
The law required EFT to be used for Federal payments to new
recipients who become eligible to receive such payments after
July 26, 1996. On that date, an Interim Rule was published in
the Federal Register, providing initial guidance on
implementation. A follow-up rulemaking will be published in
1997 to offer guidance for EFT conversion for all Federal
payments after January 1, 1999.
During 1996, FMS contracted with Booz Allen & Hamilton and
Shugoll Research for a four-phase research effort that will
help determine the future marketing efforts aimed at individual
recipients of Federal benefit checks. A comprehensive public
education and marketing campaign involving presentations
nationwide and distribution of a variety of informational
materials is being planned to communicate the requirements of
the EFT legislation and the impact it will have on recipients,
financial institutions, and Federal agencies.
FMS continues to support the implementation of Electronic
Benefit Transfer (EBT). Geared toward those individuals without
a bank account or who choose not to use Direct Deposit, EBT is
an electronic benefit delivery mechanism that enables
recipients to use plastic cards to access their benefits at
automated teller machines or point-of-sale terminals. FMS
developed guidelines for banks to use in designing low-cost
``Direct Deposit Too'' all-electronic accounts to provide basic
banking services to the unbanked.
FMS continues to support the implementation of a nationwide
program to make EBT a viable electronic payment mechanism.
Forty states have some type of EBT program which provides
benefit access to recipients: six of these are full-fledged,
state-wide programs, and the others are either in the pilot
phases or in the process of being awarded to providers. In
1996, FMS was instrumental in establishing the Southern
Alliance of States (SAS), and five contracts have been awarded
under the SAS Federal EBT contract. Nationwide EBT will be
operational by 1999, and all 50 states expect to be operating
statewide EBT systems by 2002.
U.S. Mint
The U.S. Mint continues to consider the needs and concerns
of older persons.
The Exhibits and Public Services staff of the Philadelphia
Mint and staff of the Denver Mint Visitors Center are available
to help older persons and people with special needs who wish to
take the Mint self-guided tour. A wheelchair is also available
for those wishing to take the tour. In addition, benches are
strategically placed along the tour route to provide resting
areas for visitors.
In 1996-97, seven videodisc monitors were installed in the
tour gallery of the Philadelphia Mint. The videos highlight the
history of the Mint and coin production. The new system allows
older visitors and visitors with sight impairments to view coin
production up close. While visitors may still view the factory
from forty feet above the plant floor, the monitors allow for a
better understanding of coin production.
Bureau of Engraving and Printing
Series 1996 currency
The new Series 1996 $100 notes, the first in the series,
were introduced in March 1996. During the next several years,
lower denominations will be issued in order of decreasing
value. An international public information campaign is being
coordinated between BEP, the Federal Reserve System, and the
Secret Service, to make the public aware of the new notes; the
Department has conducted a special outreach to older
individuals. The new currency is the same size, color, and has
the same feel as the old notes, and depicts the same historical
figures and national symbols. The new security features,
benefitting those with reduced vision are: the portrait is
shifted slightly off-center, to provide room for a watermark,
making it harder for counterfeiters to print; serial numbers on
the new currency differ slightly from old currency; and the ink
used for the numeral in the lower right-hand corner changes
color from green to black when viewed from different angles.
Other assistance
BEP's on-site medical staff continued to provide life-style
counseling for employees who are senior citizens. The emphasis
is on wellness and prevention of disease, and includes advice
on nutrition and weight control, testing of blood pressure and
cholesterol levels, and examination of possible vision and
hearing deficiencies.
An assessment of BEP facilities, including the tour areas,
has been completed and found to be in accordance with the
Americans with Disabilities Act (ADA).
The BEP continued its contract with the National Academy of
Sciences to conduct a study, with the cooperation of the
American Counsel for the Blind, to determine ways to assist the
blind and partially sighted with handling currency.
Office of Thrift Supervision
The Office of Thrift Supervision (OTS) carried out a number
of activities affecting older Americans.
OTS continues its Community Affairs program, established in
1993 and designed to provide outreach and support to the thrift
industry's efforts to meet housing and other community credit
and financial services needs. One of the primary objectives of
the program is to serve as a liaison between the thrift
industry and consumer and community groups on housing and
community development issues. Most of the groups with which we
interact represent low- and moderate-income individuals,
including older persons.
During 1995 and 1996, the Community Affairs staff in the
headquarters office and in each of our regional offices, along
with senior management, initiated or participated in meetings
with hundreds of thrift and community organizations across the
country, including groups with particular emphasis on the
elderly. During those meetings, information was shared on
affordable housing, financial services and economic development
needs; on thrifts' authorities and abilities to meet those
needs; and on opportunities for collaborative partnerships.
OTS also periodically issues its Community Liaison
newsletter to all thrifts and several hundred community and
consumer organizations. One goal of this publicationis to
promote understanding and awareness of successful achievements in
affordable housing and community development. By spotlighting these
initiatives, many of which have benefited elderly Americans, it is our
hope that other financial institutions, community and consumer groups,
and government entities will be encouraged to replicate these
approaches in their communities.
For many years, OTS has had an active program designed to
address complaints that consumers may have against the thrifts
that OTS regulates. OTS operates a free nationwide consumer
hotline that offers the options of obtaining information about
filing a complaint or speaking immediately with an analyst. A
senior analyst is assigned each day to help people evaluate
whether their concerns are addressed by our regulations. Senior
citizens are more likely to use this service, and appear to
appreciate the direct contact.
During 1996, OTS expanded its services to seniors and
others who have disabilities, by establishing a TDD line for
complaints, and publicizing it in OTS' consumer literature. We
also continued to provide appropriate accommodation to
customers with disabilities, such as blindness or arthritis,
that make it difficult to file a written complaint. In most
cases, this involves writing out the complaint for the consumer
and sending it to them for signature or some other form of
verification.
OTS has also issued a Customer Service Plan for consumer
complaints and urged the institutions it regulates to give high
priority to consumer relations. Of approximately 5,000
complaints filed with OTS in 1996, 17 complaints alleged credit
discrimination based on age. OTS investigated each of the
complaints in accordance with its expanded procedures for
discrimination complaints. The procedures provide that the
complainant is interviewed, the entire loan file is obtained
from the thrift, and OTS staff determines if a special on-site
investigation is needed. None of the 1996 complaints led to a
finding of discrimination.
Bureau of the Public Debt
The Bureau of the Public Debt continues to make
improvements in its programs to better serve all investors. The
following steps to streamline and simplify access to Treasury
securities are of particular benefit to the elderly investor.
Savings securities
Public Debt's Savings Bond Webb Site provides much useful
information about bonds and is a very popular site with bond
owners, many of whom are elderly. In addition to savings bond
facts, many forms can be downloaded from, or ordered through
the site.
The Bureau continues to update and improve the Savings Bond
Wizard, an easy-to-use bond pricing software application
available via diskette and on Public Debt's Web Site. With
Wizard, bond owners can keep an inventory of their bonds, and
compute current redemption values and earned interest on their
personal computers. Because the Bureau receives frequent
positive feedback about Wizard, it remains one of the highest
priorities.
By accessing a new, automated system via telephone,
customers can easily request the forms needed for savings bond
transactions and receive the forms much sooner than when
requesting them by mail.
More inquiries from savings bond owners are now answered by
telephone or Internet electronic mail. These types of contacts
allow for better communication and clearer understanding of the
information needed and provided, which is especially helpful to
older customers.
The number of Series H/HH bondowners receiving semi-annual
interest payments by electronic deposit continues to increase
steadily. Over 70 percent participate in the Automated Clearing
House (ACH) method, many of whom are older people who exchange
matured Series E/EE bonds for Series H/HH. A major benefit of
electronic deposits is the assurance that payments will be
received on time, without having to make a special trip to
deposit interest checks.
Savings Bond forms are printed in as large a print as
possible.
Public Debt plans to make savings bonds available for
purchase in 1998 by automatic, electronic debits to purchasers'
financial accounts, on the dates and in the denominations and
registrations specified by the purchasers. This process will
provide a convenient way for persons who are retired (or do not
have access to payroll savings plans through their employers)
to invest in savings bonds.
Public Debt is finalizing plans for an inflation-indexed
savings bond, which will offer investors protection from the
effects of inflation. These bonds will offer investment
security that older Americans desire.
Marketable securities
Treasury marketable securities provide a safe investment
and interest income, features that are popular with older
Americans. The latest survey of investors using the Treasury
Direct service indicated that 62 percent were aged 65 or older.
Therefore, recent improvements to Treasury Direct will benefit
older Americans.
To help all of its customers, including the elderly, Public
Debt implemented a new Statement of Account that was larger,
easier to read, and provided more information. Also, a special
brochure explaining the Statement of Account was provided to
investors.
Public Debt continues to encourage owners of registered and
bearer securities to convert these certificates to book entry
form in Treasury Direct. Holding Treasury securities in book
entry form provides a much safer and more convenient method
than holding certificates.
United States Secret Service
White House tours
The U.S. Secret Service processes approximately 1.5 to 2
million people through the White House Tours annually. In a
reinvention effort to provide better customer service to the
public, the Secret Service Uniformed Division makes available
for the elderly and physically disabled escorted wheelchair
tours of all the White House areas open to the public. Past
procedures only provided for tours of the State Floor.
Additionally, upon request, ``special sign language tours'' are
made available for the hearing impaired and ``special touch
tours'' are provided for the visually impaired.
SCEP
The Secret Service has been working to develop a senior
citizen employment program (SCEP). SCEP is a work training
program designed to provide older, economically disadvantaged
seniors with an opportunity to upgrade outdated skills and
develop new skills which may enhance future employment
opportunities. At the same time, seniors hired under this
program will provide administrative clerical support to Secret
Service offices. The Personnel Division will work closely with
designated organizations such as the American Association of
Retired Persons and other community associations to identify
eligible seniors. Implementation of the SCEP is projected for
Fiscal Year 1998.
Advance fee fraud
Advance fee fraud schemes emanating from Nigeria are
targeting American citizens and have resulted in reported
financial losses exceeding a hundred million dollars. It is
believed the true losses are much higher as many victims fail
to report their losses due to fear or embarrassment. The
Service's experience has shown that the elderly population is
especially susceptible to advance fee frauds, as they are to
other types of confidence schemes. The Secret Service has
received scores of reports from members of the older community
who report that they have lost their life savings and more in
pursuit of an advance fee scheme.
From the onset of its involvement in the investigation of
this crime, the Secret Service has realized that a large scale
public awareness program must accompany aggressive
investigation and prosecution. In conjunction with the
Departments of State and Commerce, the Secret Service has
reached out to organizations that are associated with the
principal targets of this scam, namely small businesses and the
elderly. Organizations such as the Better Business Bureau, the
American Bankers Association, and the AARP have assisted the
Secret Service in publishing articles designed to educate the
public to these schemes and hopefully prevent them from failing
prey to these frauds.
Government benefits
The Secret Service continues to protect the nation's
elderly recipients from fraud perpetrated against their
government benefits. The Secret Service is committed to
investigating all fraud related to government benefits. During
Fiscal Year 1995-1996, the Secret Service received and
investigated 16,942 cases relating to U.S. Treasury check
violations (which includes Social Security benefits, Railroad
Retirement, Office of Personnel Management, et al) of which
16,167 were closed.
As a result of the Electronic Funds Transfer (EFT)
Provision of the Debt Collection Improvement Act of 1996, the
Secret Service has received 2,778 cases for investigation
involving the illegal diversion of funds through the Direct
Deposit/Electronic Funds Transfer process. In FY 1996, the
Secret Service closed 1,136 EFT cases.
U.S. Customs
U.S. Customs Service's major activities affecting older
Americans include the following:
The Customs Service offers special treatment for the aging,
the handicapped, the ill, and those who are unable to wait in
line when arriving from abroad. Such travelers can speak with a
Customs supervisor upon arrival in the Customs processing area
of the airport or other Customs port of entry. The supervisor
is able to facilitate the traveler's Customs clearance.
Customs strives to treat all travelers entering and leaving
the United States with professionalism and courtesy. In
addition, Customs works to ensure that Federal inspection
facilities, such as restrooms, etc., facilitate the movement of
the elderly or handicapped who must rely on a wheelchair or
walker.
In addition, the Customs Service has a number of programs
to support Customs employees. For example, the Employee
Assistance Program encourages elderlyemployees to seek
additional assistance if needed. The Customs Health Enhancement Program
offers activities and classes to Customs employees, including the
elderly, in areas such as the fitness center, CPR/first aid, stress
management, conflict resolution, defense tactics, allergy and asthma,
nutrition, and health screening. The Customs Service also offers
retirement seminars several times each year to all employees who are
eligible to retire within the succeeding 5 years. These seminars cover
retirement benefits, legal matters and financial planning.
Alcohol, Tobacco and Firearms
The Bureau of Alcohol, Tobacco and Firearms (ATF) has
several programs that benefit all employees, but specifically
can be viewed as addressing an aging workforce:
ATF supports its Health Improvement Program and encourages
employees of all ages, especially those over age 50 and who are
medically cleared, to participate.
The Employees Services Branch conducts annual pre-
retirement seminars for employees who are eligible to retire
within the succeeding 5 years. These seminars address civil
service retirement benefits, social security, tax implications
and financial planning.
The Employee Assistance Program provides all employees and
their family members with free confidential assistance for
personal problems that may impact work life. This program
provides counseling/support services regarding numerous issues
such as: finances, family, health, legal, substance abuse, and
emotional well being.
Office of Comptroller of the Currency
During 1995 and 1996, the Office of Comptroller of the
Currency (OCC) continued to enforce fair lending laws relating
to age discrimination and continued its active liaison and
outreach program with national and regional consumer
organizations, including the American Association of Retired
Persons.
Comptroller Eugene Ludwig met monthly with representatives
from national consumer organizations at informal meetings held
at the OCC'S Washington, D.C., headquarters and met semi-
monthly with representatives of regional consumer and community
organizations from each of the OCC's six districts. The purpose
of these outreach meetings was to share information about OCC
policy and national bank examination practices with consumer
organizations and to learn first-hand of concerns these
organizations may have with the activities of national banks
and the OCC's supervision of the national banking system.
During 1995, the OCC established its Community Reinvestment
and Development Specialist program. As a result, the OCC now
employs two full-time specialists in community development and
consumer banking in each of the OCC's six districts. they are
responsible for regular outreach and information dissemination
to community and consumer organizations, including local and
regional organizations representing the interests of elderly
consumers. These specialists focus on banking industry and
consumer organizations awareness of innovative practices of
national banks in meeting the credit and financial service
needs of disadvantaged consumers, including those of elderly
consumers.
The OCC also is responsible for resolving consumer
complaints against national banks, including those complaints
made by older Americans. During 1995 the OCC received 15,745
written complaints and 21,970 telephone complaints. During
1996, the OCC received 13,695 written complaints and 14,077
telephone inquiries. In 1995, to improve the process for
handling consumer complaints, the OCC established the Consumer
Assistance Unit, a centralized complaint processing center in
Washington, D.C., and launched a toll-free national consumer
complaint telephone number (800-613-6743).
ITEM 14--COMMISSION ON CIVIL RIGHTS
During calendar years 1995 and 1996 the Commission
continued to process complaints received from individuals
alleging denials of their civil rights. Specifically, in 1995,
17 complaints alleging discrimination on the basis of age were
received by the Commission and referred to the appropriate
agency for resolution. In 1996, the Commission referred 40
complaints alleging age discrimination.
ITEM 15--CONSUMER PRODUCT SAFETY COMMISSION
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Report on Activities To Improve Safety for Older Consumers
Each year, according to estimates by the U.S. Consumer
Product Safety Commission (CPSC), nearly one million people
over age 65 are treated in hospital emergency rooms for
injuries associated with products they live with and use every
day. The death rate for older people is almost six times that
of the younger population for unintentional injuries involving
consumer products. Consumer products used in and around the
home are associated with over 35 deaths per 100,000 persons 65
and older, and over 6 deaths per 100,000 persons under 65.
Fires and burns in the home
Burns from fires in the home are an important source of
injury to older Americans. CPSC recommends the installation and
maintenance of smoke detectors on every floor of the home.
Older consumers should look for nightwear that will resist
flames, such as a heavy weight fabric or tightly woven fabrics
such as polyester, modacrylics, or fabrics made from wool.
Cooking fires also cause injury and death to older
consumers. As part of its work on range fires, CPSC is
evaluating the feasibility of technologies that detect a pre-
fire condition and shut the burner off before a fire occurs.
Older consumers are at greater risk of dying from fires
involving both upholstered furniture and mattresses and bedding
than the general population. CPSC is currently considering ways
to address upholstered furniture and mattress and bedding
flammability.
Burns from hot tap water are another cause of injury to
many older Americans. CPSC recommends that consumers turn down
the temperature of their water heater to 120 degrees Fahrenheit
to help prevent scalds.
In 1995 and 1996, CPSC distributed approximately 130,000
copies of the ``Home Safety Checklist for Older Consumers''
(English and Spanish). The ``Home Safety Checklist'' is a room-
by-room check of the home, identifying hazards and recommending
ways to avoid injury. Consumers may order a free copy by
sending a postcard to ``Home Safety Checklist,'' CPSC,
Washington, D.C. 20207.
CPSC also contributed to the publication ``What Smart
Shoppers Know About Nightwear Safety.'' This brochure was
developed by a group of experts in apparel flammability and
distributed by the American Association of Retired Persons
(AARP). The brochure encourages older consumers to look for
sleepwear that is flame resistant. Consumers may request a copy
by sending a postcard to AARP, 601 E Street, N.W., Washington,
D.C. 20049.
Electrical wiring in older homes
In 1994-95, CPSC conducted a study of electrical wiring
fires in older homes. This is a subject of particular
importance to senior citizens, since they frequently live in
older homes, which are especially vulnerable to electrical
wiring fires. Based on this study, CPSC produced a video
entitled ``Wired for Safety,'' emphasizing hazards with old
electrical wiring and safety measures to prevent fire and
electric shock. About 3,000 copies of the video were
distributed to electrical safety inspectors, code officials,
and others nationwide.
CPSC launched this campaign to help prevent the estimated
40,000 home electrical wiring fires each year. These fires
claim 400 lives each year and cost society $2.2 billion
annually. Working with fire departments, electrical safety
experts, and building code officials, CPSC encourages
electrical reinspections and upgrades to home electrical
wiring. Consumers may obtain a free guide to eliminating home
wiring hazards by sending a postcard to ``Home Wiring
Hazards,'' CPSC, Washington, D.C. 20207.
Adult-friendly poison prevention packaging
Older consumers are involved in the childhood poisoning
issue because many young children are poisoned when they
swallow grandparents' medicine. Child-resistant (CR) packaging
has saved children's lives. CPSC has data estimating that the
widespread use of child-resistant closures on aspirin and oral
prescription medicines saved the lives of at least 800 children
under age five since 1972. However, CR packaging can only work
if people choose it and use it properly. Many older consumers
find it difficult to open CR packaging and may not replace the
caps or use the packaging at all.
To make it easier for all adults, especially older ones, to
use child-resistant packaging, CPSC in 1995 adopted a change in
its rules for testing packaging under the Poison Prevention
Packaging Act. The new regulation requires that packaging be
tested by panels of adults 50 to 70 years of age rather than 18
to 45 years old, as was previously the case. This change--
effective for packaging marketed after January 1998--assures
that child resistant packaging will become more ``adult-
friendly.'' The change is encouraging the industry to develop
innovative closures that rely on older people's ``cognitive
skills'' instead of their physical strength. CPSC expects the
new packaging to help prevent more child poisonings. In
addition, CPSC reminds all adults to keep medicines locked up
and out of reach of children.
In 1994, Chairman Ann Brown awarded commendations to two
companies for safety innovations in child-resistant packaging
that were especially useful for older consumers. Procter and
Gamble received an award for marketing a major product in
adult-friendly child-resistant packaging and Sunbeam Plastics
was recognized for developing an entire line of adult-friendly
child-resistant packaging.
ITEM 16--CORPORATION FOR NATIONAL SERVICE
ITEM 17--ENVIRONMENTAL PROTECTION AGENCY
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Environmental Protection Agency--Senior Environmental Employment (SEE)
Program
The SEE Program was established by the Environmental
Programs Assistance Act, P.L. 98-313. This law authorizes EPA
to enter into grants or cooperative agreements with
organizations authorized by the Secretary of Labor under Title
V of the Older Americans Act. The EPA funded cooperative
agreements with six national aging organizations during
calendar years 1995 and 1996 that included the American
Association of Retired Persons, National Council on the Aging,
National Caucus and Center on Black Aged, Inc., National
Association for Hispanic Elderly, National Senior Citizens
Education and Research Center, and the National Asian Pacific
Center on Aging.
The SEE Program draws upon the vast pool of talent,
experience and skills possessed by retired and older workers
age 55 or older. The Program has two major benefits, to support
the Environmental Protection Agency (EPA) staff in
administering projects necessary for the support of
environmental programs and to give older workers an opportunity
to remain active using their matured skills in meaningful
tasks.
SEE enrollees performed a wide range of technical
assistance for EPA from answering telephones to performing
clerical support to providing assistance in radiation and air
pollution monitoring. No matter what is the critical
environmental concern of the day, from understanding and
explaining in a credible manner the analyzed data of nearby
toxic substance exposures to local citizens or providing the
temporary technical talent of local monitors to spot check
underground storage tanks, the SEE program provides support
where it is most needed. The work being done by the many SEE
participants demonstrates the effectiveness of older Americans
in helping to prevent, abate and control environmental
pollution.
SEE Program participants work in one year temporary
positions at EPA Headquarters offices, ten EPA Regional
offices, EPA Laboratories, and in other federal, state, and
local environmental offices. The utilization of the SEE Program
offers EPA a golden opportunity for achieving the environmental
challenges of today.
ITEM 18--EQUAL EMPLOYMENT OPPORTUNITY COMMISSION
ITEM 19--FEDERAL COMMUNICATIONS COMMISSION
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SUMMARY OF 1995-1996 ACTIVITIES OF THE FEDERAL COMMUNICATIONS
COMMISSION AFFECTING OLDER AMERICANS
This report summarizes the major 1995-1996 activities of
the Federal Communications Commission (hereafter ``FCC'' or
``the Commission'') affecting older Americans.
A number of these actions were taken to implement statutory
requirements or Commission policies on behalf of the general
public, the 49 million Americans with some kind of hearing,
vision, speech or other disability, and all consumers of
telecommunications, rather than ``on behalf of older
Americans.'' However, since many older Americans may be in
declining health, e.g., losing hearing or vision, or may be
especially vulnerable to anti-consumer scams and schemes, e.g.,
``slamming'', or unauthorized transfer to a new long distance
carrier, older Americans clearly were affected by and benefited
from the various disability-related and consumer protection
activities described below.
Disabilities Issues Task Force
One of the Commission's chief concerns in 1995 was to
ensure that the benefits of the information revolution were
available to everyone, including the disability community. This
community contains a sizeable percentage of older Americans
with a hearing, vision, speech or other disability. Thus, many
of the activities the FCC undertook in 1995 and 1996 to assist
the disability community also affected and benefited older
Americans.
The FCC's Disabilities Issues Task Force (DITF) was formed
in March 1995 with representatives of each of the FCC's Bureau
and Offices. The Task Force serves as the FCC's main point of
contact and coordination on all disability access initiatives,
and works to ensure that the FCC takes steps to promote access
to the Information Superhighway by individuals with
disabilities, including many older Americans.
In 1995, the Commission implemented a policy ensuring that
all Commission open meetings are closed-captioned for people
with hearing disabilities. Members of the DITF and other FCC
officials also met in 1995 with cable industry representatives
and representatives of the disability community to negotiate a
plan to ensure that the Emergency Alert System for emergency
local, state and national emergencies is accessible to persons
with disabilities.
In 1996, the DITF completed pending projects noted above
and began educational outreach within the Commission's various
Bureau and Offices, the activities of many of which affecting
older Americans are summarized below.
Common Carrier Bureau
Some of the most important policy actions of the FCC
affecting older Americans were initiated in 1995-1996 by the
Commission's Common Carrier Bureau (``CCB''). This Bureau
regulates wire and radio communications common carriers in the
telephone and telegraph industries. An excellent example of a
relevant CCB issue is hearing aid compatibility and volume
control ``HAC/VC''). This is of great relevance to older
Americans because many people who lose their hearing later in
life depend on HAC telephones with VC to be able to use the
telephone.
Hearing Aid Compatibility.--The Hearing Aid Compatibility
Act of 1998 required the Commission to establish rules that
ensure reasonable access to telephone service by persons with
hearing disabilities, and to seek to eliminate the disparity
between hearing aid users and non-users in obtaining access to
the telephone network.
To resolve various compliance issues, and recommend new
rules to replace original rules suspended in April 1993, the
Commission in the spring of 1995 established a 19-member
Hearing Aid Compatibility Negotiated Rulemaking Committee. Its
members represented all interested parties, including the
Commission, telephone equipment manufacturers, employers,
hospitals, nursing homes, hotels and motels, and persons with
disabilities, including some older Americans.
On July 3, 1996, the Commission adopted final rules, many
of which were recommended to it by the Negotiated Rulemaking
Committee in its report to the FCC of August 1995. In general,
the FCC's revised and final rules required eventually all
wireline telephones in workplaces, in confined settings (e.g.,
hospitals and nursing homes) and in hotels and motels to be
hearing aid compatible according to certain timelines. In
addition, telephones that are newly acquired or are replacement
telephones eventually will have to have volume control
features. Workplaces with fewer than 15 employees were
exempted, except for telephones provided directly for employees
with hearing disabilities. Finally, the date of November 1,
1998 adopted by the FCC in July 1996 for implementation of the
volume control features in all telephones manufactured or
imported for use in the United States was later extended on
reconsideration to January 1, 2000.
Anti-``Slamming.''--``Slamming'' is the prohibited practice
of the unauthorized conversion of a person's long distance
telephone company. Older Americans, especially those with
speech and/or hearing disabilities, are especially vulnerable
to such anti-consumer activity. In 1995, the Commission amended
its rules to ensure that carriers do not use misleading or
confusing forms that consumers sign to change their long
distance service. The Commission required that certain
information be clearly stated on the form and prohibited the
inclusion of misleading promotional material. The Commission
took this action because some carriers were using forms, such
as contest entry forms, that masked the effect of the
subscriber's signature.
On June 13, 1995, the Commission adopted a Report and Order
amending the rules concerning the Letters of Agency used to
change the long-distance carrier of a telephone consumer. The
new rule requires that the Letters of Agency be separated from
inducements such as prizes or contests, and that they clearly
state that by signing the Letter of Agency, the consumer is
requesting a change in his or her long distance service.
In conjunction with the amendment of the rules concerning
the unauthorized conversion of long distance service, the
Common Carrier Bureau's Enforcement Division initiated a series
of investigations in 1995 into carrier ``slamming'' practices.
Notably, one carrier was fined for converting a widow's
telephone service by forging the signature of her husband who
had been dead for three years!
Charges for Toll-free Numbers.--In 1996, the Commission
amended its rules to place further restrictions on the use of
toll-free numbers to provide information services. The
Commission took this action because certain companies were
encouraging consumers, including many older Americans, to call
an 800 number they though would be a free call and then later
charging a fee on the telephone where the call originated. The
rules now require the consumer's written authorization, or the
use of a calling or credit card, for such charges to be valid.
Renting of Telephone Sets.--In 1996, the Commission and the
Federal Trade Commission issued information advising consumers
that they may be unknowingly renting their phone sets at a cost
that far exceeds the purchase of a set. Continuing to rent
rather than buy telephone handsets is a very common practice
among older Americans. The Commission found that in many cases,
the unintended, long-term rental resulted from consumers not
buying their handsets from AT&T when, in the early 1980s, the
Commission required AT&T to offer the sets for sale rather than
charge each month for rental of the handset equipment.
Brochures on Unauthorized Changes and Excessive Charges.--
In June 1996, the Commission issued bi-color, consumer-friendly
brochures containing information to help consumers, including
older Americans, avoid ``slamming'' or unauthorized changes in
their long distance service as well as excessive charges for
calls from public telephones.
Telecommunications Relay Services (``TRS'').--Older
Americans in 1995-1996, especially those with hearing
disabilities, also continued to benefit from the Commission's
rules implementing Title IV of the Americans with Disabilities
Act (``ADA''). Title IV of the ADA governs the operation and
funding of both interstate and intrastate telecommunications
relay services. The TRS technology allows people with hearing
and speech disabilities to use the telephone. TRS facilities
are equipped with specialized equipment and staffed by trained
communications assistants who relay conversations between
people who are using text telephones, sometimes also called a
TTY, and people using wireline telephones.
Universal Service.--The Telecommunications Act of 1996
established certain principles for the Commission to follow in
revising and expanding the scope and definition of ``universal
service'' in telecommunications services for all Americans,
including older Americans. Among the explicit provisions
established by this landmark legislation, Section 254 (b)(6)
mandates access to advanced telecommunications services for
``health care providers'', including hospitals and health
clinics which, of course, serve many older Americans.
Cable Services Bureau
Older Americans with hearing and sight disabilities can now
be helped by a number of technologies related to television,
especially closed captioning and video description. These two
technologies are designed to increase ``video accessibility.''
Video Accessibility.--In December 1995, the Commission
adopted a Notice of Inquiry to assess the current availability,
cost and uses of closed captioning and video description, and
to examine what further Commission action may be appropriate to
promote these services. It also asked for comments on the
appropriate means of promoting their wider use in programming
delivered by television broadcasters, cable operators, and
other video programming providers. Closed captioning provides
important benefits primarily for individuals with hearing
disabilities by displaying the audio portion of a television
signal as printed words on the television screen. Video
description benefits individuals with visual disabilities by
providing audio descriptions of a program's key visual elements
that are inserted during the natural pauses in the program's
dialogue.
Closed Captioning.--In the 1996 Act, Congress directed the
Commission to ensure that closed captioning is available to
persons with hearing disabilities and to assess the appropriate
method for phasing video description into the marketplace to
benefit persons with visual disabilities. As a first step,
Congress required the Commission to submit a report addressing
these issues. Since the 1996 Act adopted the provisions
concerning the availability of video programming with closed
captioning and video description which formed the basis of the
Commission's inquiry, the Commission decided to use the
comments filed in that proceeding and publicly available
information for its report to Congress. The Commission
submitted its Report to Congress on July 29, 1996.
In its Report, the Commission found that between 50 and 60
million U.S. homes can receive closed captioning; through the
efforts of Congress, government agencies and a variety of
private parties, captioned video programming has grown over the
past 25 years and is now a common feature of many video
programming types; and the quality of closed captioning varies
greatly and generally reflects the method of adding the
captions, the quality of the captions and the entity providing
the captions. Estimates of the cost of captioning range from
$800 to $2500 per hour of prerecorded programming and from $150
to $1200 per hour of live programming. The Report also found
that the Department of Education provided about $7.9 million
for closed captioning last year, which represents roughly 40%
of the total amount spent on captioning.
Video Description.--With respect to video description, the
Commission reported to Congress that there is a lack of
experience with developing and assessing the best means for
promoting its use since it is a newer service. The Public
Broadcasting Service and a few cable networks include video
description with some of their programming. Costs for video
description are approximately one and a half the costs
associated with closed captioning of similar programming. Video
description also receives substantially less government
funding, which has been a significant factor in promoting the
development of closed captioning. For example, the Commission
observed that the Department of Education allocated only $1.5
million for video description in 1995. Additional legal and
technical issues exist. For example, video description requires
the development of a second script, which raises creativity and
copyright issues, must use the second audio programming channel
and thus must compete for use with other audio services,
particularly bilingual audio service.
Mass Media Bureau
Digital Television.--In 1996, the Mass Media Bureau, which
regulates the radio and television industries, drafted and the
Commission adopted a Report and Order dealing with technical
standards for digital television (``DTV''). This proceeding
addressed technical standards for DTV which will be the next
generation of television. DTV will affect all citizens,
including older Americans, by providing more choices in video
programming with dramatically better visual and aural
resolution. Future proceedings may deal with the potential
effects of DTV on society in general, including people with
disabilities and older Americans.
Wireless Telecommunications Bureau
In 1995-1996, the Wireless Telecommunications Bureau which
regulates all wireless telecommunications services such as
cellular, paging and personal communications services undertook
a number of activities that affected older Americans. These
included the following:
Section 255 (Access to Telecommunications) Notice of
Inquiry.--Section 255 of the Communications Act, added by the
Telecommunications Act of 1996, provides that
telecommunications equipment manufacturers and service
providers must make their equipment and services accessible to
those with disabilities, to the extent that it is readily
achievable to do so. The Commission initiated the
implementation of Section 255 by adopting a Notice of Inquiry
in September 1996.
Wireless Hearing Aid Compatibility.--In January, 1996, the
Commission launched a Hearing Aid Compatibility Summit to
encourage consumers, hearing aid manufacturers, and wireless
telephone equipment manufacturers to address the interference
and compatibility problems for hearing aid wearers that are
caused by digital phones.
Possible Interference Between Wireless Phones and
Pacemakers.--The Commission met in 1996 with researchers,
consumers, industry, and the Food and Drug Administration on
concerns regarding possible interference between wireless
phones and pacemakers and industry efforts to resolve any
possible interference.
Spectrum for assistive listening devices.--In July 1996,
the Commission established a Low Power Radio Service in the
216-217 Mhz band for, among other things, auditory assistive
listening devices (``ALDs'') and radio-based health care aids
(i.e., remote monitoring of patients' vital signs in hospitals
and health care facilities.). ALDs are designed to help hard of
hearing people to better understand speech, music, and the
sounds during a movie, play, concert, lecture, etc. ALDs are
sound-reinforcement equipment which, figuratively, gets the
speaker's mouth close to the listener's ear in order to
minimize the negative impact and sound distortions of distance,
room reverberation, and ambient noise.
Family Radio.--In May 1996, the Commission established a
very short distance, unlicensed, two-way voice personal radio
service called the Family Radio Service to give families,
friends and associates the capability to communicate with one
another during group outings where group members may become
separated, either planned or inadvertently.
Public Safety.--During 1995-1996, the Commission took a
number of steps to improve the Nation's public safety wireless
communications system. These improvements will benefit all
citizens, including older Americans who may need the services
and telecommunications capabilities of police, fire and medical
emergency personnel as much as, or even more than, any other
segment of the population. For example, the Commission together
with NTIA established the Public Safety Wireless Advisory
Committee (PSWAC) to provide advice and recommendations on
various requirements of public safety agencies through the year
2010. The Commission also initiated a rulemaking proceeding (WT
Docket No. 96-86) to address the present deficiencies in public
safety wireless communications.
Combatting Telecommunications Fraud.--The Commission in
1995-1996 published with the Federal Trade Commission consumer
alerts for Specialized Mobile Radio (``SMR'') and paging
licensees and gave presentations to the public on ``How to
Avoid Being Bilked by Telecommunications License Investment
Scams.''
Finally, in 1995-1996, three of the Commission's support
offices also undertook activities affecting and benefiting
older Americans. These are summarized as follows;
Office of Engineering and Technology
In 1995-1996, the Office of Engineering and Technology
(``OET'') began and continued an investigation of potential
interference from handheld Personal Communications Services
devices to hearing aids. (OET is the FCC's chief technical
adviser on engineering and scientific matters, and is
responsible for helping the FCC manage the non-Government use
of the electromagnetic spectrum.)
Office of Managing Director
In 1995-1996, the Office of Managing Director, Human
Resources Management, continued its past practice of expanding
the FCC's job recruitment activities to reach more older
Americans by, for example, sending vacancy announcements to
various older American groups such as ``Forty Plus of Greater
Washington.''
Office of Public Affairs
In 1995-1996, the Commission expanded its outreach to
senior citizens, the population most at risk of being
victimized by schemes and scams via telephone. The Commission
held off-site sessions for diverse groups of seniors and senior
organizations around the Washington Metropolitan area, and
produced special fact sheets, brochures and other informational
products, both in print versions and electronically for the
Commission's Internet Web Site.
In 1995, the FCC participated in a special ``Fireside
Forum,'' an off-site program for senior citizens at ``Leisure
World'' in Silver Spring, Maryland. The program provided the
audience the opportunity to learn about telephone issues and
telephone frauds and scams. FCC subject matter experts offered
explanations and guidance about telephone issues as well as
about competitive bidding or auctioning of spectrum and other
spectrum licensing processes.
In 1996, FCC-sponsored events included fora for seniors on
telephone-related topics. The Commission held four off-site
workshops. For example, the session in Washington included
representatives of the District of Columbia Commission on
Aging, the Greater Washington Urban League's Annual Senior
Citizens Crime Prevention and Education program, the American
Association of Retired Persons, and the FCC.
Another session also on telephone-related topics was
presented to a culturally diverse group of older Americans with
simultaneous translation in Vietnamese, Chinese, and Spanish.
Finally, one of the sessions was covered by a local access
community cable TV station and cablecasted to its audience.
Conclusion
This report has summarized the many activities undertaken
by the Bureaus and Offices of the Federal Communications
Commission in 1995-1996 affecting and benefiting older
Americans. Any one who wants more information on any of these
activities can contact the Commission via its Office of Public
Affairs at 202-418-0500, its National Call Center at 1-888-
CALL-FCC (225-5322), or its Web Site on the Internet at
www.fee.gov.
ITEM 20--FEDERAL TRADE COMMISSION
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1995-1996 REPORT
Staff Summary of Federal Trade Commission Activities Affecting Older
Americans
This report discusses the Federal Trade Commission's
activities of particular significance for older consumers in
calendar years 1995 and 1996. The first section of the report
describes Commission initiatives to eliminate telemarketing
frauds that target older consumers, who represent the majority
of victims in many telemarketing scams. The second section
reports Commission activities relating to the health concerns
of senior citizens. Older consumers, in general, experience
more health problems and therefore may be more vulnerable to
injury from misleading health claims made about products or
services or from anticompetitive mergers or other forms of
anticompetitive conduct in health care markets. The third
section discusses Commission law enforcement activities of
particular importance to older consumers in other areas. The
final section of the report addresses the Commission's consumer
education initiatives that may be of particular benefit to
older consumers.
Telemarketing Fraud Initiatives
On March 6, the Senate Special Committee on Aging conducted
a hearing on one of the greatest societal problems affecting
older Americans--telemarketing fraud.\1\ Fraudulent
telemarketers often target older citizens, knowing that many of
them may have significant assets from a lifetime of saving,
including self-directed retirement accounts. These
telemarketers also know that the victim, shamed at suffering
such losses, often will not tell friends and family about the
scam and will be desperate to make back the losses. The
telemarketers then have other con artists ``reload'' the victim
with more offers until the victim has no more to give,
monetarily or psychologically. One witness at the Senate
hearing, Mary Downs, testified that she lost over $74,000 to
fraudulent telemarketers from April 1992 to March 1993.\2\ Some
fraudulent telemarketers, in perhaps the most pernicious
scheme, also operate ``recovery rooms'' that purport to help
fraud victims get back their money for a substantial fee.
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\1\ Hearing before the Senate Special Committee on Aging, March 6,
1996: ``Telemarketing Fraud and Senior Consumers,'' March 6, 1996.
\2\ Statement of Mary Ann Downs, March 6, 1996.
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It has been estimated that telemarketing fraud may cost all
American consumers as much as $40 billion a year in losses.
Older Americans account for 60% of the fraud victims who call
the National Consumers League's National Fraud Information
Center.
To combat these and other frauds, the Federal Trade
Commission in 1995 and 1996 employed a new array of effective
weapons. First, the Commission promulgated a new Telemarketing
Sales Rule (``TSR''), as directed by Congress in the
Telemarketing Consumer Fraud and Abuse Prevention Act of 1994,
15 U.S.C. Sec. 6101. This Rule, which went into effect on
December 31, 1995, defines a number of telemarketing frauds
with greater specificity and allows both the FTC and state
Attorneys General to bring actions in federal court. Second,
the Commission used both the Rule and its FTC Act authority to
conduct coordinated law enforcement ``sweeps,'' working with
state Attorneys General, state securities officials, the FBI,
the U.S. Postal Service, and other agencies. In 1996 alone, the
Commission formed alliances that produced over 200 actions
against fraudulent telemarketers. The Commission itself, from
October 1995 through December 1996, brought nearly 100 federal
court actions stoppingfraudulent operations that cost consumers
$250 million a year and over $700 million over the lives of these
schemes.
telemarketing sales rule
The Telemarketing Sales Rule, 16 CFR Part 310, imposes
general requirements for all telemarketers and addresses
specific fraudulent practices. Under the TSR, telemarketers
must promptly disclose certain information in telephone calls
to consumers, including their identities, the fact that they
are making a sales call, and the nature of the goods or
services they are offering. The Rule also prohibits
telemarketers from misrepresenting the services or products
they sell and from debiting a consumer's checking account
without the consumer's express authorization. The TSR also
outlaws a number of telemarketing practices such as credit card
laundering. In addition to addressing the conduct of
telemarketers, the TSR also bars third parties from providing
substantial assistance to telemarketers--specifically,
assistance such as providing consumer lists, marketing
materials, or appraisals of investment offerings--when the
person ``knows or consciously avoids knowing'' that the
telemarketer is engaged in unlawful conduct. Violations of the
TSR may result in civil penalties of as much as $11,000 per
violation, and consumers who have lost over $50,000 are able to
sue under the TSR to recoup their losses.
In 1995 and 1996, the telemarketing frauds that most
affected older Americans included bogus prize promotions,
investment frauds, charitable solicitations, recovery rooms,
and credit schemes sold over the telephone. This Report
discusses each below.
prize promotions
Prize promotion is an egregious type of telemarketing fraud
in which a high percentage of victims are older Americans. In
1996, more than 40% of the complaints logged into the
Telemarketing Complaint System \3\ pertained to prize
promotion. In a typical scheme, telemarketers make unsolicited
calls or mail notification cards to consumers stating that they
have won a valuable prize, such as a vacation, car, cash or
jewelry. Consumers are told that they should purchase some
product such as vitamins, cosmetics or magazine subscriptions
and they will then receive the prize.\4\ The TSR requires that,
in any prize promotion, telemarketers must disclose that no
purchase or payment is required to win a prize, and must
provide information about the odds of winning the prize and how
to participate in the promotion at no cost. 16 CFR
Sec. 310.3(a)(1)(iv).
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\3\ The Telemarketing Complaint System (``TCS'') is a nationwide
database of consumer complaints on telemarketing fraud. The Commission
maintains this database, which is accessible by 100 participating law
enforcement organizations who can query the system to locate the
victims of telemarketing fraud, target law violators, identify other
investigative agencies that have opened investigations, and coordinate
law enforcement efforts. In 1995 alone, over 16,000 complaints were
entered on the TCS, reflecting dollar losses of more than $21 million.
\4\ The Commission has traced expenditures by victims of bogus
prize promotion schemes and found that some consumers have actually
lost tens of thousands of dollars to prize promotion telemarketers.
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Operation Senior Sentinel: The FTC played a significant
role in Operation Senior Sentinel, announced in December 1995.
This enforcement effort, led by the U.S. Department of Justice,
was the largest criminal crackdown ever on telemarketing fraud.
It focused on telemarketing scams targeting older Americans
such as prize promotions and recovery rooms. Nearly 80% of the
victims in the underlying prize promotion and recovery room
cases targeted in Operation Senior Sentinel were older persons.
The operation was launched with the simultaneous arrest of
nearly 400 telemarketers. By the end of 1996, more than 800
individuals had been prosecuted or arrested on charges of
federal crimes.
The Commission participated by assisting criminal law
enforcement authorities to identify victims and witnesses as
well as by filing five civil complaints--four against allegedly
fraudulent prize promotions and the fifth against an alleged
recovery room. The courts in these actions issued strong
preliminary relief, closing down those ``boilerrooms''--
telephone sales rooms--and freezing defendants' assets.
Chattanooga Project: During 1995 and 1996, the Commission
also provided other substantial direct support to the criminal
prosecution of fraudulent prize promoters. In 1995, the FTC
detailed eight attorneys to the Chattanooga, Tennessee
Telemarketing Fraud Task Force. Chattanooga had became a
leading center of fraudulent telemarketing activity,
particularly prize promotions. The overwhelming majority of the
victims of the Chattanooga operations were senior citizens. The
FTC attorneys were cross-designated as Special Assistant U.S.
Attorneys and brought criminal actions against telemarketers
operating in the area. By the end of 1996, the Chattanooga Task
Force largely had completed its work, having obtained fifty
convictions and combined prison sentences against fraudulent
telemarketers totaling over 1,695 months. The defendants were
ordered to pay more than $13 million in restitution. In
recognition of the FTC's contributions, the U.S. Department of
Justice honored the FTC attorneys with its John Marshall Award
for interagency cooperation in support of litigation in 1996.
Operation Jackpot: In June and July 1996, the Commission
joined with the U.S. Postal Inspection Service and 16 state
Attorneys General to bring 56 law enforcement actions against
79 fraudulent prize promoters in 17 states. The Commission
itself brought eight cases alleging violations of both the FTC
Act and the TSR.\5\ The complaints named companies that
allegedly lured consumers to buy ``Say No to Drugs''
paraphernalia or magazine subscriptions to obtain a prize.
Another target, Publishers Award Bureau, allegedly promised
land in Baja California as awards accompanying magazine sales.
In another case, American Exchange Group, Inc., the Commission
alleged that the company had promised consumers that they would
receive large, valuable awards on the condition that they
purchase magazine subscriptions. As with other prize promotion
offerings, the prizes were allegedly either non-existent or
were worth significantly less than the amount paid. The
Commission also filed suit against Ideal Concepts and its
principals, charging that the defendants, who operated a
nationwide telemarketing operation selling novelty items, e.g.,
hats, frisbees, etc., imprinted with anti-drug statements, had
fraudulently promised that consumers would receive valuable
prizes.
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\5\ Other 1996 Commission-led sweeps to enforce the Telemarketing
Sales Rule or to target other types of fraud included ``Operation
Payback'' (fraudulent credit repair operations), ``Operation Loan
Shark'' (advance fee loan schemes), ``Operation CopyCat'' (fraudulent
telemarketing of office supplies), ``Project Career Sweep'' (misleading
offers of employment services), ``Project $cholar$cam'' (bogus
scholarship search services), Internet/Credit Repair (deceptive
Internet advertising of credit repair), ``Project BuyLines''
(fraudulent marketing of 900-number business opportunities), and
``Operation Missed Fortune'' (deceptive offers of get-rich-quick and
self-employment schemes).
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investment frauds
Fraudulent telemarketers know that many senior citizens
have substantial savings and that many may need substantial
investment returns to help finance retirement. The stock market
boom of the mid-1990's also led many investors to seek and
expect high returns. Fraudulent telemarketers were only too
happy to respond to these desires, peddling bogus investment
opportunities ranging from gold, rare coins, art prints,
gemstones, and wine investments totelecommunications licenses
issued by the Federal Communications Commission. The telemarketers
invariably assured consumers that they would realize a substantial
return on their investment, usually in a short period of time and with
minimal risk. The amounts of individual losses often were quite high,
sometimes $5,000 to $20,000 or more per person. In one case, a woman
who had saved over $100,000 over forty years of babysitting lost all of
it to a scam touting investments in supposed application services for
FCC paging system licenses. Older citizens taken by these scams often
are not in a position to recoup their losses.
DIRECTV and IVDS Frauds: In 1995, the Commission brought a
coordinated action against three alleged purveyors of
investment frauds touting new FCC license technologies. Two
cases involved supposed profits to be made in connection with
new wireless communication FCC licenses for Interactive Video
and Data Service (IVDS). In one case, Digital Interactive
Associates, the telemarketers sold over $19 million in
partnership interests in such businesses allegedly by such
means as understanding their risks and failing to disclose the
amount of funds being drained off to telemarketers and
insiders. In a second case, Chase McNulty Group, Inc. allegedly
misrepresented the nature and value of these IVDS licenses and
made other misrepresentations. Finally, the Commission alleged
that Satellite Broadcasting Corp. misrepresented that it had
the rights to market a type of satellite television programming
called DIRECTV to certain markets and that investors could earn
a substantial return from investing in the venture. The courts
in all three cases issued injunctive relief that included asset
freezes and the appointment of receivers. In the case against
Chase McNulty, the court approved a consent decree awarding a
judgment of $1 million \6\ and requiring individual defendants
to pay $160,000 and to post a bond of $350,000 before engaging
in future telemarketing. Defendants in the Satellite
Broadcasting Corp. case agreed to pay more than $700,000 in
consumer redress. The Digital Interactive case is still in
litigation.
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\6\ The consumer redress amounts included in McNulty and the
following cases have been ordered by the court (whether through
litigation or settlement) and may be higher than the amounts collected
and returned to consumers. Collection is often difficult because, in
many cases, the defendants do not have identifiable assets subject to
execution. In December 1995, the Commission entered into a Memorandum
of Understanding with the U.S. Treasury, under which Treasury provides
assistance in collecting judgments owed to the Commission. The
Commission was the first agency to refer its uncollected judgments to
Treasury's Financial Management Services Division, which uses its
collection expertise to aggressively collect on these judgments.
Where practicable, the Commission seeks to redress injured victims.
Where redress is not practicable, any monies paid by defendants
typically are disgorged to the U.S. Treasury.
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Operation Roadblock: In January 1996, the Commission,
together with the North American Securities Administrators
Association, coordinated a federal and state initiative aimed
at high-tech scam promoters peddling Federal Communications
Commission paging licenses and 900-number companies as
investments. The Commission and 21 states filed 85 law
enforcement actions against telemarketing companies. These
companies had taken in more than $250 million from consumers
touting bogus investments on the ``Information Superhighway.''
As a result of Operation Roadblock, FTC-FCC cooperation, and
intensive consumer education efforts, telemarketing scams
relating to FCC licenses took a sharp drop in 1997.
Miscellaneous Investment Frauds: Counterfeit art works were
the subject of a 1995 Commission lawsuit against Renaissance
Fine Arts, Ltd. and its owner. In that case, the individual
defendant fled the United States but subsequently returned and
was arrested by U.S. Postal authorities on charges related to
the Commission's complaint allegation. The court-ordered
default judgment required the defendants to pay $2.3 million in
consumer redress and banned the company's president from
further telemarketing of artwork. Permanent injunctions also
were entered in settlement of pending lawsuits against
Georgetown Galleries (alleged misrepresentations in the
telemarketing of antiquarian art prints) and Cambridge
Exchange, Ltd. (alleged misrepresentations in the telemarketing
of animation cells and other art works coupled with an
allegedly deceptive prize promotion).
Finally, the Commission obtained a settlement in an earlier
case against Unimet Credit Corp., involving allegations that
defendants had assisted other companies that deceptively
telemarketed leveraged investments in precious metals and
foreign currency. The defendants were required to pay $1.9
million in consumer redress.
Charitable Solicitations
Legitimate charities often offer prizes in connection with
their fundraising efforts. However, the Commission in 1995 and
1996 also saw substantial numbers of telemarketing operations
where salespeople, in the name of a charity, promised consumers
extravagant prizes in return for an allegedly tax-deductible
donation to a specific charity (``telefunding''). Not
surprisingly, the prizes were almost worthless and the amounts
of money that ever reached charitable organizations were
infinitesimal.
In 1995, the Commission charged NCH, Inc. and its
principals for their roles in a fraudulent telefunding scheme.
The Commission alleged that the company had misrepresented that
consumers would win valuable prizes in exchange for making a
donation to a charity called``Operation Life.'' The court
ordered the defendants to pay over $2.6 million in redress to consumers
and permanently banned them from engaging in prize promotion
activities.
During the 1995-96 period, the Commission also settled a
number of lawsuits previously brought against other
telefunders. In one matter, the complaint had alleged that
corporate defendants, Publishing Clearing House (not the
familiar Publishers Clearinghouse), M.A.A., Inc. and certain
individual defendants had made unsolicited calls to consumers,
telling them that they had been selected to receive a valuable
prize--ranging in value from $3,500 to $50,000 in cash. The
consumers were then told that all they had to do to receive the
prize was to make a tax-deductible donation of a significant
specified amount to a designated charity. The Commission
alleged that the consumers did not receive the promised prize
(or if they did, it was of nominal value) and that the
``donation'' was not tax-deductible. In settling this case, the
Commission required the defendants to post a $1 million
performance bond before engaging in any prize promotion or
charitable solicitation activity.
The Commission obtained comparable relief through
settlement of another case with a Las Vegas telemarketer and
telefunder, Marketing Twenty-One dba Genesis Enterprises. As
with PCH, the company promised prizes in exchange for a
purportedly tax-deductible contribution. The Commission alleged
that these claims were false. The settlement requires the
individual defendant, Markos Mendoza, to post a $1 million
performance bond before engaging in a similar telemarketing
venture.
In 1995 and 1996, the Commission also obtained consent
decrees with 24 defendants involved with an organization of
telefunders for The Gleaners. In these cases, the Commission
charged that defendants falsely represented the value and
nature of prizes that consumers would receive in return for
their donations to teenage alcohol and drug-abuse
rehabilitation programs and food banks purportedly run by The
Gleaners. The complaint also alleged that defendants
misrepresented the charitable activities undertaken by the two
charitable organizations. The settlements provide that the
individual defendants must post a $1 million bond before
engaging in any telephone prize promotion business and must
disclose the existence of the bond to customers.
Recovery Rooms
``Recovery rooms'' prey on persons who have already been
victimized by telemarketers. Telemarketers obtain the names and
addresses of these victims by purchasing, or trading for, lists
of victims from other fraudulent operations. The recovery room
salesperson then falsely promises the victims that, for a fee,
the telemarketer can help them obtain the promised prize or
money lost in a previous telemarketing scam. Often,
telemarketers represent themselves as governmental entities or
as agents hired to locate victims and distribute money back to
them. After the consumers sends in the requested fee, the
company invariably fails to deliver the refund or prize,
thereby exacerbating the victim's losses. A review of victim
demographics in several of the Commission's recovery room cases
has confirmed that older consumers are prominent in the victim
universe. In one case, 81% of the consumers were at least 65
years of age and 23% were at least 80 years old. In another
case, 82% were at least 65 and 32% were at least 80 years old.
During 1995 and 1996, the Commission brought or settled
lawsuits against numerous individuals and companies involved in
nearly a dozen recovery room operations. Some of these cases
were brought as part of Senior Sentinel or other sweeps.
Examples include the Commission's cases against USM and
Meridian Capital Management. In USM, the defendants did
business as Senior Citizens Against Telemarketing, or ``SCAT.''
SCAT allegedly masqueraded as a consumer protection
organization that worked closely with government agencies.
According to the Commission's complaint, SCAT represented to
consumers that it would recover substantial sums of money that
consumers had lost in previous telemarketing scams and would
even file lawsuits on consumers' behalf, if necessary. The
charge to consumers ranged from $200 to $1,000.
Another of the Commission's 1995 lawsuits targeted Meridian
Capital Management, which allegedly made unsolicited telephone
calls to consumers who had been victims of various investment
frauds, often involving Federal Communications Commission
wireless telecommunications licenses. For a fee of 10% of the
consumer's previous investment, Meridian claimed it could
recover all or a substantial portion of the money invested. In
addition, according to the complaint, Meridian also represented
that it was on the verge of filing a class action lawsuit and
the consumer had to pay immediately in order to participate as
a member of the class. Finally, the complaint also challenged
Meridian's representation that it could collect on performance
bonds supposedly posted by fraudulent telemarketers.\7\ In
1996-1997, the Commission obtained default judgments for $1.6
million against Meridian and several individual defendants, and
stipulated or court-ordered permanent injunctions were entered
against all defendants. With Commission staff acting as Special
Assistant U.S. Attorneys, the U.S. Department of Justice in
1998 obtained indictments charging 17 defendants involved in
the Meridian scam with the crimes of conspiracy, mail fraud,
and wire fraud. In addition, seven of the defendants were
charged with money laundering.
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\7\ The Commission also settled its recovery room case against
Regeneration & Renewing dba AWARE, described in the 1994 report, with
monetary judgments of more than $4.1 million.
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The Commission's efforts against recovery rooms were
enhanced by the implementation of the Telemarketing Sales Rule,
which specifically prohibits telemarketers from requesting or
receiving payment for recovery room services until after the
refund or prize is delivered to the consumer. 16 C.F.R.
Sec. 310.4(a)(3). Our law enforcement efforts and the deterrent
effect of this TSR provision have borne fruit. The volume of
consumer complaints concerning recovery rooms logged into the
FTC Telemarketing Complaint System in 1996 plummeted to 153--
less than one-fifth the record high volume of 869 complaints
recorded in 1995.
Credit Fraud
Three types of credit-related telemarketing scams that have
plagued older Americans involved unauthorized check cashing,
advance fee loan schemes, and bogus credit repair services. The
Telemarketing Sales Rule addresses prevalent practices in these
areas.
In attacking unauthorized check cashing or demand draft
fraud, the Commission filed complaints against a cluster of
telemarketers, including, for example, Windward Marketing,
Ltd., charging violations of the demand draft provision of the
TSR. These telemarketers allegedly tricked consumers into
revealing their checking account numbers and then used that
information to debit consumers' checking accounts without the
consumers' authorization. This ruse was in conjunction with a
magazine subscription offering. The case was settled with
monetary judgments of more than $14 million.
In mid-1996, the Commission and 15 state Attorneys General
joined in a sweep called Project Loan Shark, bringing 13
lawsuits against 45 firms and individuals that ran advance
feeloan schemes, in which telemarketers represent that, for a fee, they
will guarantee consumer credit in the form of a loan or credit card.
The TSR makes it illegal for telemarketers who guarantee consumers a
loan or credit to charge an advance fee. Among the targets of Project
Loan Shark was Global E, which marketed credit cards for an advance fee
and was charged with violations of the TSR. The Commission also filed a
complaint alleging that Patricia Popp charged advance fees in
connection with the offer of debt-consolidation services and loans.
Bogus credit repair firms promise that, for a fee, they
will remove negative, though accurate, information contained in
consumers' credit reports. Since credit reporting bureaus
legally may include verifiable, negative information in
consumers' reports for a period of seven years, and
bankruptcies for ten years, credit repair companies cannot
deliver the service they promise. The TSR prohibits credit
repair companies from obtaining payment until six months after
they have, in fact, fulfilled their promise to clean up credit
histories. The Commission charged Universal Credit Corp., with
violations of both the FTC Act and the TSR--the company claimed
a 90% success rate in removing negative, accurate information
from customers' reports and promised a money-back guarantee.
The company was also charged with making unauthorized demand
drafts on customers' checking accounts. As part of the
enforcement strategy in this industry, the Commission launched
Operation Payback, a joint federal-state law enforcement sweep
in 1996 in which the Commission filed four complaints against
deceptive credit repair companies.\8\
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\8\ As part of the 1996 Fair Credit Reporting Act Amendments, the
Congress enacted the Credit Repair Organization Act, 15 U.S.C.
Sec. 1679 et seq., which specifically addresses credit repair scams.
Effective April 1, 1997, the law will be enforced by the Federal Trade
Commission and state Attorneys General.
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cross-border telemarketing fraud
In 1995, the Commission stepped up its response to the
globalization of telemarketing fraud. The Commission had
detected an increase in Canadian-based telemarketing companies
targeting United States citizens, often older consumers.
Canadian officials confirmed that the reverse was also true.
The Commission is tackling this problem through workshops, task
forces, and cooperative law enforcement efforts. In August
1995, representatives of U.S. and Canadian law enforcement
agencies agreed to coordinate enforcement of their competition
and deceptive marketing practices laws. In 1996, the Commission
co-sponsored two conferences on cross-border fraud and
established a task force on Cross-Border Deceptive Marketing
Practices with Canada's Competition Bureau to facilitate
coordinated law enforcement between the two countries.
Also in 1996, the Commission brought its first enforcement
actions against Canadian-based telemarketers. The first case
was against Ideal Credit Referral Services, which operated from
a boilerroom in British Columbia and peddled advance fee loan
services. The next cross-border firm to be sued was another
Canadian firm, Incentive International, which allegedly
fraudulently ran a prize promotion.
The Commission also has pursed defendant's assets across
international borders. In an Operation Roadblock case against
Online Communications, one of the defendants allegedly
transferred assets to the Bahamas. With FTC staff's assistance,
the Department of Justice's Office of Foreign Litigation
obtained an injunction freezing the assets in the Bahamas; the
defendant subsequently agreed to repatriate $300,000 to the
U.S. This was the first time the U.S. government obtained an
asset freeze from a foreign court and obtained the funds for
redress to American telemarketing victims.
internet fraud
Finally, the Commission has anticipated the next great
competitor to telemarketing fraud--fraud on the Internet. Older
Americans are frequent users of the Internet, and the
Commission in 1995 and 1996 held hearings on how not only the
Internet, but many new technologies, were likely to be of
concern in the coming decades.\9\ The Commission also
extensively trained its staff and brought the first significant
actions against Internet fraud artists. In 1996, the Commission
joined with criminal authorities to bring actions against
Fortune Alliance involving a multi-million dollar, online
international pyramid scheme. Other cases included allegations
that defendants used the Internet as a medium for fraudulent
messages.
---------------------------------------------------------------------------
\9\ Anticipating the 21st Century: Consumer Protection Policy in
the New High-Tech Global Marketplace, a Report of the Federal Trade
Commission Staff, May 1996.
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In December 1996, the Commission also initiated the first
of many subsequent ``surf days,'' in which Commission staff
join with other law enforcement agencies and private groups to
detect and warm potentially fraudulent sellers on the Internet.
In this project, the Commission coordinated an effort by four
federal agencies and 70 state and local law enforcement
officials from 24 states to target pyramid schemes. The FTC
staff and other law enforcers contacted over 500 Internet web
sites, advising them of applicable law and conducting follow-up
communications. Since then, the Commission has conducted surf
days in numerous areas of concern, including health fraud,
business opportunities, scholarship scams, and others.
Health-Related Activities
While health care is a subject of concern for all of our
citizens, it is of disproportionate concern to the aging. A
significant portion of the Commission's consumer protection
work helps to ensure that consumers are not harmed by deceptive
claims about the health benefits of products or services.
Similarly, a substantial portion of the Commission's antitrust
law enforcement activity is aimed at ensuring that competition
among providers of health care goods and services is not
unlawfully impaired. This activity contributes both to cost
containment and to the maintenance of quality in health care.
consumer protection in health-related matters
Hearing aids and eyeglasses
In 1994, the Commission filed an order-enforcement action
against Dahlberg, Inc., one of the largest hearing aid
manufacturers in the United States. The Commission's complaint
charged that Dahlberg, maker of the ``Miracle-Ear'' brand of
hearing aids, violated a 1976 FTC order by making false and
unsubstantiated claims about its Miracle-Ear ``Clarifier,''
purportedly a ``noise-suppression'' hearing aid. These claims
included assertions that the Clarifier focuses its
amplification on sounds the user wants to hear, such as speech,
and reduces all unwanted background noise. In 1995, the court
entered a consent decree requiring Dahlberg to pay a penalty of
$2.75 million--at that time the highest penalty obtained for
alleged violations of an FTC consumer protection order.
In another case, the Commission charged in federal court
that the Telebrands Corporation exaggerated the benefits of its
WhisperXL hearing aid, and also violated the Commission's Mail
or Telephone Order Merchandise Rule, 16 CFR Part 435, by
failing to ship products in a timely fashion. The 1996 consent
decree prohibits violations of the Rule, requires the company
to pay a $95,000 civil penalty, and prohibits
misrepresentations about hearing devices. That year, the
Commission also obtained an administrative consent order that
banned false claims, including that the WhisperXL hearing aid
produces clear amplification of whispered or normal speech and
allows the user to hear a whisper from as far as 100 feet away.
The consent order further requires that any claim that is made
about the performance or effectiveness of any hearing aid be
truthful and supported by competent and reliable evidence.
In the vision care area, the Commission obtained a court-
ordered consent decree that required Doctors Eyecare Center,
Inc. and its president to pay a $10,000 civil penalty to settle
charges that they violated the Commission's Ophthalmic Practice
Rules, 16 CFR Part 456, by failing to provide many patients
with a copy of their eyeglass prescription after completing an
eye examination and by unlawfully including on their
prescription forms a waiver of liability as to accuracy. The
purpose of this Rule is to remove unwarranted restraints on the
ability of consumers to shop for competitive eyeglass prices.
Health claims for food and dietary supplements
Consumers rely on the truthfulness of health claims for
food and dietary supplements when making purchasing decisions.
Senior citizens, because of special dietary requirements or
other health concerns, may be particularly vulnerable to
misleading claims for such products. The Commission continues
to be active in this area and has engaged in several important
law enforcement efforts since 1994.
In 1995, the Commission accepted a consent agreement that
prohibits Good News Products, Inc. from claiming that its eggs
were lower in saturated fat and total fat than ordinary eggs,
and that these eggs contained Omega 3 fatty acids that could
positively affect heart attack risk factors. The order against
Good News Products prohibits the company from misrepresenting
the absolute or comparative amount of total fat, saturated fat,
or any other nutrient or ingredient in eggs or food containing
egg yolks. It also requires the company to have competent and
reliable scientific evidence before making claims about the
absolute or comparative effects of such food on heart disease,
heart disease risk factors, and serum cholesterol, and claims
about the health benefits for such foods.
In 1996, the Commission obtained a civil penalty of
$100,000 from Eggland's Best, Inc. to settle allegations that
the company violated a 1994 order by making unsubstantiated
cholesterol-related claims for its eggs. Specifically, the
Commission alleged that Eggland's violated the order by: (1)
representing, without substantiation, that eating its eggs will
not increase serum cholesterol at all, or that doing so will
not increase cholesterol as much as ordinary eggs; and (2)
misrepresenting that clinical studies have proven that adding
12 Eggland's Best eggs a week to a low-fat diet does not
increase serum cholesterol.
Also in 1996, the Commission obtained a settlement with
Mrs. Field's Cookies, Inc. The company claimed that a certain
line of cookies was ``low fat,'' when, in fact, the cookies did
not meet the FDA requirements for low fat claims. The Mrs.
Field's order prohibits the company from misrepresenting the
existence or amount of fat, saturated fat, cholesterol, or
calories in any bakery food product.
Finally, the Commission in 1996 issued a cease and desist
order against The Dannon Company to settle allegations that it
made deceptive fat and calorie content claims for its frozen
yogurt. The order prohibits Dannon from making false claims
regarding the existence or amountof fat, saturated fat,
cholesterol, or calories in any frozen food product. It also requires
the respondent to pay the Commission $150,000.
In the dietary supplement area, the Commission in 1996
completed administrative litigation against Metagenics, Inc.,
challenging claims for its over-the-counter calcium supplement.
The Administrative Law Judge ruled that Metagenics could not,
without adequate substantiation, represent that the product,
Bone Builder, restores lost bone, restores bone strength,
reduces or eliminates bone pain, and is superior to other forms
of calcium. The ALJ found for Metagenics with respect to
certain other complaint allegations, and both sides appealed
the ALJ's ruling.\10\
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\10\ The Commission in 1997 issued a final consent order in the
Metagenics case, among other things, requiring the respondents to have
scientific substantiation for any claim that Bone Builder or any food,
drug, or dietary supplement containing calcium will treat or prevent
any disease, disorder, or condition, or that any food, drug, or dietary
supplement is more effective than any other product in doing so.
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In 1995, the Commission issued a cease and desist order
against Nature's Bounty, Inc. and two of its subsidiaries to
settle allegations that they made deceptive weight-loss, body-
building, disease-treatment and/or other health-related claims
for 26 nutrient supplements they marketed. The order prohibits
the respondents from making various allegedly false claims, as
well as requiring them to have substantiation for future health
claims. The order also requires the respondents to pay $250,000
to the Commission--to be used for consumer redress, if
practical, or to be paid to the U.S. Treasury.
Also in 1995, the Commission gave final approval to a
consent agreement with Body Wise International, Inc., settling
charges that the company made deceptive weight-loss and
cholesterol-reduction claims for its nutritional supplements.
The order prohibits the company from making health benefits
claims regarding its products--including weight loss or
cholesterol reduction claims--unless the claims, including
those made through testimonials, are true and supported by
adequate scientific evidence.
Finally, the Commission in 1995 obtained a civil penalty of
$45,000 from HealthComm, Inc. and Jeffrey S. Bland to settle
allegations that they violated a 1992 order by making deceptive
weight loss and related health claims. The Commission alleged
that the defendants violated the order by: (1) representing
that their supplements UltraMaintain and UltraMeal alter the
mitochondria in the body's cells so that cells convert more
food into energy; and (2) making unsubstantiated weight-loss,
disease symptom-reduction, toxin-elimination, and blood
cholesterol and blood pressure-reduction claims.
Over-the-counter drugs and medical devices
Senior citizens rely heavily on the truthfulness of
advertising claims for over-the-counter (``OTC'') drugs and
medical devices. While the Commission has primary
responsibility for ensuring that advertising for these products
is truthful and nondeceptive, the FDA exercises primary
jurisdiction with respect to the labeling of such products and
their safety.
In 1996, the Commission announced a settlement with Natural
Innovations, Inc., advertiser of ``The Stimulator,'' a
purported pain-relief device said to effectively relieve all
types of pain and provide immediate, long-term pain relief
better than other medications and treatments. In a separate
settlement with World Media T.V., Inc., the Commission alleged
that World Media directly participated in the creation and
dissemination of the ``Say No To Pain'' infomercial on behalf
of Natural Innovations. The Commission charged that the claims
were unsubstantiated. The orders require the companies to
provide scientific proof to back up any pain-relief or other
health or medical benefit claims they make in the future.
In 1995, the Commission issued consent orders against two
marketers of ``facilitated communications'' devices--devices
similar to a typewriter, computer or alphabet chart that
purportedly enable those with developmental or communication
disabilities to communicate through the device. One company,
for example, claimed that its device would help consumers who
had problems such as speech disorders, cerebral palsy, multiple
sclerosis, or Alzheimer's disease. The Commission alleged that
the companies' advertisements contained false or
unsubstantiated representations concerning the efficacy of
their devices. The consent orders ban certain claims and
prohibit the companies from making representations about the
ability of any communications aid to assist those with other
disabilities to communicate through facilitated communications,
unless the representation is true and substantiated by
competent and reliable scientific evidence.
Other health-related devices and services
As with OTC drugs and devices, older consumers are
particularly vulnerable to fraudulent practices and misleading
health benefit claims for other devices and services. The
Commission in 1995-1996 took numerous law enforcement actions
in this area.
One initiative was against telemarketing firms engaged in
fraudulent medical billing practices. The Commission brought
federal court actions against three medical equipment companies
that allegedly marketed relatively inexpensive wheelchairs,
scooters, and other devices to disabled persons but then
submitted insurance claims for more expensive equipment that
was never delivered. In some cases, the Commission charged,
insurance claims were filed for items that had never been
ordered by consumers. Under the court-approved settlements,
Freedom Medical, Inc., Independence Medical, Inc., Motion
Medical, Inc., and individual defendants were required to pay a
total of $754,850 for consumer redress, and some individual
defendants were barred from any aspect of marketing medical
products or services for ten years. In addition, some
defendants were required to post a performance bond before
engaging in the sale or rental of durable medical equipment,
and all defendants were prohibited from making various
misrepresentations in the future.
In addition, Cancer Treatment Centers of America, Inc. and
two affiliated hospitals agreed to settle Commission charges
that they made false and unsubstantiated claims promoting their
cancer treatments. The companies also allegedly failed to
substantiate a claim that their five-year survivorship rate
ranked among the highest recorded for cancer patients. The
consent order requires the companies to have competent and
reliable scientific evidence to substantiate future claims
regarding the success or efficacy of their cancer treatments
and to ensure that testimonials they use do not misrepresent
the typical experience of their patients.
In another settlement, Genetus Alexandria, Inc. and its
owners, who sold impotence treatments, agreed to settle charges
that they falsely represented that a physician would examine,
diagnose, and treat every patient, that the treatment was
unqualifiedly safe, and that the treatment would arrest each
patient's impotence. The respondents also allegedly billed
insurance companies for medical tests that were not performed.
The consent order prohibits the respondents from
misrepresenting the nature or extent of a physician's
participation in any treatment, the safety or efficacy of any
procedure, and the extent to which a treatment is covered by a
patient's medical insurance.
The Commission also brought a number of actions that could
affect older consumers with respiratory ailments. In a matter
involving air pollution claims, Ford Motor Company and its
advertising agency, Young & Rubicam, Inc., agreed to settle
Commission charges that they made false claims about the extent
to which Ford's MicronAir Filtration System could remove air
pollution from automobile passenger cabins. The Commission
alleged that the system had no effect on gaseous pollutants,
such as hydrocarbons, carbon monoxide and nitrogen oxide. The
1996 consent orders prohibit certain claims and require the
firms to have competent and reliable scientific evidence for
any efficacy claims for car cabin air filters.
In 1995, the Commission in two separate cases also obtained
consent agreements with marketers of ozone generator air
cleaners. One case involved Living Air Corporation and its
sister company, Alpine Industries, Inc. The other involved
Quantum Electronics Corporation. In both matters, the
Commission alleged that the companies lacked substantiation for
claims that the devices eliminate or clear specified chemicals,
gasses, mode, mildew, bacteria, or dust from the environment,
that the devices do not create harmful by-products, and that
the devices prevent or provide relief from allergies, asthma,
or other specified conditions. The consent orders require that
the manufacturers of the devices have competent and reliable
scientific evidence before making such claims and contain other
relief to prevent misleading claims about other air cleaning
products.
Finally, the Commission settled allegations that David
Green, M.D. deceptively advertised as pain-free permanent his
varicose vein and spider vein treatments. The consent order
requires Dr. Green to have competent and reliable scientific
evidence to substantiate any future claims on this subject.
Diet and weight loss products and services
Older consumers continue to invest heavily in the weight-
loss industry. The Commission in 1995-1996 has continued to be
active in this area, and has taken numerous actions involving
diet and weight-loss products, programs, and services. These
cases include the settlements mentioned above with Mrs. Field's
Cookies, The Dannon Company, Nature's Bounty, Body Wise
International, and HealthComm, all of which included claims
relating to weight-loss products. The Commission also obtained
a consent order against NordicTrack, Inc., a major manufacturer
of indoor exercise equipment. The Commission had charged that
the firm had made false and unsubstantiated claims about the
weight-loss benefits of its cross-country ski exercise machine,
including claims that overstated users' weight-loss success.
The consent order requires the company to have competent and
reliable evidence to support weight-loss, weight maintenance,
or related claims for any weight-loss equipment that it sells.
The Commission also entered a final consent order against
Choice Diet Products and its owner, marketers of the
FormulaTrim 3000, MegaLoss 1000, and MiracleTrim diet pills,
settling charges of false advertising. The order requires the
company's owner to post a $300,000 performance bond to be used
for consumer redress should he engage in deceptive practices
when marketing weight-loss products in the future and contains
further relief to prevent misleading claims regarding such
products.
In addition to weight-loss products, many older consumers
purchase services from diet clinics. The Commission, having
obtained twelve consent orders against such firms in 1992-1994,
continued this program with further actions in 1995-1996
involving low-calorie and very-low-calorie weight-loss
programs. Formu-3 International, Inc., the franchisor of Form-
You-3 or Formu-3 weight-loss centers, and two related companies
agreed to settle allegations that they made unsubstantiated
weight-loss and weight-loss maintenance claims, engaged in
deceptive pricing, and made misleading representations about
the program's safety, participants' rate of weight loss, and
other deceptive claims. The consent order prohibits the company
from misrepresenting the performance, efficacy, or safety of
any weight-loss program they offer or the competence or
training of their personnel. The order also requires them to
have scientific data to back up future claims about weight-loss
success, rates, or time frames, and weight maintenance.
In a case involving Diet Workshop, Inc., a franchisor of
weight-loss plans and products, the Commission's consent order
similarly prohibits the firms from misrepresenting the
performance of any weight-loss program and requires them to
have reliable scientific evidence to substantiate claims about
achieving or maintaining weight loss, or the rate at which the
loss can be expected to occur. The order also requires
disclosure statements in certain advertising and bars the
misleading use of consumer testimonials. The Commission's
administrative complaints against Weight Watchers
International, Inc. and Jenny Craig, Inc., issued in 1993,
remained in litigation,\11\ and the Commission obtained a
consent order against J. Walter Thompson USA, Inc. in
connection with advertising it had created for the Jenny Craig
Weight Loss Program. That case concerned a study purportedly
showing that nine out of ten Jenny Craig clients would
recommend the program to a friend.
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\11\ The Commission in 1998 issued final consent orders in
settlement of the charges against Jenny Craig and Weight Watchers.
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Finally, the Commission obtained consent orders against
three marketers of single-session, group-hypnosis seminars that
purportedly helped consumers lose weight. The Commission had
charged that the companies and their owners had made false and/
or unsubstantiated claims about the success of participants in
losing weight. The consent orders prohibit the respondents from
making performance or efficacy claims for any weight-loss
program they sell in the future without having competent and
reliable scientific evidence that substantiates the claims.
antitrust guidance to health care providers
The rapid evolution of health care markets in response to
changes in the way health care services are paid for and
delivered has created concerns that the impact of antitrust
enforcement in this sector might impede efficient,
procompetitive combinations and collaborations. As was
described in the Commission's 1994 report, the Commission and
the Department of Justice's Antitrust Division jointly issued,
in September 1993, their Antitrust Enforcement Policy
Statements in the Health Care Area in response to these
concerns. These statements defined ``antitrust safety zones''
for health care activity in various areas; these ``safety
zones'' identified conduct that will not be challenged by the
agencies, absent extraordinary circumstances. Additionally, for
conduct falling outside these ``safety zones,'' the statements
explained how the agencies will analyze the conduct to
determine its legality. Finally, the statements highlighted the
availability of Commission advisory opinions and DOJ business
review procedures, and, for the first time, adopted time limits
for agency answers to most health industry requests.
Subsequently, in September 1994, the Commission and the
Antitrust Division issued updated and expanded policy
statements, Analytical Principles Relating to Health Care and
Antitrust.
The agencies recognized that additional guidance might
become necessary as the health care market continued to evolve
in response to consumer demand and competition in
themarketplace. New arrangements and variations on existing
arrangements involving joint activity by health care providers continue
to emerge to meet the desire of consumers, purchasers and payers for
more efficient delivery of high quality health care services. This
evolution has led, in particular, to the development of many physician
and multiprovider networks.
On August 28, 1996, the agencies announced revisions to the
agencies' enforcement policy statements regarding health care
provider networks. These changes expanded upon the guidance
contained in the agencies' 1993 and 1994 policy statements, in
order to ensure that uncertainty about the antitrust laws does
not deter the formation of new types of networks that could
benefit competition and consumers. Revisions were made
affecting two kinds of networks: (1) physician network joint
ventures; and (2) multiprovider networks.
The revised statement on physician network joint ventures
provides an expanded discussion of the antitrust principles
that apply to such ventures. The revised statement explains
that where physician integration through the network is likely
to produce significant efficiencies, any agreements on price
reasonably necessary to accomplish the venture's procompetitive
benefits will be analyzed under the rule of reason. The
revisions focus on networks that fall outside of the safety
zones, particularly those networks that do not involve the
sharing of substantial financial risk by the physician
participants. The statements stress that a physician network
that falls outside of the safety zones is not necessarily
anticompetitive.
Because multiprovider networks involve a large variety of
structures and relationships among many different types of
health care providers, the agencies have not set out a safety
zone in this area. The 1996 revisions state that multiprovider
networks will be evaluated under the rule of reason, and will
not be viewed as per se illegal if the providers' integration
through the network is likely to produce significant
efficiencies that benefit consumers, and if any price
agreements by the networks are reasonably necessary to realize
those efficiencies.
In 1995 and 1996, the Commission staff provided substantial
guidance in the form of advisory opinions analyzing proposed
ventures on a case-by-case basis.
antitrust law enforcement in the health care sector
Hospital mergers
Pressures for cost-containment have led to an increasing
number of hospital mergers. As in other industries, the
Commission challenges only those hospital mergers that it has
reason to believe are likely to have anticompetitive results,
and it seeks a remedy that is carefully tailored to eliminate
only the anticompetitive part of the transaction while allowing
the remainder to proceed.
In 1995 and 1996, the Commission obtained consent
agreements in five cases involving hospital mergers. Three
cases involved mergers of large hospital chains and
demonstrated the Commission's sharply focused approach to
anticompetitive situations. In the first of these cases, the
Commission issued a final consent order involving Columbia/HCA
Healthcare Corporation's acquisition of Healthtrust Inc., which
combined the two largest chains of acute-care hospitals in the
country. Although there were a significant number of overlaps
throughout the country--where both chains had hospitals in the
same area--Commission staff, after thorough investigation,
found that the merger would substantially lessen competition
for general acute-care hospital services in only six geographic
markets: the Salt Lake City-Ogden Metropolitan Statistical
Area, Utah; the Denton, Texas area; the Ville Platte-Mamou-
Opelousas, Louisiana area; the Pensacola, Florida area; the
Okaloosa, Florida area; and the Orlando, Florida area. As part
of a settlement agreement, the companies agreed to divest seven
hospitals in those areas. The Commission did not challenge
other aspects of the merger.
The Commission also issued final consent orders in two
other hospital merger cases involving large national chains.
One involved the merger of Charter Medical Corporation and
National Medical Enterprises, the two largest chains of
psychiatric hospitals in the country. Charter agreed to modify
its purchase agreement so as not to acquire the NME facilities
in four geographic markets--Atlanta, Memphis, Orlando and
Richmond--in which the Commission alleged that the acquisition
would substantially lessen competition in the psychiatric care
market. Charter's acquisition was allowed to proceed in the
other markets. Another case involved the merger of HEALTHSOUTH
Rehabilitation Corporation, the nation's leading operator of
rehabilitation hospitals and other rehabilitation facilities,
with ReLife Inc., which operated a number of rehabilitation
facilities. The Commission obtained a consent agreement in
which HEALTHSOUTH agreed to divest a hospital in Nashville,
Tennessee, and to terminate management contracts to operate
rehabilitation units at hospitals in Birmingham and Charleston.
In a fourth hospital merger case, the Commission approved a
consent agreement concerning Columbia/HCA's acquisition of John
Randolph Medical Center in Hopewell, Virginia. John Randolph
provided psychiatric services in that market and Columbia
already owned Poplar Springs Hospital, a psychiatric hospital
in Petersburg, Virginia. Under the consent agreement, Columbia/
HCA was allowed to purchase John Randolph only if it divested
Poplar Springs.
Finally, the Commission authorized the staff to seek a
preliminary injunction to block the merger of Port Huron
Hospital and Mercy Hospital-Port Huron, Inc., the only two
general acute care hospitals in Port Huron, Michigan. Prior to
trial, the Port Huron hospitals called off the transaction and
a consent agreement was signed requiring prior approval before
the parties attempt to merge again.
Conduct involving health care providers
During 1995 and 1996, the Commission issued four final
consent orders in cases alleging joint conduct by physicians
that prevented competition among health care providers.
The Commission issued a consent order against the medical
staff of Good Samaritan Regional Medical Center in Phoenix,
Arizona. The agreement settled charges that the staff members
conspired, or threatened, to boycott the hospital in order to
induce it to end its ownership interest in the Samaritan
Physicians Center, a multi-specialty physicians' clinic that
would have competed with the medical staff. Under the
agreement, members of the medical staff are prohibited from
agreeing, or attempting to agree, to prevent or restrict the
services offered by Good Samaritan, the Samaritan Physicians
Center, or any other health care provider.
The Commission also issued a consent order against
Physicians Group, Inc. and seven physician board members of the
organization, settling charges that they conspired to fix the
prices, terms, and conditions of cost-containment under which
they would deal with third-party payers. The complaint alleged
that the group conspired to prevent or delay the entry of
third-party payers into Pittsylvania County and Danville,
Virginia. The order required the dissolution of Physicians
Group, Inc. and prohibits the physician respondents from
engaging in similar anticompetitive conduct with respect to
third-party payers.
In addition, the Commission issued a consent order against
the Medical Association of Puerto Rico, its Physiatry Section,
and two of its physiatrist members. The Commission charged that
the Association illegally conspired to boycott a government
insurance program in order to obtain exclusive referral powers
from insurers, and to increase reimbursement rates. The
respondents agreed not to boycott or refuse to deal with any
third-party payer, or refuse to provide services to patients
covered by any third-party payer. The agreement places
restrictions on meetings of physiatrists to discuss refusals to
deal with any third-party payer, or the provision of services
covered by any third-party payer; and prohibits the respondents
from soliciting information from physiatrists about their
decisions to participate in agreements with insurers and
provide service to patients, passing such information along to
other doctors, and giving physiatrists advice about making
those decisions.
Finally, the Commission issued a consent order against a
physician association (MAPI) and a physician-hospital
organization (BPHA) in Billings, Montana. The complaint alleged
that MAPI blocked the entry of an HMO into Billings, obstructed
a PPO that was seeking to enter, recommended physician fee
increases, and later acted through BPHA to maintain fee levels.
The associations agreed not to boycott or refuse to deal with
third-party payers, to determine the terms upon which
physicians deal with such payers, or to fix the fees charged
for any physician services. MAPI also is prohibited from
advising physicians to raise, maintain, or adjust the fees
charged for their medical services, or from creating or
encouraging adherence to any fee schedule. The order does not
prevent these associations from entering into legitimate joint
ventures that are non-exclusive and involve the sharing of
substantial financial risk.
restraints on advertising
The Commission issued a complaint charging that the
California Dental Association had unreasonably restricted its
dentist members' truthful and nondeceptive advertising of the
price, quality, and availability of their services, and had
imposed what were effectively prohibitions against advertising
senior-citizen discounts. In March 1996, the Commission issued
an opinion and order affirming an ALJ's decision finding that
the California Dental Association's rules violated Section 5 of
the FTC Act. The Commission's order requires CDA, among other
things, to cease and desist from restricting truthful,
nondeceptive advertising (including truthful, nondeceptive
superiority claims, quality claims, and offers of discounts);
to remove from its Code of Ethics any provisions that include
such restrictions; and to contact dentists who have been
expelled or denied membership in the last 10 years based on
their advertising practices and invite them to re-apply. The
order also requires CDA to set up a compliance program to
ensure that its constituent societies interpret and apply CDA's
rules in a manner that is consistent with the order. The
Commission's order was affirmed by the 9th Circuit in 1997.\12\
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\12\ California Dental Association v. FTC, 128 F. 3d 720 (9th Cir.
1997).
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Competition activities in the pharmaceutical field
Competition and competitive prices in the pharmaceutical
industry are particularly important to older Americans. There
are at least three reasons why this is so. First, merely by
virtue of their age, older persons are more likely to have
medical problems than the average American and thus are more
likely to purchase pharmaceutical products. It has been
reported that roughly 13 percent of our population is over the
age of 65 but that this group consumes more than a third of all
prescription drugs dispensed, and that this percentage is
increasing. Second, older persons are less likely to have
insurance that helps pay for their drugs and thus must bear the
entire cost of their medicines. Almost all elderly consumers
rely on Medicare, which does not have a prescription drug
benefit. Reimbursement is available only to Medicare recipients
who can afford Medi-gap coverage, are poor enough to qualify
for Medicaid, or are in a managed care plan that offers a
prescription drug benefit. Third, because many of the nation's
senior citizens have limited financial resources, as a group
they are disproportionately affected by pharmaceutical prices.
Mergers in manufacture and distribution of pharmaceuticals
The Commission was quite active during 1995 and 1996 in the
role of protecting competition in this area, focusing on
oversight of merger activity in both the manufacturing and
distribution of pharmaceuticals.
In the manufacturing sector, in 1995 the Commission issued
a consent order requiring American Home Products to divest its
tetanus and diphtheria vaccines and to license its rotavirus
vaccine research as a condition for acquiring American Cyanamid
Company. Also made final in 1995 was a consent order
prohibiting IVAX Corporation from acquiring any rights to
market a generic version of verapamil--a drug used to treat
patients with chronic cardiac conditions--from Zenith
Laboratories. IVAX and Zenith were the only two suppliers of
generic verapamil. This settlement ensured that two generic
suppliers of this drug remained in the market.
In 1995, the Commission also accepted a consent agreement
with Glaxo plc, settling charges that its acquisition of
Wellcome plc lessened competition in the research and
development of drugs to treat migraine headaches. The consent
order required Glaxo to divest one of the competing research
and development projects to a Commission-approved buyer.
The Commission also obtained relief in four pharmaceutical
markets when it challenged the proposed acquisition of Marion
Merrell Dow by Hoechst AG. The consent agreement with Hoechst
required the company to divest assets and take other actions to
restore competition in the following markets: (1) once-a-day
diltiazem, a medication used to treat hypertension and angina;
(2) mesalamine, a medication used to treat gastrointestinal
diseases; (3) rifampin, a drug for tuberculosis; and (4) drugs
used to treat intermittent claudication, a circulatory disease.
These four product markets have annual sales of over $1.25
billion. The consent order against Hoechst was issued in 1996.
Another consent order that was issued in 1996 involved the
merger of Upjohn Company and Pharmacia Aktiebolag. In that
case, the companies agreed to divest one of their research and
development projects to develop a drug to treat colorectal
cancer, in order to maintain competition in the development of
such drugs.
Finally, two consent agreements were accepted for public
comment in December of 1996. In one, Baxter International, Inc.
agreed to divest blood plasma products in order to proceed with
its acquisition of Immuno International AG. In the other
consent agreement, the Commission required Ciba Geigy, Ltd. and
Sandoz, Ltd. to license their patents and intellectual property
in the broad area of gene therapy research to an independent
competitor as a condition for allowing their merger to proceed.
The Commission also challenged two acquisitions in the
retail sale of prescription drugs in order to protect
competition for the millions of Americans that obtain
prescription drugs through pharmacy benefit plans. In December
of 1996, J.C. Penney/Thrift agreed to divest over 100
drugstores in North and South Carolina before it purchased the
Eckerd drugstore chain and certain drugstores from Rite Aid. In
the other case, the Commission voted on April 17, 1996, to seek
a preliminary injunction in federal district court to block
Rite Aid's proposed acquisition of Revco. As a result of this
vote, Rite Aid abandoned its planned acquisition.
Pharmacy services
Older consumers also are vulnerable to non-merger-related
anticompetitive conduct in the pharmacy industry. The
Commission has therefore acted to eliminate agreements among
pharmacies that raise the price of medications.
In June 1996, the Commission issued a consent order barring
RxCare of Tennessee, Inc., a pharmacy network, and the
Tennessee Pharmacists Association, its owner, from using ``Most
Favored Nation'' clauses in RxCare's contracts with pharmacies.
The Commission alleged that RxCare enforced these clauses
against pharmacies that accepted reimbursement rates from other
third-party payers that were lower than the RxCare rate, and
thus discouraged pharmacies from participating in rival, lower-
priced networks. The clause forced third-party payers to pay
higher rates in Tennessee than in other states.
Finally, Commission staff in 1996 opened an investigation
of a pharmacy network and its members, who are large
institutional pharmacies in one state that serve nursing homes
and similar institutions. The investigation concerned joint
negotiation of prescription drug reimbursement rates for the
state's Medicaid program.
health care regulation
The staff of the Commission continued in 1995-1996 to
monitor restraints imposed by existing or proposed regulations
and actions that could raise costs to consumers by reducing
competition in the health care industry, without providing
countervailing benefits to consumers. As part of the
Commission's competition advocacy programs, Commission staff
\13\ in 1995-1996 submitted comments to the Kansas legislature
on a bill to amend Kansas's laws governing optometry. The bill
proposed clarifying the restrictions on commercial forms of
practice and would have facilitated optometrists locating in
space leased from optical goods stores. The staff concluded
that relaxing constraints on commercial practices is consistent
with the direction the Commission took in its Eyeglasses II
rulemaking, and clarifying conditions under which optometrists
may lease space from optical goods stores could benefit
consumers through greater competition and efficiencies in
operation.
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\13\ Staff advocacy comments and testimony are authorized by the
Commission but are not substantively approved by the Commission and do
not necessarily reflect the views of the Commission or any individual
Commissioner.
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Regarding consumer protection issues, the staff filed two
sets of comments with the Food and Drug Administration in
response to a notice of proposed rulemaking. The first
concerned its regulation of direct-to-consumer advertising for
prescription drugs. The staff suggested that the FDA consider
adopting an approach similar to the FTC's Deception Policy
Statement and Statement on Advertising Substantiation to assist
in evaluating the accuracy of prescription drug advertisements.
The staff recommended that limiting current disclosure
requirements and adjusting disclosure requirements according to
advertising venues could increase the net benefits of direct-
to-consumer advertisements. The staff also recommended that the
FDA consider alternative means for ensuring consumer access to
important information to replace the highly technical and
lengthy ``brief summary'' currently appearing in consumer-
directed prescription drug advertising. The second comment
concerned how structural changes in the health care industry
affect its responsibilities to regulate drug marketing and
promotion. The staff suggested that the FDA consider a more
flexible substantiation standard--one that requires competent
and reliable evidence whose level could depend on the claim
being made, rather than on an a priori requirement. The staff
also suggested that the FDA may wish to consider a disclosure
approach for any deception concerning ``switch'' programs,
because clear and conspicuous disclosures of material
connections between pharmacy benefit plans and drug producers
could cure deception while preserving the potential economic
benefits of the programs.
Commission Action in Other Fields
funeral services
Consumer protection
The Commission is responsible for enforcing the FTC's
Funeral Industry Practices Rule, 16 CFR Part 453, a Rule of
considerable importance to older Americans and their families.
The Rule is designed to ensure that consumers receive accurate
information about prices, options, and legal requirements for
funeral services, so that they can make informed purchasing
decisions. Funeral services, which often cost $10,000 or more,
come at emotionally difficult times and may be among the most
expensive of consumer purchases. In many cases, these also are
first-time purchases, making it particularly important for
consumers to receive immediate and accurate information.
From 1984 through 1994, the Commission brought 43
enforcement actions against funeral homes for failing to comply
with the Rule. Despite the Commission's enforcement efforts,
compliance with the Rule remained as low as 36 percent. Thus,
it became apparent that a new strategy was needed. In 1995 and
1996, Commission staff, with the assistance of the Tennessee,
Mississippi, and Delaware Attorneys General, conducted four
sweeps in which investigators posing as consumers ``test
shopped'' funeral homes in those states for Rule compliance.
The FTC also conducted a pilot sweep in Florida. Those sweeps
of 89 funeral homes resulted in 20 FTC enforcement actions,\14\
nearly half as many as were brought in the previous decade
since the Rule went into effect.
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\14\ The State of Tennessee also brought four additional actions in
connection with the sweep conducted in that state. Also in 1995, in
settling a case filed against Restland Funeral Homes, Inc. of Dallas
and four subsidiaries, the Commission obtained a civil penalty of
$121,600, the highest ever paid in a Funeral Rule case. In other non-
sweep 1995 cases, the Commission filed actions against two Northern
California funeral homes: Chapel of the Chimes agreed to pay a $70,000
civil penalty to settle charges that it violated the Funeral Rule; and
Lewis & Ribbs Mortuary, Inc. agreed to pay $20,000 as a civil penalty.
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The funeral industry took note of the Commission's new
enforcement efforts, and in September 1995, the National
Funeral Directors Association (``NFDA'') submitted a proposal
to the Commission for an industry self-certification and
training program to increase Rule compliance. The Commission
agreed to this proposal in January 1996.
The first component of this new NFDA initiative is the
Funeral Rule Offenders Program (``FROP''), which offers a non-
litigation alternative for correcting apparent ``core''
violations of the Rule--i.e., failing to provide itemized price
lists of available goods and services to consumers seeking to
arrange a funeral. Under FROP, if a funeral home is identified
by investigators as having failed to provide the required price
lists, the home may, at the Commission's discretion, be offered
the choice of a conventional investigation and potential law
enforcement action resulting in a federal court order and civil
penalties as high as $11,000 per violation, or participation in
FROP. Violators choosing to enroll in FROP make voluntary
payments to the U.S. Treasury or state Attorney General, but
those payments generally are less than the amount the
Commission would seek as a civil penalty. NFDA attorneys then
review the home's practices, revise them so they are in
compliance with the Funeral Rule, and then conduct on-site
training and testing.
The Commission, in cooperation with state Attorneys
General, has continued to conduct Funeral Rule sweeps since the
adoption of FROP. Those sweeps, conducted in Massachusetts,
Oklahoma, Ohio, Colorado, and Illinois, indicate that
compliance among funeral homes has improved significantly since
1994. Nearly 90 percent of funeral homes subjected to test
shopping in 1996 complied with the key general price list
requirements.\15\
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\15\ In one survey conducted before the Commission adopted FROP,
only 36 percent of the homes tested were in compliance.
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Competition activities
The Commission is active on the antitrust side of its
jurisdiction in ensuring that competition is maintained in
funeral services and cemetery services. Where mergers take
place between two chains providing such services, we examine
them for overlaps in particular local markets, in order to
ensure that every local market retains enough providers to give
consumers acompetitive range of alternatives. As part of this
program, the Commission during 1995 obtained a consent order against
Service Corporation International (``SCI''), the largest owner and
operator of funeral homes and cemeteries in North America, for its
acquisition of Uniservice Corporation. That acquisition was likely to
result in a substantial lessening of competition for funeral services
and perpetual care cemetery services in and around Medford, Oregon. The
consent agreement required the divestiture by SCI of two funeral homes,
a cemetery, and a crematory there. The Commission also obtained a
number of other, similar consent agreements involving funeral-chain
acquisitions during 1995-96. These orders protected local markets in
Amarillo, Brownsville, Harlingen, and San Benito, Texas; Brevard and
Lee Counties, Florida; and Castlewood, Virginia.
mail or telephone order merchandise
The Commission's Mail or Telephone Order Merchandise Rule,
16 CFR Part 435, requires sellers to make timely shipment of
orders; give options to consumers to cancel an order and
receive a prompt refund, or to consent to any delay in
delivery; have a reasonable basis for any promised shipping
dates (the Rule presumes a 30-day shipping date when no date is
promised in an advertisement); and make prompt refunds. In
issuing the original Mail Order Rule in 1975, the Commission
noted that consumers with mobility problems, including older
consumers, frequently order by mail. On March 1, 1994, the
Commission amended the Rule to include telephone sales, one
consideration being evidence submitted by the AARP indicating
that a significant percentage of persons age 65 and older order
products and services by telephone.
The Commission staff works closely with industry members
and trade associations to obtain compliance with the Rule, and
it initiates law enforcement actions where appropriate. During
1995 and 1996, courts entered three consent decrees resolving
alleged Rule violations, resulting in judgments for civil
penalties totaling $245,000.
used car sales
The Used Car Rule, 16 CFR Part 455, requires that used care
dealers display ``Buyers Guides'' on the windows of their cars
to tell consumers whether the vehicle comes with a warranty or
is sold ``as is.'' These warranty disclosure requirements can
be of particular benefit to older consumers, who may be on
fixed incomes and therefore more likely to purchase less
expensive used cars. They also may be less able to meet sudden,
unexpected repair expenses. In 1995, a U.S. District Court
judge upheld Commission charges against an Illinois used car
dealer for Rule violations. The defendant paid a civil penalty
of $4,500 and is prohibited from any future violations of the
Rule. The Commission solicited public comment on the Rule in
1994 as part of its systematic review of all current Commission
regulations and guides, and, in December 1995, announced that
it would retain the Rule with minor changes.
door-to-door sales
The Cooling-Off Rule, 16 CFR Part 429, requires that
consumers be given a three-day right to cancel certain sales
occurring away from the seller's place of business (often known
as ``door-to-door sales''). In addition, the Commission, in
some administrative cease and desist orders against companies
engaged in door-to-door sales, has required companies to allow
consumers the right to cancel purchases not covered under the
Rule. The Rule and these orders can particularly benefit older
Americans who are retired and at home, and who may be exposed
more frequently to high pressure sales tactics by door-to-door
or other sellers.
As part of its systematic review of all current Commission
regulations and guides, the Commission requested public
comments in 1994 on, among other things, the economic impact
of, and the continuing need for, the Cooling-Off Rule; possible
conflict between the Rule and state, local or other federal
laws; and the effect on the Rule of any technological,
economic, or other industry changes. Comments from both buyers'
and sellers' representatives were submitted. All of the
comments stated that the Rule provides important protections
for consumers and favored retaining the Rule. The AARP
commented that the Rule is especially needed to protect older
consumers who are most vulunerable to unscrupulous door-to-door
sellers. In 1995, the Commission decided to retain the Rule
with minor changes.
energy costs
The cost of heating and cooling one's home can be
especially burdensome to older consumers. Retired individuals,
who tend to spend more time at home than working individuals,
may have less opportunity to lower their home heating or
cooling requirements during the day. In addition, senior
citizens, being more susceptible to hypothermia, are often
counseled to maintain a higher temperature in their homes than
younger persons might comfortably tolerate. Those on fixed
incomes also may face greater relative economic burdens in
meeting energy costs.
Properly insulated homes can maintain more constant
temperatures and can save consumers substantial amounts on
heating and cooling costs. The Commission's Rule Concerning the
Labeling and Advertising of Home Insulation (``R-value Rule''),
16 CFR Part 460, assists consumers by requiring that sellers of
insulation accurately disclose the ``R-value,'' or insulating
effectiveness, of such products. The Rule also requires
installers and new home sellers to give consumers a written
disclosure of the type and R-value of the insulation installed;
requires retailers to make specific information available at
the point-of-sale to consumers who purchase insulation for do-
to-yourself installation; and requires advertisers to include
important disclosures in advertisements that contain claims.
The Commission solicited public comments in 1995 on the current
need for, benefits of, and burdens imposed by, the Rule. Based
on the comments submitted, the Commission in 1996 found that
the Rule had significant benefits for both consumers and
insulation sellers, imposed minimal, if any, costs or other
burdens on consumers or sellers, and that there was a
continuing need for the Rule.
The Commission also has investigated the accuracy of claims
of the insulating effectiveness, known as ``U-value'' of
windows and doors used in homes. Insulating effectiveness of
such products is often determined by independent laboratories
following government-approved test methods. State and local
governments then use the U-value test results to determine if
windows and doors comply with state and local building codes.
In 1996, the Commission filed a consent decree in the U.S.
District Court for the Western District of Washington settling
charges that Insulate Industries modified test samples to
improve the U-Value of its windows and used the deceptive
results to sell windows that did not perform as the test
results indicated that they would. The decree prohibited the
alleged conduct and required the manufacturer to provide new
windows for distribution to customers by the states of
Washington and Oregon, which maintain certification programs
for that industry.
appliance labeling rule
Utility costs are some of the least discretionary items in
the household budget, and are of particular concern to those on
fixed incomes. The Commission's Appliance Labeling Rule, 16CFR
Part 305, helps consumers control costs in several ways. First, the
Rule enables consumers to reduce energy costs by requiring
manufacturers to disclose the energy usage of major household
appliances and the water usage of showerheads, faucets, toilets, and
urinals. For appliances, the Rule requires disclosure of specific
energy consumption, efficiency, or cost consumption for covered
products in catalogs. It also requires information at the point of sale
in the form of an ``Energy Guide'' label or fact sheet, or in an
industry directory. Because energy efficient appliances cost less to
run over the life of the product, the Rule enables those older
consumers who may be on limited incomes to keep down monthly expenses
for running major home appliances, such as refrigerators and heating
and cooling equipment.
Second, the Rule requires certain disclosures relating to
three categories of light bulbs or tubes: general service
incandescent bulbs (including spot lights and flood lights);
general service fluorescence tubes; and medium screw-base
compact fluorescent tubes. For the bulbs most commonly used in
the home, incandescent light bulbs and screw-base compact
fluorescent tubes, the Rule requires that package labels
disclose: light output, in lumens; energy used, in watts;
voltage, average life, in hours; the number of bulbs or tubes
in the package; and a statement explaining how to select the
most energy efficient bulb.
Compliance with the Rules is generally high. The appliance
industry is largely self-policing through certification
programs maintained by the several large trade associations
that represent most manufacturers.
fuel rating rule
The Commission's Fuel Rating Rule, 16 CFR Part 306,
established national, standardized procedures for determining,
certifying, and posting (on pumps) octane rating for gasoline
and other ratings for certain liquid alternative fuels like
ethanol and methanol. Accurate certification and posting of
fuel ratings deter distributors and retailers from deceptively
selling lower-rated fuel as being higher-rated. The Rule may be
particularly beneficial to many older Americans who increase
vacation travel during retirement, and, with more time and
reduced income, do so by automobile or recreation vehicles.
To help ensure accurate ratings, the Commission in 1995
completed a nationwide survey of gasoline distributors to
determine whether they are accurately certifying gasoline
octane ratings and keeping required records. The survey, which
began in 1991, focused on gasoline distributors in states that
have no octane-testing program, and in states that had
expressed concern about possible octane mislabeling problems.
While indicating generally high overall compliance with the
Commission's Fuel Rating Rule, the investigation did lead to
three law enforcement actions, and the FTC obtained a total of
$82,500 in civil penalties in those cases.
credit practices
Credit fraud
The Credit Practices Program enforces several federal
credit statutes that affect more than 113 million consumers
holding credit cards and many millions more who apply for
credit and loans. Credit fraud continues to affect consumers of
all ages and income levels. The impact of such abuses can be
particularly devastating to seniors who rely on credit to
augment their income and therefore may be more receptive to
credit offers that are ``to good to be true.''
Each year, the Commission receives thousands of consumer
complaints regarding harassing and abusive behavior by debt
collectors. Often, these letters come from senior citizens. The
Commission brought a number of lawsuits in 1995 and 1996
against debt collectors for violations of the Fair Debt
Collection Practices Act (``FDCPA''), 15 U.S.C. Sec. 1692 et
seq.
In March 1995, Payco American Corporation (``Payco''), one
of the nation's largest debt collection agencies, agreed to pay
a $500,000 civil penalty to settle allegations that it violated
the FDCPA. The Commission's lawsuit, filed in August 1993
through the Department of Justice, charged, among other things,
that Payco illegally revealed consumer debts to third parties;
used obscene or profane language; telephoned debtors at times
and places known to be inconvenient to the consumers being
contacted; and made several misrepresentations to consumers. In
addition to the $500,000 civil penalty, the settlement
prohibits Payco from violating the FDCPA in the future, and
requires the company to give notice to all employees who are
responsible for debt collection that they may be held liable
individually if they are found to be violating the FDCPA.
The Commission brought several other FDCPA actions in 1995.
The Commission settled allegations that Great Lakes Collection
Bureau, Inc. violated the FDCPA by, among other things,
communicating or threatening to communicate with the third
parties and to disclose the debt, harassing and abusing the
consumer, and falsely representing or implying that an attorney
had been involved in the collection effort and that non-payment
would result in attachment, garnishment, or legal action. The
company paid $150,000 in civil penalties, and agreed to
injunctive relief. The Commission also sued Trans Continental
Affiliates (``TCA'') and TCA principal charging a number of
egregious violations of the FDCPA, including using obscene
language, calling repeatedly or calling at all hours, and
misrepresenting that failing to pay debts would result in
arrest or imprisonment. Settlements with two of the individual
defendants were filed with the compliant.
During 1996, the Commission, through the Department of
Justice, concluded its litigation against National Financial
Services (``NFS''), its owner, and an attorney who helped
devise and mail the collector's dunning notices for serious,
persistent violations of the FDCPA involving false threat of
legal action. In July 1995, the district court ordered NFS and
its owner to pay a $50,000 civil penalty, and its attorney to
pay a $500,000 civil penalty. That order was upheld on appeal
by the Fourth Circuit in 1996. Finally, the Commission in 1996
resolved a variety of similar allegations in settlements with
United Creditor's Alliance Corp. ($146,000 civil penalty),
Allied Bond and Collection Agency ($140,000 civil penalty), and
G & L Financial Services, Inc. ($10,000 civil penalty). The
federal court consent decrees in these cases also include
injunctive relief to prohibit future violations.
Equal Credit Opportunity Act
Among other things, the Equal Credit Opportunity Act
(``ECOA''), 15 U.S.C. Sec. 1691 et seq., prohibits
discrimination based on age in determining whether or not to
extend credit. To help detect discrimination based on age or
other prohibited factors (such as sex or race), the ECOA
requires written notice to consumers of the reasons for a
denial of consumer credit. In 1996, the Commission filed a
settlement with J.C. Penny to resolve allegations that the
company had violated consumers' rights under the ECOA to
receive such written notice. The settlement provided for an
innovative consumer notification program costing the company an
estimated $1 million, in addition to $225,000 in civil
penalties.
consumer protection regulation
In 1995 and 1996, the Commission continued to monitor
regulatory proposals and actions by federal, state and other
entities that could have actual or potential economic impact
onconsumers. Commission staff testified before the Michigan State House
of Representatives on proposed legislation that would have amended the
Michigan statutes regulating the licensing and operation of funeral
establishments and cemeteries in Michigan. The staff supported the
legislation, concluding that joint ownership or operation of a funeral
establishment and a cemetery could make possible new business formats
and improvements in efficiency and could encourage entry of new
competitors, which could, in turn, lead to lower prices and improved
service to consumers.
Also during the period, Commission staff filed comments
with the Federal Communications Commission supporting the FCC's
efforts to keep unscrupulous pay-per-call service providers
from evading federal regulations governing the 900-number
industry. In particular, the staff supported the FCC's efforts
to prevent pay-per-call transactions from being disguised as
long-distance calls, by requiring that whenever a provider of
information or entertainment programs receives any remuneration
for calls to such a program, the call must fall within the 900-
number dialing code. The staff said that consumers would likely
benefit from this proposal, because it would allow them to
recognize telephone numbers for calls that entail charges above
regular long distance charges, would subject the calls to cost-
disclosure and billing-dispute requirements, and would enable
consumers to prevent charges for unauthorized calls by blocking
900 numbers.
Consumer Education Activities Affecting Older Consumers
The Commission, through its Office of Consumer and Business
Education (``OCBE''), is involved in preparing and distributing
a variety of consumer publications and broadcast materials.
Many of the subjects are of significant interest to older
consumers. In addition, Commission staff in 1995-1996 engaged
in substantial, additional consumer education efforts at the
local and regional levels, including regional ``town hall''
meetings with consumers and Consumer Education Fairs.
1995-1996 Consumer education activities
During calendar years 1995-1996, the OCBE produced or
revised more than 100 publications covering a broad range of
consumer protection topics. Eighteen of these publications are
of special interest to older Americans. Most FTC consumer
publications are not age-specific. However, publications on
certain topics, such as telemarketing scams, health care,
funeral services, or credit issues highlight many of the needs
and concerns of older citizens.
telemarketing scams
Some telemarketers have admitted that older consumers are
attractive targets for unscrupulous promotions. The FTC
produced or revised five publications during this period that
focus on a variety of telemarketing scams and offer solid tips
on how to recognize and avoid these scams. One especially
offensive scheme that preys on former victims of telemarketing
fraud is covered in the publication Telemarketing Recovery
Scams. The Commission issued this brochure in 1996. The four
related brochures issued during the period include Straight
Talk About Telemarketing, Prize Offers, International Telephone
Number Scams, and Are You A Target of Telephone Scams? The last
brochure mentioned also was published in a large-print edition
for older consumers.
At the local level, the elderly in many cultures and
communities seek advice on business transactions from their
religious leaders, particularly where they may not have adult
children, lawyers, or accountants to consult. In 1995,
Commission staff co-sponsored the Commission's first Consumer
Workshop for religious leaders. In partnership with the Harlem
Consumer Education Council, the U.S. Office for Consumer
Affairs, and the Harlem Branch Office of the New York State
Attorney General, workshops were conducted at a Harlem church
for ministers, priests, and rabbis on a wide range of consumer
issues, including the continued victimization of older
Americans via telemarketing fraud and door-to-door sales. The
workshop was aired on two local Cable TV channels over a period
of three-months.
In Denver, Colorado, Commission staff teamed with the
Colorado Attorney General, the Denver District Attorney, the
Better Business Bureau, and the American Association of Retired
Persons to sponsor a conference to educate seniors about all
types of fraud, including telemarketing fraud, under the group
name Seniors Against Fraud and Exploitation (``SAFE''). Also,
Commission staff trained student and senior volunteers to give
presentations on telemarketing fraud to senior centers in the
Seattle area. Seven volunteers made presentations at 14 senior
centers during the summer of 1996. In Columbia, South Carolina,
the staff participated in a video-teleconference that included
presentations by the White House Special Assistant for Consumer
Affairs and the AARP, as well as representatives from several
other consumer protection agencies. The teleconference was
aired on South Carolina Education Television, channel C,
reaching about 150,000 to 200,000 consumers. The telecast
included statements from consumers who had been victimized and
actual footage of scam artists making various
misrepresentations to consumers. The topics discussed included
telemarketing travel fraud, sweepstakes and prize promotions,
recovery scams, investment scams, charitable solicitations and
tips on how to avoid being scammed.
Finally, Commission staff participated in two ``reverse
boilerrooms'' coordinated by the AARP and the Illinois Attorney
Generals's Office. The reverse boilerroom is a means of
providing consumer education to persons whose names appear on
lead, or ``mooch,'' lists and therefore are particularly likely
to be contacted by fraudulent telemarketers. The volunteers in
a reverse boilerroom call consumers on the lists, talk with
them about the risks of telemarketing fraud, and inform them
that their names and telephone numbers are circulating among
real boilerroom scam artists.
health
Two Commission publications produced in 1996 address health
issues that affect older consumers. The first, Fraudulent
Health Claims: Don't Be Fooled, produced in cooperation with
the U.S. Food and Drug Administration, focuses on the
worthless, and sometimes life-threatening, bogus health care
products and treatments upon which American consumers spend
billions of dollars each year. The brochure also addressed
cross-border health care fraud by providing information on
government contacts in Mexico and its states. The second
brochure, Who Cares?--Sources of Information About Health Care
Products and Services, is a joint effort with the National
Association of Attorneys General and provides a listing of
federal, state and private organizations that provide
assistance and information to consumers about such things as
prescription drugs, hearing aids, nursing facilities,
alternative medicine, cataract surgery, purported arthritis
cures, direct-mail schemes, and abusive care-givers.
funerals
Choosing and buying funeral services and caskets and
understanding consumer rights protected by the FTC's Funeral
Rule were topics of two publications revised during this
period--Caskets and Burial Vaults Funerals: A Consumer Guide.
In a third brochure, Viatical Settlements: A Guide for People
with Terminal Illnesses, the Commission describes this method
of allowing living persons to receive the benefits of their
life insurance policies, which benefits could be used to pre-
pay funeral expenses.
credit and financial matters
Credit and money issues that have a direct impact on older
consumers were among the topics of several publications
distributed by the FTC in 1995-96. Credit and Older Americans,
Equal Credit Opportunity, and Mortgage Discrimination emphasize
and explain consumer rights under the law. The pros-and-cons of
taking advantage of home equity is discussed in Reverse
Mortgages, a brochure designed for older consumers and their
families. Likewise, High-Rate, High-Fee Loans (Section 32
Mortgages) explains consumer rights under the Home Ownership
Equity Protection Act of 1994, 15 U.S.C. Sec. 1639. According
to reports from federal and state law enforcement agencies and
the AARP, older consumers are frequently the targeted victims
of unscrupulous high-rate lenders.
access to FTC publications
In early 1995, the FTC began to offer its publication
online through the Internet. By December 1996, FTC
Consumerline, a component of the FTC world wide web site, was
offering the full-text of all consumer publications produced by
the agency.
conclusion
This report reviews Commission programs in 1995 and 1996
that may be of particular concern to older consumers and their
families. Through the combination of law enforcement and
consumer education described above, the Commission strives to
ensure a vigorous, fair, and competitive marketplace for all
consumers.
ITEM 21--GENERAL ACCOUNTING OFFICE
AGING ISSUES: RELATED GAO REPORTS AND ACTIVITIES IN CALENDAR YEARS 1995
AND 1996
The elderly represent one of the fastest growing segments
of the country's population, and the Congress faces many
complex issues as a result of this growth. In the United
States, the number of people aged 65 and older has grown from
about 9 million in 1940 to about 34 million in 1995. Moreover,
the number is expected to reach 80 million by 2050, according
to Bureau of the Census projections. In 1940, people aged 65
and older made up 7 percent of the total population, and this
proportion is expected to grow to 20 percent by as early as
2030. Although the aging of the baby-boom generation will
contribute greatly to these trends, increased life expectancies
and falling fertility rates are also important factors.
Together, these demographic changes pose serious challenges for
our Social Security system, Medicare, Medicaid, the federal
budget, and our economy as a whole.
This report responds to your request for a compilation of
our products from calendar years 1995 and 1996 that pertain to
programs and issues affecting older Americans and their
families.
In summary, our work on these programs and issues reflects
the broad range and importance of federal programs for older
Americans. Some federal programs, such as Social Security and
Medicare, are directed primarily at older Americans. Other
federal programs, such as Medicaid or federal housing programs,
target older Americans as one of several groups served. Our
work during calendar years 1995 and 1996 covered issues
concerning education and employment, health care, housing and
community development, income security, and veterans. In the
enclosures, we describe three types of GAO products that relate
to older Americans:
166 reports and correspondence (see encl. I) and
69 congressional testimonies (see encl. II).
The summaries in these enclosures were prepared shortly
after the products were issued and have not been updated to
reflect subsequent developments.
Table 1 gives a breakdown of those products by category.
The table shows that health, income security, and veterans'
issues were the areas most frequently addressed among our
products that focused on older Americans.
TABLE 1: GAO PRODUCTS RELATING TO THE ELDERLY IN CALENDAR YEARS 1995 AND
1996
------------------------------------------------------------------------
Reports and
Elderly issues correspondence Testimonies
------------------------------------------------------------------------
Education and employment.......... 4 2
Health............................ 75 35
Housing and community development. 8 3
Income security................... 45 20
Veterans and defense.............. 34 9
-------------------------------------
Total....................... 166 69
------------------------------------------------------------------------
[Enslosure I]
Calendar Years 1995 and 1996 Reports and Correspondence on Issues
Affecting Older Americans
During calendar years 1995 and 1996, GAO issued 166 reports
on issues affecting older Americans. Of these, 4 were on
education and employment, 75 on health, 8 on housing and
community development, 45 on income security, and 34 on the
Department of Defense (DOD) and veterans.
education and employment issues
Adult Education: Measuring Program Results Has Been Challenging (GAO/
HEHS-95-153, Sept. 8, 1995)
According to a recent national survey, nearly 90 million
adults in the United States have difficulty writing a letter
explaining an error on a credit card bill, using a bus
schedule, or calculating the difference between the regular and
sale price of an item. To address these deficient literary
skills, the Congress passed the Adult Education Act, which
funds state programs to help adults acquire the basic skills
needed for literate functioning, benefit from job training, and
continue their education at least through the high school
level. The most common types of instruction funded under the
act's largest program--the State Grant Program--are basic
education (for adults functioning below the eighth grade
level), secondary education, and English as a second language.
Because many clients of federal employment training programs
need instruction provided by the State Grant Program,
coordination among these programs is essential. Although the
State Grant Program funds programs that address the educational
needs of millions of adults, it has had difficulty ensuring
accountability for results because of a lack of clearly defined
program objectives, questionable validity of adult student
assessments, and poor student data.
Adult Education Review (GAO/HEHS-95-65R, Feb. 16, 1995)
GAO provided information on the Adult Education Act (AEA)
that focused on the (1) funding history of AEA; (2) changes
that have taken place in the amount of services that the State-
Administered Basic Grant Program provides; and (3) goals,
targeted populations, and service recipients of the State-
Administered Basic Grant Program. GAO noted that (1) AEA
funding under this program increased from $100 million in
fiscal year 1984, to $255 million in fiscal year 1995, (2)
enrollment in the State-Administered Basic Grant Program rose
from approximately 377,000 participants in 1966 to almost 4
million participants in 1994, and (3) the purpose of the
program is to provide educational opportunities for adults who
lack the necessary literacy skills to become a citizen and to
be productive in their employment.
Department of Labor: Senior Community Service Employment: Program
Delivery Could Be Improved Through Legislative and
Administrative Actions (GAO/HEHS-96-4, Nov. 2, 1995)
The Department of Labor's Senior Community Service
Employment Program finances part-time minimum-wage community
service jobs for about 100,000 poor elderly Americans. GAO
found that Labor distributes program funds through
noncompetitive grants to 10 national organizations, called
national sponsors, and to state agencies. These national
sponsors and state agencies, in turn, use the grant funds to
finance local employment projects run by community service host
agencies, such as libraries, nutrition centers, and parks, that
directly employ older Americans. GAO found that the relative
distribution of funds to the national sponsors and state
agencies along with Labor's method of implementing the hold-
harmless provisions have resulted in the distribution of funds
among and within states that bears little relationship to
actual need. GAO also found that, under Labor's regulations,
expenditures that GAO believes to be administrative in nature
may be charged to another cost category, allowing grantees to
exceed the statutory 15-percent limit on administrative costs.
GAO summarized this report in testimony before the Congress;
see Senior Community Service Employment: Program Delivery Could
Be Improved Through Legislative and Administrative Actions,
(GAO/T-HEHS-96-57, Nov. 2, 1995), statement by Cornelia M.
Blanchette, Associate Director for Education and Employment
Issues, before the Subcommittee on Early Childhood, Youth and
Families, House Committee on Economic and Educational
Opportunities.
People With Disabilities: Federal Programs Could Work Together More
Efficiently to Promote Employment (GAO/HEHS-96-126, Sept. 3,
1996)
How efficient are federal efforts to help people with
disabilities? In 1994, the government provided a range of
services to people with disabilities through 130 different
programs, 19 federal agencies, and a host of public and private
agencies at the state and local levels. Although research
groups and independent panels have stressed the need to
simplify and streamline programs serving the disabled, creating
a new service delivery system may prove difficult. GAO urged
caution in 1992 when the Congress was considering proposals
that would have made fundamental changes in human service
delivery systems at the federal, state, and local levels. GAO
also urges caution with regard to programs serving people with
disabilities. Although the potential benefits of creating a new
system to deliver services more comprehensively to people with
disabilities may be great, so are the barriers and the risks of
failure. Obstacles preventing officials from reorganizing
service agencies, creating new funding and service agreements,
and divesting authority from their own agencies are hard to
overcome. Mandates alone are unlikely to secure the major time
and resource commitments needed from officials--whether they
are charged with directing reforms or have responsibility for
administering services. In the current fiscal environment, a
renewed focus by federal agencies on improving coordination
would be a useful step toward improving services and enhancing
the customer orientation of their programs.
health issues
AARP Medigap Premium Increases, 1996 (GAO/HEHS-96-119R, Apr. 19, 1996).
Pursuant to a congressional request, GAO examined why
Medigap premiums offered through the American Association of
Retired Persons (AARP) were increasing. GAO noted that (1) in
January 1996 premiums for more than 3 million AARP Medigap
policyholders increased an average of 26 percent; (2) the 1996
increases varied by state and ranged from 0 to 40 percent for
both standardized and prestandardized policies; (3) in 1994 and
1995, premiums increased in 8 and 10 states, respectively; (4)
because benefit payments were less than expected, AARP
standardized policyholders received an average credit of $75
and prestandardized policyholders received an average credit of
$79 in 1994 and 1995; (5) in 1992, policyholders in 45 states
received refunds averaging $47 because of lower-than-expected
benefit payments; (6) AARP believes that the 1996 Medigap rate
increases are justified because the number of services received
and costs incurred by policyholders substantially increased;
(7) although the average Medigap loss ratio decreased to 81
percent between 1991 and 1993, in 1994, the average loss ratio
increased to 93 percent; (8) in 1994, the average loss ratio
for prestandardized policies was 98 percent and 82 percent for
standardized policies; and (9) the average loss ratio for 1995
policies was 100 percent and could increase to 112 percent
without a rate increase.
Analysis of ``Florida's Fair Share'' (GAO/HEHS-96-168R, June 10, 1996)
Pursuant to a congressional request, GAO commented on the
appropriateness of the Medicaid funding formula contained in
H.R. 3507. GAO noted that (1) over time, the proposed formula
would cause Medicaid funding distribution to more closely
reflect states' poor and elderly populations; (2) there are
more generous matching rates for low-income states that spend
more on Medicaid services for eligible recipients; (3) because
Florida spends less on benefits for eligible recipients than
the other states reviewed, it receives less matching federal
funds; (4) the new funding formula would establish targets for
federal funding in proportion to the poor population in each
state; (5) each state's federal allocation would increase
depending on the differences between the current level of
federal funding and the target amount; and (6) by giving states
like Florida higher growth rates, the new formula would enable
states to receive federal funding in proportion to their poor
population.
Arizona Medicaid: Competition Among Managed Care Plans Lowers Program
Costs (GAO/HEHS-96-2, Oct. 4, 1995)
Many states are converting their traditional fee-for-
service Medicaid programs to managed care delivery systems.
Arizona's Medicaid program offers valuable insights--especially
in fostering competition and monitoring plan performance. Since
1982, Arizona has operated a statewide Medicaid program that
mandates enrollment in managed care and pays health plans a
capitated fee for each beneficiary served. Although the program
had problems in its early years, such as the dismissal of the
program administrator and the state's takeover of the
administration, it has successfully contained health care costs
while maintaining beneficiaries' access to mainstream medical
care. Arizona's recent cost-containment record is noteworthy.
According to one estimate, Arizona's Medicaid program saved the
federal government $37 million and the state $15 million in
acute care costs during fiscal year 1991 alone. Arizona
succeeded in containing costs by developing a competitive
Medicaid health care market. Health plans that submit
capitation rates higher than their competitors' bids risk not
winning Medicaid contracts. Other states considering managed
care programs can benefit from Arizona's experience. GAO
concludes that the key conditions for holding down Medicaid
costs without compromising beneficiaries' access to appropriate
medical care include freedom from some federal managed care
regulations, development and use of market forces, controls to
protect beneficiaries from inadequate care, and investment in
data collection and analysis capabilities.
Blue Cross FEHBP Pharmacy Benefits (GAO/HEHS-96-182R, July 19, 1996).
Pursuant to a congressional request, GAO provided
information on the Blue Cross and Blue Shield Association's two
pharmacy benefit managers and the services they provide to the
Federal Employees Health Benefits Program (FEHBP). GAO noted
that (1) to control drug costs, the Association is requiring
Medicare part B participants to pay the standard copayment for
drugs bought at participating retail pharmacies, but it is
waiving copayments on drugs bought through its mail-order
program for those participants; (2) the Association expects
this change to achieve significant savings and prevent a
premium increase in standard option coverage; (3) the
Association's mail-order subcontractor has had significant
difficulty meeting its customer-service performance measures
because the increase in mail orders has been much larger and
quicker than expected; (4) the subcontractor has increased its
processing capacity to meet the unexpected demand; (5) retail
pharmacies have experienced a 36-percent decrease in drug sales
to part B participants and a 7-percent decrease in drug sales
to all enrollees; and (6) the Association believes its pharmacy
benefits managers provide valuable services to FEHBP, meet most
of their contractual performance measures, and produce
significant savings.
Cholesterol Treatment: A Review of the Clinical Trials Evidence (GAO/
PEMD-96-7, May 14, 1996).
Clinical trials showed men who took cholesterol-lowering
treatments had fewer non-fatal heart attacks compared to those
not treated. Reductions in coronary deaths in the same trials
were restricted to high risk men, that is, those with a history
of heart disease and high cholesterol. Surprisingly, the men
that took the cholesterol lowering treatments suffered higher
death rates from all non-coronary causes that canceled out the
modest reduction in coronary deaths. The mixed benefit picture
here may result from the generally modest cholesterol
reductions achieved by the group of trials in our review. One
of two recent trials that lowered cholesterol more found a
significant reduction in total fatalities.
Trials are limited by the selected populations recruited
and by limited duration. Since trials focused on middle-aged
white men with higher than average cholesterol readings and a
history of heart disease, useful trial data are lacking on
benefits or risks for women, minorities, the elderly or people
with the most common cholesterol readings. Trials proposed or
underway may provide information on these groups. Trials
usually follow people for 5 years or less, while drug treatment
would be longer.
Community Health Centers: Challenges in Transitioning to Prepaid
Managed Care (GAO/HEHS-95-138, May 4, 1995).
As states move to prepaid managed care to control costs and
improve access for their Medicaid clients, the number of
participating community health centers continues to grow.
Medicaid prepaid managed care is not incompatible with health
centers' mission of delivering health care to medically
underserved populations. However, health centers face
substantial risks and challenges as they move into these
arrangements. Such challenges require new knowledge, skills,
and information systems. Centers lacking expertise and systems
face an uncertain future, and those in a vulnerable financial
position are at even greater risk. Today's debate over possible
changes in federal and state health programs heightens the
concern over the financial vulnerability of centers
participating in prepaid managed care. If this funding source
continues to grow as a percentage of total health center
revenues, centers must face building larger cash reserves while
not compromising services to vulnerable populations. GAO
summarized this report in testimony before the Congress; see
Community Health Centers: Challenges in Transitioning to
Prepaid Managed Care, (GAO/T-HEHS-95-143, May 4, 1995),
statement by Mark V. Nadel, Associate Director for Health
Financing and Policy Issues, before the Senate Committee on
Labor and Human Resources.
Consumer Health Information: Emerging Issues (GAO/AIMD-96-86, July 26,
1996)
Technology has increased the amount of health information
available to the public, allowing consumers to become better
educated and more involved in their own health care. Government
and private health care organizations rely on a variety of
technologies to disseminate health information on preventive
care, illness and injury management, treatment options, post-
treatment care, and other topics. This report discusses
consumer health informatics--the use of computers and
telecommunications to help consumers obtain information,
analyze their health care needs, and make decisions about their
own health. GAO provides information on (1) the demand for
health information and the expanding capabilities of
technology; (2) users' and developers' views on potential
systems advantages and issues surrounding systems development
and use; (3) government involvement--federal, state, and
local--in developing these technologies; and (4) the status of
related efforts by the Department of Health and Human Services
(HHS). As part of this review, GAO surveyed consumer health
informatics experts and presents their views on issues that
need to be addressed when developing consumer health
information systems. GAO summarized this report in testimony
before the Congress; see Consumer Health Informatics: Emerging
Issues (GAO/T-AIMD-96-134, July 26, 1996), statement by
Patricia T. Taylor, Director of Information Resources
Management Issues, before the Subcommittee on Human Services
and Intergovernmental Relations, House Committee on Government
Reform and Oversight.
District of Columbia: Information on Health Care Costs (GAO/AIMD-96-42,
Apr. 22, 1996).
Recent studies on the District of Columbia's health care
system have concluded that the city's health care problems are
aggravated by such social factors as high rates of poverty,
crime, substance abuse, and unemployment. These factors account
for the sizable numbers of persons who do not seek preventive
health care and cannot pay for medical treatment, the
inappropriate use of D.C. General Hospital for primary care,
and the many trauma care patients at area hospitals. To help
the Congress evaluate various restructuring proposals being
considered for the District, this report discusses the
District's health care budget and the composition of the
District's health care system, including the number of Medicaid
recipients and uninsured and the distribution of hospitals and
clinics.
Durable Medical Equipment: Regional Carriers' Coverage Criteria Are
Consistent With Medicare Law (GAO/HEHS-95-185, Sept. 19, 1995).
In November 1993, the Health Care Financing Administration
(HCFA) began consolidating the work of processing and paying
claims for durable medical equipment, prostheses, orthoses, and
supplies at four regional carriers. Claims for such items had
previously been processed and paid by local Medicare carriers.
As part of the transition to regional processing, the four
regional carriers developed coverage criteria for the items.
GAO found that the final criteria adopted by the regional
carriers are consistent with Medicare's national coverage
policies and the law. GAO does not believe that the criteria
have impeded disabled beneficiaries' access to needed durable
medical equipment and other items. Also, in 1994 the regional
carriers approved a similar percentage of service for durable
medical equipment and other items for the disabled and aged
Medicare beneficiaries, so there was no significant difference
in access to durable medical equipment and other items between
the two groups of beneficiaries.
Employer-Based Health Plans: Issues, Trends, and Challenges Posed by
ERISA (GAO/HEHS-95-167, July 25, 1995).
As the movement for comprehensive federal health care
reform has lost steam, the focus of reform has shifted to the
states and the private market. States remain concerned about
the growing number of people lacking health coverage and about
financing health plans for poor people. Employers have become
increasingly aggressive in managing their health plans and have
adopted various managed care plans and innovative funding
arrangements. However, the Employee Retirement Income Security
Act of 1974 (ERISA) effectively blocks states from directly
regulating most employer-based health plans, although it allows
states to regulate health insurers. GAO found that nearly 40
percent of enrollees in employer-based health plans--44 million
people--are in self-funded plans. The divided federal and state
framework for regulating health plans produces a complex set of
trade-offs for regulating health plans. Self-funded plans,
which are exempt from state regulation under ERISA, provide
employers greater flexibility to design a health benefits
package that may have been less feasible to provide under state
regulation. At the same time, however, states are unable to
extend regulations, such as solvency standards, preexisting
condition clause limits, and guaranteed issue and renewal
requirements, even indirectly, to enrollees in these self-
funded plans. GAO summarized this report in testimony before
the Congress; see Employer-Based Health Plans: Issues, Trends,
and Challenges Posed by ERISA (GAO/T-HEHS-95-223, July 25,
1995), statement by Mark V. Nadel, Associate Director for
National and Public Health Issues, before the Senate Committee
on Labor and Human Resources.
Food Assistance Programs (GAO/RCED-95-115R, Feb. 28, 1995)
GAO reviewed the Department of Agriculture's (USDA)
domestic food and nutrition assistance programs, focusing on
those programs that target benefits to women, children,
infants, the elderly, and the needy. GAO noted that (1) USDA
food assistance programs constitute about 60 percent of the
USDA budget, and the Food Stamp Program accounts for more than
one-half of those benefits; (2) 6 of the 14 USDA food programs
target the groups reviewed; (3) participants' characteristics
and the nature and level of benefits vary widely across the
programs; (4) most of the programs have income eligibility
criteria and some programs have additional criteria that
individuals must meet to receive benefits; (5) benefit overlap
is built into most of the programs, but it is not known how
many persons participate in more than one program; (6) state
and local governments and nonprofit organizations play a large
role in distributing program benefits; (7) some USDA programs
are similar to other agencies' assistance programs; (8)
ineffective targeting of low-income people, burdensome
administration, subsidizing providers rather than families,
rising costs, duplication of services, inequitable funding
allocations, and unfunded mandates affect the distribution of
food benefits; and (9) alternatives to reduce costs and
streamline program operations include improving low-income
targeting, consolidating multiple programs, reducing some
programs' funding levels, and eliminating some ineffective
programs.
Fraud and Abuse: Providers Target Medicare Patients in Nursing
Facilities (GAO/HEHS-96-18, Jan. 24, 1996)
Nursing home patients are an attractive target for
fraudulent and abusive health care providers that bill Medicare
for undelivered or unnecessary services. A wide variety of
providers, ranging from durable medical equipment suppliers to
laboratories to optometrists and doctors, have been involved in
fraudulent and abusive Medicare billing schemes. Several
features make nursing home patients attractive targets. First,
because a nursing facility houses many Medicare beneficiaries
under one roof, unscrupulous billers of services can operate
their schemes in volume. Second, nursing homes sometimes make
patient records available to outsiders, contrary to federal
regulations. Third, providers are permitted to bill Medicare
directly, without certification from the nursing home or the
attending physician that the items are necessary or have been
provided as claimed. In addition, Medicare's automated systems
do not collect data to flag improbably high charges or levels
of services. Finally, even when Medicare spots abusive billings
and seeks recovery of unwarranted payments, it often collects
little money from wrongdoers, who either go out of business or
deplete their resources so that they cannot repay the funds.
HCFA: Medicare Program--Changes to the Hospital Inpatient Prospective
Payment Systems and Fiscal Year 1997 Rates (GAO/OGC-96-41,
Sept. 13, 1996)
Pursuant to a legislative requirement, GAO reviewed the
Health Care Financing Administration's (HCFA) new rule on
changes to the Medicare program's hospital inpatient
prospective payment systems and fiscal year 1997 rates. GAO
found that (1) the rule would adjust the classifications and
weighting factors for diagnosis related groups, update the wage
index associated with hospital operating costs, and make
certain clarifications regarding the calculation of hospital
payments excluded from the prospective payment systems; and (2)
HCFA complied with applicable requirements in promulgating the
rule.
HCFA's Approach to Evaluating Medicare Technology (GAO/AIMD-95-234R,
Sept. 29, 1995)
GAO reviewed HCFA's approach to analyzing the benefits of
commercial technology in the Medicare program. GAO noted that
HCFA (1) is limiting its analysis of the benefits of commercial
technology to determining whether Medicare contractors complied
with existing payment controls and is using a flawed sampling
methodology to select claims for review; (2) is attempting to
verify the savings achievable through commercial systems
without understanding how the systems operate; (3) believes
that it cannot examine commercial systems without actually
procuring a system; and (4) is failing to identify real
monetary benefits of commercial detection systems in its
analysis.
Health Care Fraud: Information-Sharing Proposals to Improve Enforcement
Efforts (GAO/GGD-96-101, May 1, 1996)
Estimates of health care fraud range from 3 to 10 percent
of all health care expenditures--as much as $100 billion based
on estimated 1995 expenditures. In late 1993, the Attorney
General designated health care fraud as an enforcement priority
second only to violent crime initiatives. This report discusses
(1) the extent of federal and state immunity laws protecting
persons who report information on health care fraud and (2) the
advantages and disadvantages of establishing a centralized
health care fraud database to strengthen information-sharing
and support enforcement efforts.
Health Care Shortage Areas: Designations Not a Useful Tool for
Directing Resources to the Underserved (GAO/HEHS-95-200, Sept.
8, 1995)
Many Americans live in places where barriers exist to
obtaining basic health care. These areas range from isolated
rural locations to inner-city neighborhoods. In fiscal year
1994, the federal government spent about $1 billion on programs
to overcome access problems in such locations. To be effective,
these programs need a sound method of identifying the type of
access problems that exist and focusing services on the people
who need them. The Department of Health and Human Services
(HHS) uses two main systems to identify such locales. One
designates Health Professional Shortage Areas, the other
Medically Underserved Areas. More than half of all U.S.
counties fall into these two categories. GAO reviewed the two
systems to determine (1) how well they identify areas with
primary care shortages, (2) how well they help target federal
funding to benefit those who are underserved, and (3) whether
they are likely to be improved under proposals to combine them.
Health Insurance: Coverage of Autologous Bone Marrow Transplantation
for Breast Cancer (GAO/HEHS-96-83, Apr. 24, 1996)
Although many insurers now cover the cost of autologous
bone marrow transplantation, a new and expensive treatment for
breast cancer, issues surrounding the procedure have put
several goals of the U.S. health care system in conflict:
access to the best, most advanced care; cost containment; and
research adequate to assess the value of new treatments.
Proponents of insurance coverage argue that autologous bone
marrow transplantation provides breast cancer patients with a
promising, potentially life-saving treatment. Critics say that
the proliferation of such unproven treatments is costly and
harmful, potentially hindering clinical research to determine
whether the treatment is effective. This report discusses (1)
the factors that have influenced insurers' decisions on whether
to cover the treatment, (2) the status of research on
autologous bone marrow transplantation for breast cancer and
the consensus on what is known about its effectiveness, and (3)
the consequences of increased use and insurance coverage of the
treatment while it is still being evaluated in clinical trials.
Health Insurance Portability: Reform Could Ensure Continued Coverage
for up to 25 Million Americans (GAO/HEHS-95-257, Sept. 19,
1995)
Although federal and state laws have improved the
portability of health insurance, an individual's health care
coverage could still be reduced when changing jobs. Between
1990 and 1994, 40 states enacted small group insurance
regulations that include portability standards, but ERISA
prevents states from applying these standards to the health
plans of employers who self-fund. As a result, some in the
Congress have proposed broader national portability standards.
GAO estimates that as many as 21 million Americans each year
would benefit from federal legislation to ensure that workers
who change jobs would not be subject to new health insurance
plans that impose waiting periods or preexisting condition
exclusions. In addition, as many as 4 million Americans who at
some point have been unwilling to leave their jobs because they
feared losing their health care coverage would benefit from
national portability standards. Such a change, however, could
possibly boost premiums, according to insurers.
Health Insurance Regulation: Varying State Requirements Affect Cost of
Insurance (GAO/HEHS-96-161, Aug. 19, 1996)
As concern about the affordability of health coverage has
grown, the costs attributed to state regulation of health
insurance have come under increasing scrutiny. State health
insurance regulation is intended to protect consumers through
oversight of health plans' financial solvency, monitoring of
insurers' market conduct to prevent abuses, and mandated
coverage for particular services. Although these measures do
benefit consumers, they result in costs to insurers that are
ultimately passed on to consumers in their premiums. These
costs may influence an employer to self-fund its health plan--a
move that avoids state insurance regulation. This report
examines the costs associated with (1) premium taxes and other
assessments, (2) mandated health benefits, (3) financial
solvency standards, and (4) state health insurance reforms
affecting small employers. GAO discusses the impact of these
requirements on the costs of insured health plans compared with
the cost of self-funded health plans.
HMO Enrollment Data (GAO/HEHS-95-159R, May 25, 1995)
GAO provided information on health maintenance organization
(HMO) enrollment, focusing on the number of Medicare
beneficiaries enrolled in risk-based HMOs. GAO noted that (1)
between December 1993 and 1994, the percentage of Medicare
beneficiaries enrolled in risk-based HMOs increased from 5.1 to
6.3 percent for a total of about 2.3 million beneficiaries; (2)
although older beneficiaries had lower enrollment rates than
the general Medicare population, they also increasingly joined
risk-based HMOs; (3) between 1993 and 1994, the percentage of
Medicare beneficiaries aged 75 and older enrolled in risk-based
HMOs increased from 4.8 to 6.1 percent; and (4) the percentage
of beneficiaries aged 85 and older enrolled in risk-based HMOs
increased from 3.9 to 4.7 percent between 1993 and 1994.
Hospital-Based Home Health Agencies (GAO/HEHS-95-209R, July 19, 1995)
GAO reviewed whether increased hospital ownership of home
health agencies (HHA) has contributed to the growth in Medicare
home health costs. GAO found that hospital-based HHAs (1)
generally care for beneficiaries with less chronic conditions
and provide fewer visits to patients than all other types of
HHAs, except those run by the government, and (2) apparently
are not driving up Medicare costs any more than other types of
HHAs.
Indian Health Service: Improvements Needed in Credentialing Temporary
Physicians (GAO/HEHS-95-46, Apr. 21, 1995)
Indian Health Service (IHS) facilities, which provide
medical care to more than 1 million American Indians and
Alaskan Natives, supplement their staffs with temporary
physicians. But weak policies have led IHS to unknowingly hire
doctors who have been disciplined for such offenses as gross
and repeated malpractice and unprofessional conduct. IHS does
not explicitly require verifying all active and inactive state
medical licenses that a temporary physician may have. Further,
most IHS facilities that have contracts with companies that
supply temporary physicians do not require the companies to
inform IHS of the status of all medical licenses a physician
may hold. In addition, IHS facilities do not have a formal
system for sharing information on temporary physicians who have
worked within the IHS medical system. This report also
discusses what happens when requested medical services are
delayed.
Long-Term Care: Current Issues and Future Directions (GAO/HEHS-95-109,
Apr. 13, 1995)
Today, an increasing number of Americans need long-term
care. Unprecedented growth in the elderly population is
projected for the twenty-first century, and the population aged
85 and older--those most in need of long-term care--is expected
to outpace the rate of growth for the entire elderly
population. In addition to the dramatic rise in the elderly
population, a large portion of the long-term care population
consists of younger people with disabilities. The importance of
long-term care was underscored by the 1994 congressional debate
over health care reform and, more recently, by the ``Contract
with America,'' which proposed assistance such as tax
deductions for long-term care insurance and tax credits for
family caregiving. This report (1) defines what is meant by
long-term care and discusses the conditions that give rise to
long-term care need, how such need is measured, and which
groups--young and old--require long-term care; (2) examines the
long-term care costs that are borne by federal and state
governments as well as by families; (3) addresses strategies
that states and foreign countries are pursuing to contain
public long-term care costs; and (4) discusses predictions by
experts on the future demand for long-term care.
Long-Term Care: Some States Apply Criminal Background Checks to Home
Care Workers (GAO/PEMD-96-5, Sept. 27, 1996)
Pursuant to a congressional request, GAO examined federal
and state requirements for criminal background checks of home
health care workers. GAO found that (1) there are few formal
safeguards to protect elderly persons from unscrupulous home
care workers; (2) the federal government indirectly regulates
home care workers by requiring home care organizations or the
individual provider to meet certain requirements for
participation in Medicaid or Medicare; (3) states may be
directed to disqualify home care providers convicted of
fraudulent health care delivery; obstruction of justice; or the
illegal manufacture, distribution, prescription, or dispensing
of controlled substances; (4) state and local governments, as
well as professional boards, impose certain restrictions on
home care organizations and individual providers; (5) some
states require all home care organizations to meet state
imposed licensure or Medicare certification requirements; (6)
some states incorporate home care workers into their state
nursing home aide registry; (7) few states require criminal
background checks of home care workers; and (8) most states do
not use the Federal Bureau of Investigation's national criminal
database system to check home care workers' backgrounds due to
cost concerns.
Mammography Services: Initial Impact of New Federal Law Has Been
Positive (GAO/HEHS-96-17, Oct. 27, 1995)
The Mammography Quality Standards Act of 1992 imposed
uniform standards for mammography in all states, requiring
certification and annual inspection of mammography facilities.
GAO found that the act has had a positive impact, resulting in
higher quality equipment, personnel, and practices. Mammography
quality standards are now in place in all states, and these
standards do not appear to have hampered access to services. To
avoid large-scale closure of facilities, however, the Food and
Drug Administration (FDA) settled on an approach that allowed
some delay in meeting the certification requirements. For this
and other reasons, such as the availability of outcome data,
more time will be needed before the act's full impact can be
determined. GAO is required to assess the effects of the act
again in 2 years and to issue a report in 1997.
Medicaid Funding Formula Changes (GAO/HEHS-96-164R, June 10, 1996)
Pursuant to a congressional request, GAO provided
information on the proposed changes to Medicaid funding
formulas under H.R. 3507. GAO noted that (1) states with large
numbers of poor and disabled persons receive less federal
assistance than states with larger numbers of poor and weaker
tax bases; (2) states that offer extensive services and provide
high provider reimbursement rates receive more federal funding;
(3) the revised Medicaid formula would link the amount of
federal aid a state receives to the number of poor people in
need of Medicaid services; (4) over 90 percent of the federal
formula grant programs target funding on the basis of need; (5)
H.R. 3507 would realign federal Medicaid funding over a number
of years, so that funding is related more to state need than to
state spending patterns; (6) H.R. 3507 would place greater
weight on the number of elderly and disabled people that
require expensive services; and (7) the proposed formula change
would enable states with low funding to acquire more federal
funds.
Medicaid Long-Term Care: State Use of Assessment Instruments in Care
Planning (GAO/PEMD-96-4, Apr. 2, 1996)
GAO examined how publicly funded programs assess the need
for home and community-based long-term care for the elderly
with disabilities. This care is provided to persons living at
home who, because of a chronic condition or illness, cannot
care for themselves. Services range from skilled nursing to
assistance with day-to-day activities, such as bathing and
housekeeping. Under the Medicaid program, 49 states have
obtained waivers to provide home and community-based services
to low-income elderly persons who would otherwise need
institutional care paid for by Medicaid. These states are
responsible for developing a care plan tailored to a client's
specific needs. A well-designed assessment instrument helps
identify all appropriate needs--increasing the likelihood that
important aspects of the client's situation will not be
overlooked in care planning. Standardized administration of the
assessment instrument increases the likelihood that the needs
of all clients will be determined in the same way. This report
provides information on the (1) comprehensiveness of assessment
instruments, (2) uniformity of their administration, and (3)
training for staff who do the assessments.
Medicaid Managed Care: More Competition and Oversight Would Improve
California's Expansion Plan (GAO/HEHS-95-87, Apr. 28, 1995)
The Medicaid program was established to make health care
more accessible to the poor. In many communities, however,
beneficiaries' access to quality care is far from guaranteed.
Too few doctors and other health care providers choose to
participate in Medicaid because of low payment rates and
administrative burdens. To address the access problem, as well
as rising costs and enrollment in its $15 billion Medi-Cal
program (which serves about 5.4 million beneficiaries),
California intends to increase its reliance on managed care
delivery systems. This report (1) describes California's
current Medicaid managed care program, (2) reviews the state's
oversight of managed care contractors with a focus on financial
incentive arrangements and the provision of preventive care for
children, (3) describes the state's plans for expansion, and
(4) identifies key issues the state will face as it implements
the expanded program.
Medicaid: Restructuring Approaches Leave Many Questions (GAO/HEHS-95-
103, Apr. 4, 1995)
Over the years, various proposals have been made to
restructure the Medicaid program. One approach calls for
providing federal block grants to the states and giving them
increased responsibility for running the program. Under another
proposal, Medicaid would be entirely funded and administered by
the federal government. Yet another would split Medicaid into
two programs, one encompassing acute and primary care and the
other long-term care. This report compares the different
restructuring approaches and discusses their implications for
federal-state financing and administration of the program. GAO
also provides information on the need to establish a federal
``rainy day'' fund if restrictions, such as block grants, are
placed on federal revenues paid to states. GAO also provides
the most recent data on the amount of federal Medicaid funds
provided to each state.
Medicaid Managed Care: Serving the Disabled Challenges State Programs
(GAO/HEHS-96-136, July 31, 1996)
With its emphasis on primary care, restricted access to
specialists, and control of services, managed care is seen as a
way to control spiraling Medicaid costs, which totaled $159
billion in fiscal year 1995. So far, states have extended
prepaid care largely to low-income families--about 30 million
persons--but to few of the additional 6 million Medicaid
beneficiaries who are mentally or physically disabled. Managed
care's emphasis on primary care and control of services is
seemingly at odds with the care requirements of disabled
beneficiaries, many of whom need extensive services and access
to highly specialized providers. However, because more than
one-third of all Medicaid payments go for the care of the
disabled, policymakers have been exploring the possibility of
enrolling disabled persons in managed care plans. These efforts
affect three key groups: disabled beneficiaries, who include a
small number of very vulnerable persons who may be less able to
effectively advocate on their own behalf for access to needed
services; prepaid care plans, which are concerned about the
degree of financial risk in treating persons with extensive
medical needs; and the state and federal governments, which run
Medicaid. This report examines the (1) extent to which states
are implementing Medicaid prepaid managed care programs for
disabled beneficiaries and (2) steps that have been taken to
safeguard the interests of all three groups. GAO's review of
safeguards focuses on two areas: efforts to ensure quality of
care and strategies for setting rates and sharing financial
risk.
Medicaid: Oversight of Institutions for the Mentally Retarded Should Be
Strengthened (GAO/HEHS-96-131, Sept. 6, 1996)
Medicaid provides more than $5 billion each year to support
state institutions that house and care for the mentally
retarded. Despite federal standards, serious quality-of-care
problems exist at some institutions. Insufficient staffing,
lack of treatments to enhance patients' independence and
functional ability, and deficient medical and psychiatric care
are some of the shortcomings that have been cited most
frequently. In a few cases, these practices have led to
injuries, illness, physical degeneration, and even death for
some residents. States, which play a key role in ensuring that
these institutions meet federal standards, do not always
identify serious deficiencies and sometimes do not take
adequate enforcement measures to prevent therecurrence of poor
care. Although the Health Care Financing Administration has tried to
improve the process for spotting serious deficiencies in these
institutions and has sought to make more efficient use of limited
federal and state resources, oversight weaknesses persist. Moreover,
state surveys may lack independence because states are responsible for
surveying their own institutions. This potential conflict of interest
raises concern, given the decline in direct federal oversight of both
care in these facilities and the performance of state surveying
agencies.
Medicaid: Spending Pressures Drive States Toward Program Reinvention
(GAO/HEHS-95-122, Apr. 4, 1995)
The $131 billion Medicaid program is at a crossroads.
Between 1985 and 1993, Medicaid costs tripled and the number of
beneficiaries rose by more than 50 percent. Medicaid costs are
projected to rise to $260 billion, according to the
Congressional Budget Office. Despite federal and state
budgetary constraints, several states are exerting pressure to
expand the program and enroll hundreds of thousands of new
beneficiaries. The cost of expanded coverage, they believe,
will be offset by the reallocation of Medicaid funds and the
wholesale movement of beneficiaries into some type of managed
care arrangement. This report examines (1) federal and state
Medicaid spending, (2) some states' efforts to contain Medicaid
costs and expand coverage through waiver of federal
requirements, and (3) the potential impact of these waivers on
federal spending and on Medicaid's program structure overall.
The Comptroller General summarized this report in testimony
before the Congress; see Medicaid: Spending Pressures Drive
States Toward Program Reinvention (GAO/T-HEHS-95-129, Apr. 4,
1995), by Charles A. Bowsher, Comptroller General of the United
States, before the House Committee on the Budget.
Medicaid: Tennessee's Program Broadens Coverage But Faces Uncertain
Future (GAO/HEHS-95-186, Sept. 1, 1995)
In early 1993, Tennessee predicted that increases in state
Medicaid expenditures and the loss of tax revenues used to
finance Medicaid would produce a financial crisis. To avert a
financial crisis, control its Medicaid expenditures, and extend
health insurance coverage to most state residents, Tennessee
converted its Medicaid program into a managed care health
program--TennCare--to serve both Medicaid recipients and
uninsured persons. GAO found that although TennCare met its
objectives of providing health coverage to many uninsured
persons while controlling costs, concerns remain with respect
to access to quality care and managed care performance.
Specifically, questions have been raised about TennCare's rapid
approval and implementation, lack of provider buy-in to the
program, and delays in monitoring TennCare's access and quality
of care. In addition, the soundness of the methodology for
determining and the resulting adequacy of the program's
capitation rates have been questioned. This report discusses
(1) TennCare's basic design and objectives, (2) the degree to
which the program is meeting these objectives, and (3) the
experiences of TennCare's insurers and medical providers and
their implications for TennCare's future.
Medicare: Allegations Against ABC Home Health Care (GAO/OSI-95-17, July
19, 1995)
In response to a congressional request, GAO investigated
allegations against ABC Home Health Care, a home health agency
(HHA), and its participation in Medicare's home health care
program. In the Medicare program, providers may receive
reimbursement for only those expenses that are reasonable in
amount and related to patient care for eligible patients.
Current and former employees told GAO that local ABC office
managers directed them to alter records to make it appear that
patients continued to need home health visits. Additionally,
managers directed employees to continue visiting patients who,
in the employees' opinions, did not qualify for home health
care because they no longer met Medicare rules defining
homebound status. ABC also reportedly charged Medicare for the
cost of acquiring other HHAs by paying owners a small sum up
front and the balance in the form of salary under employment
agreements, a practice that is inconsistent with Medicare
regulations for reimbursement. Finally, according to former
employees, some managers directed employees to market ABC and
its services with the intent of charging Medicare for costs
that were not reimbursable. GAO has shared information
concerning possible illegal activities with appropriate law
enforcement authorities. GAO summarized this report in
testimony before the Congress; see Medicare: Allegations
Against ABC Home Health Care (GAO/T-OSI-95-18, July 19, 1995),
by Richard C. Stiener, Director, Office of Special
Investigations, before the Subcommittee on Health and
Environment and the Subcommittee on Oversight and
Investigations, House Commerce Committee.
Medicaid Section 1115 Waivers: Flexible Approach to Approving
Demonstrations Could Increase Federal Costs (GAO/HEHS-96-44,
Nov. 8, 1995)
Several states have been given waivers allowing them to use
savings from managed care Medicaid programs to cover additional
beneficiaries. GAO found that contrary to assertions that such
waivers would be ``budget neutral,'' most of them could
increase federal Medicaid expenditures. Specifically, approved
spending limits for demonstration waivers in Oregon, Hawaii,
and Florida could boost federal Medicaid outlays. Only
Tennessee's 1115 waiver agreement should cost no more than the
continuation of its smaller, prewaiver program and, in fact,
should yield savings. Federal Medicaid spending could rise
significantly if the administration continues to show a similar
flexibility in reviewing state 1115 financing strategies. Five
waivers have been approved since Florida's in late 1994, and
the large backlog of pending waivers includes three states with
large Medicaid programs--New York, Illinois, and Texas.
Additional federal dollars are available along with other
funding sources identified in state waiver applications. GAO
believes that the potential for additional federal funding
serves as a hedge against the many uncertainties states face in
implementing these ambitious demonstrations--including changing
economic conditions, the accuracy of cost-containment
assumptions, the availability of anticipated funding cited in
waiver applications, and the lack of reliable cost data on the
uninsured.
Medicaid: States' Efforts to Educate and Enroll Beneficiaries in
Managed Care (GAO/HEHS-96-184, Sept. 17, 1996)
With managed care now being increasingly offered as an
option for Medicaid recipients, reports of marketing abuses by
managed care organizations have grown, prompting several states
to restrict direct marketing efforts by managed care
organizations. GAO found that some managed care organizations
and their agents have engaged in unscrupulous practices to
maximize beneficiary enrollment--and thereby boost plan
revenues and commissions. These practices include bribing
public officials to obtain confidential information on
beneficiaries, paying beneficiaries cash and providing other
incentives to sign up, deliberately misinforming beneficiaries
about access to care, and enrolling ineligible beneficiaries--
as many as 4,800 in one state. To avoid these problems, many
states have banned or restricted direct-marketing activities by
managed care organizations and have retained responsibility for
enrolling or disenrolling Medicaid beneficiaries. This report
provides detailed information on four states--Minnesota,
Missouri, Ohio, and Washington--with innovative education and
enrollment programs.
Medicaid: Waiver Program for Developmentally Disabled Is Promising But
Poses Some Risks (GAO/HEHS-96-120, July 22, 1996)
More than 300,000 adults with developmental disabilities--
typically mental retardation--receive long-term care paid for
by Medicaid or, to a lesser extent, state and local programs.
Such long-term care often involves supervision and assistance
with everyday activities, such as dressing or managing money.
Persons with developmental disabilities receive more than $13
billion annually in public funding for long-term care, second
only to the elderly. Recently, states have begun to
significantly expand the use of the Medicaid waiver program,
which seeks to provide alternatives to institutional care for
persons with developmental disabilities. The waiver program has
two advantages. First, it helps states to control costs by
allowing them to limit the number of recipients being served.
Without the waiver, states must serve all eligible persons in
the regular Medicaid program. Second, it permits states to meet
the needs of many persons with developmental disabilities by
offering them a broader range of services in less restrictive
settings, such as group or family homes, rather than in an
institutional setting. This report examines (1) expanded state
use of the waiver program, (2) the growth in long-term care
costs for individuals with developmental disabilities, (3) how
costs are controlled, and (4) strengths and limitations in
states' approaches to ensuring quality in community settings.
Medical ADP Systems: Defense Achieves Worldwide Deployment of Composite
Health Care System (GAO/AIMD-96-39, Apr. 5, 1996)
As the backbone of the military's medical operations, the
Composite Health Care System--an automated medical system
developed by the Department of Defense (DOD) at a cost of $2.8
billion--will provide doctors and nurses with almost instant
access to patient information, from medical history to current
treatment and vital statistics. DOD should be able to
significantly improve operations at its medical facilities
while reducing costs. Improved appointment scheduling will
increase patients' access to health care, while better access
to patient information will save medical personnel time. If DOD
is to realize the system's full potential, however, physicians
and other health care providers must be able to access the
system at all times. Although DOD's backup and recovery plan
provides for recovery from disruptions in computer service
because of power outages, it does not effectively address major
disruptions requiring the repair or the replacement of
equipment damaged by a natural disaster. Health care providers
have become dependent on the patient data in the system, so any
major disruption could result in injury or even death. DOD
could greatly reduce this risk by developing a more effective
backup and recovery plan for its equipment.
Medicare: Antifraud Technology Offers Significant Opportunity to Reduce
Health Care Fraud (GAO/AIMD-95-77, Aug. 11, 1995)
Medicare continues to suffer large losses each year due to
fraud. Existing risks are sharply increased by the continual
growth in Medicare claims--both in number and in percentage
processed electronically. Existing Medicare payment safeguards
can be bypassed and apparently do not deter fraudulent
activities. HCFA should be able to benefit by taking full
advantage of emerging antifraud technology to better identify
and prevent Medicare fraud. The number and types of Medicare
fraud schemes perpetrated in south Florida may make that area
the best place to test antifraud systems before nationwide use.
Medicare Claims: Commercial Technology Could Save Billions Lost to
Billing Abuse (GAO/AIMD-95-135, May 5, 1995)
With an investment of only $20 million in off-the-shelf
commercial software, Medicare could save nearly $4 billion over
5 years by detecting fraudulent claims by physicians--primarily
manipulation of billing codes. On the basis of a test in which
4 commercial firms reprocessed samples of more than 20,000 paid
Medicare claims,GAO estimates that the software could have
saved $603 million in 1993 and $640 million in 1994. GAO estimates that
because beneficiaries are responsible for about 22 percent of the
payment amounts--mainly in the form of deductibles and copayments--
Medicare could have saved them $134 million in 1993 and $142 million in
1994. The test results indicate that only a small portion of providers
are responsible for most of the abuses: fewer than 10 percent of
providers in the sample had miscoded claims. GAO summarized this report
in testimony before the Congress; see Medicare Claims Billing Abuse:
Commercial Software Could Save Hundreds of Millions Annually (GAO/T-
AIMD-95-133, May 5, 1995), by Frank W. Reilly, Director of Information
Resources Management in the Health, Education, and Human Services Area,
before the Subcommittee on Labor, Health and Human Services, Education,
and Related Agencies, Senate Committee on Appropriations.
Medicare Claims (High Risk Series) (GAO/HR-95-8, Feb. 1995)
In 1990, GAO began a special effort to identify federal
programs at high risk of waste, fraud, abuse, and
mismanagement. GAO issued a series of reports in December 1992
on the fundamental causes of the problems in the high-risk
areas. This report on Medicare claims is part of the second
series that updates the status of this high-risk area. Readers
have the following three options in ordering the high-risk
series: (1) request any of the individual reports in the
series, including the Overview (HR-95-1), the Guide (HR-95-2),
or any of the 10 issue area reports; (2) request the Overview
and the Guide as a package (HR-95-21SET); or (3) request the
entire series as a package (HR-95-20SET).
Medicare Drug and Nutrient Prices (GAO/HEHS-97-22R, Oct. 11, 1996)
Medicare part B covers (1) drugs that are incident to
physician services and are not self-administered and (2) tube-
fed liquid nutrients for patients who cannot ingest food orally
or whose digestive systems are impaired. Reports by the
Department of Health and Human Services Office of Inspector
General have indicated that the prices paid by Medicare for
some medications and nutrients are higher than necessary and
recommended reduced reimbursement for these items. Also, a home
infusion and nutritional service provider GAO contacted had
collected data indicating that Medicare payment levels for some
drugs were much higher than the provider's cost to acquire
them.
Medicare: Early Resolution of Overcharges for Therapy in Nursing Homes
Is Unlikely (GAO/HEHS-96-145, Aug. 16, 1996)
Nursing homes and therapy companies continue to bill
Medicare at very high rates for occupational and speech
therapy. Moreover, the bills do not specify the amount of time
spent with patients or the treatments provided. The weaknesses
that GAO reported more than a year ago--the lack of salary
guidelines setting limits on Medicare reimbursements for
occupational and speech therapist's services and unclear
billing for these services--persist. Although HCFA recognized
as early as 1990 that inappropriate charges for occupational
speech therapy were a problem, it is still trying to establish
salary equivalency guidelines for these services. HCFA proposed
guidelines based on a Bureau of Labor Statistics survey of
average salaries for hospital therapists, but the industry was
not satisfied and did its own survey. HCFA is now analyzing
those survey results. The prospect for a quick resolution to
the billing problem with therapy services is unlikely.
Historically, it has taken HCFA years to reduce high payment
rates for supplies or services. Given the typical time involved
in meeting federal notification and publication requirements
for changing Medicare prices, salary equivalency guidelines may
not be implemented until the summer of 1997 at the earliest.
GAO urges the Congress to consider granting HCFA legislative
relief from these requirements.
Medicare: Enrollment Growth and Payment Practices for Kidney Dialysis
Services (GAO/HEHS-96-33, Nov. 22, 1995)
Medicare is the predominant health care payer for people
with end-stage renal disease--the permanent and irreversible
loss of kidney function. Medicare's cost for this program has
increased, mainly because of the substantial increase in new
program enrollees. The annual rate of increase averaged 11.6
percent between 1978 and 1991. In addition to the rise in
enrollment, the mortality rate for new patients decreased. For
example, deaths among beneficiaries during the first year in
the program fell from 28 percent to 24 percent between 1982 and
1991. Because the program began in 1973, technological advances
and greater availability of kidney dialysis machines have meant
that persons who were not considered good candidates for kidney
dialysis in 1973--those 65 years old or older and those whose
kidney failure was caused by diabetes and hypertension--are now
routinely placed on dialysis. GAO's review of medical services
and supplies provided to all Medicare end-stage renal disease
patients in 1991 shows that no separately billable service or
supply was provided often enough to make it a good candidate to
be considered part of the standard dialysis treatment and thus
included in a future composite rate.
Medicare: Excessive Payments for Medical Supplies Continue Despite
Improvements (GAO/HEHS-95-171, Aug. 8, 1995)
In fiscal year 1994 alone, Medicare was billed more than
$6.8 billion for medical supplies. Congressional hearings and
government studies have shown that Medicare has been extremely
vulnerable to fraud and abuse in its payments for medical
supplies, especially surgical dressings. In one case discussed
in congressional testimony in 1994, Medicare paid more than
$15,000 in claims for a month's supply of surgical dressings
for a single patient, apparently without reviewing the
reasonableness of the claims before payments. Until recently,
medical suppliers had considerable freedom in choosing the
Medicare contractors that would process and pay their claims.
Some exploited this freedom by ``shopping'' for contractors
with the weakest controls and highest payment rates. This
report discusses the (1) circumstances allowing payment for
unusually high surgical dressing claims and (2) adequacy of
Medicare's internal controls to prevent paying such claims.
Medicare: Federal Efforts to Enhance Patient Quality of Care (GAO/HEHS-
96-20, Apr. 10, 1996)
In the past decade, Medicare costs have risen on average
more than 10 percent per year. Expanding managed care options
for Medicare patients has been proposed as a way to contain
costs. Concerns have been raised, however, that such changes
may undermine the quality of care provided to Medicare
beneficiaries. Currently, Medicare reimburses only for care
provided in health maintenance organizations (HMO) and by the
fee-for-service sector. This report (1) discusses the present
and future strategies of HCFA, which administers the Medicare
program, to ensure that Medicare providers furnish quality
health care in both fee-for-service and HMO arrangements and
(2) provides the views of experts on attributes a quality
assurance program should have if more managed care options are
made available to Medicare beneficiaries.
Medicare: HCFA Should Release Data to Aid Consumers, Prompt Better HMO
Performance (GAO/HEHS-97-23, Oct. 22, 1996)
Until recent years, nearly all Medicare beneficiaries
received care through a fee-for-service arrangement, with
benefits and cost-sharing provisions standardized nationwide.
Today, however, nearly 4 million beneficiaries have opted for
health maintenance organizations (HMO), Medicare's leading
managed care alternative. Although HMOs must cover the benefits
available under traditional fee-for-service Medicare, they
differ from one another in the provision of additional
benefits, required premiums, provider networks, and ability to
satisfy members. As a result, beneficiaries need reliable
information to pick the plan that is right for them. Some
beneficiaries do not understand even the basic difference
between traditional Medicare and HMOs and may confuse HMOs with
supplemental ``Medigap'' insurance. Moreover, some HMO sales
agents have misled or used other questionable marketing
practices to enroll poorly informed beneficiaries. This report
reviews (1) the performance of HCFA, which administers
Medicare, in providing beneficiaries with enough information on
Medicare HMOs and (2) the usefulness of readily available HCFA
data to caution beneficiaries about poorly performing HMOs.
Medicare Hospital Payments (GAO/HEHS-95-158R, May 25, 1995)
GAO provided information on the growth in Medicare hospital
payments, focusing on the annual payment growth rates for
various types of hospitals. GAO noted that (1) while general
inflation grew about 3.5 percent annually from 1984 through
1992, hospital payments per discharge grew at an annual rate of
5.4 percent; (2) major teaching hospitals averaged a 5.7
percent annual payment growth rate and nonteaching hospitals
averaged a 5.3 percent annual payment growth rate; (3)
hospitals receiving disproportionate share payments had a
higher per discharge payment growth rate than hospitals not
receiving such payments; (4) larger hospitals in both urban and
rural settings had higher payment growth rates; (5) government-
owned hospitals had higher payment growth rates than voluntary
or proprietary hospitals; (6) increased payments did not
necessarily translate to increased profits, since expenses were
not accounted for; and (7) case complexity grew more rapidly
among large urban and rural hospitals, which partially explains
their higher payment growth rate.
Medicare: Increased HMO Oversight Could Improve Quality and Access to
Care (GAO/HEHS-95-155, Aug. 3, 1995)
This report discusses problems that HCFA has had monitoring
HMOs it contracts with to provide services to Medicare
beneficiaries and ensuring that they comply with Medicare's
performance standards. GAO found weaknesses in HCFA's quality
assurance monitoring, enforcement measures, and appeal
processes. Although HCFA routinely reviews HMO operations for
quality, these reviews are generally perfunctory and do not
consider the financial risks that HMOs transfer to providers.
Moreover, HCFA collects virtually no data on services received
through HMOs to enable it to identify providers who may be
underserving beneficiaries. In addition, HCFA's HMO oversight
has two other major limitations: enforcement actions are weak
and the beneficiary appeal process is slow. HCFA's current
regulatory approach to ensuring good HMO performance appears to
lag behind the private sector. GAO summarized this report in
testimony before the Congress; see Medicare: Increased Federal
Oversight of HMOs Could Improve Quality of and Access to Care
(GAO/T-HEHS-95-229, Aug. 3, 1995), by Sarah F. Jaggar, Director
of Health Financing and Public Health Issues, before the Senate
Special Committee on Aging.
Medicare HMOs: Rapid Enrollment Growth Concentrated in Selected States
(GAO/HEHS-96-63, Jan. 18, 1996)
Private-sector insurers cite extensive use of HMOs and
other managed care approaches as a key factor in slowing the
growth of their insurance premiums. As a result, part of the
current interest in controlling Medicare costs has centered on
ways to increase HMO use among Medicare beneficiaries. This
report provides informationon trends in the number of (1)
Medicare beneficiaries enrolling in HMOs and (2) HMOs enrolling
beneficiaries. GAO analyzed these data for factors that might be
influencing decisions by HMOs to enroll Medicare beneficiaries and
decisions by beneficiaries to enroll in HMOs. GAO found that about 2.8
million Medicare beneficiaries--about 7 percent of the total--were
enrolled in risk-contract HMOs as of August 1995. This was double the
percentage enrolled in 1987. The growth has been particularly rapid
during the past 4 years and has centered on certain states. California
and Florida, for example, have more than half of all enrollees.
Medicare: Home Health Utilization Expands While Program Controls
Deteriorate (GAO/HEHS-96-16, Mar. 27, 1996)
Use of the Medicare home health benefit has increased
dramatically, with spending rising from $2.7 billion in 1989 to
$12.7 billion in 1994. Costs are projected to reach $21 billion
by the year 2000. In earlier reports (GAO/HRD-81-155 and GAO/
HRD-87-9), GAO cited lax controls over the use of the home
health benefit and recommended measures to improve Medicare's
ability to detect claims that were not medically necessary or
did not meet the coverage criteria. Medicare's escalating home
health outlays continue to raise concerns about the extent of
benefit abuse. This report examines the factors underlying the
growth in the use of the home health benefit. GAO discusses (1)
changes in the composition of the home health industry, (2)
changes in the composition of Medicare home health users, (3)
differences in utilization patterns across geographic areas,
(4) incentives to overuse services, and (5) the effectiveness
of payment controls in preventing payments for services not
covered by Medicare.
Medicare Insured Groups (GAO/HEHS-6-93R, May 1, 1996)
Pursuant to a legislative requirement, GAO examined
Medicare insured groups, focusing on (1) the status of the
demonstration program and individual projects and (2) efforts
to establish a reliable payment system. GAO found that (1) with
the passage of the Omnibus Reconciliation Act of 1987, five
groups had entered into agreements with HCFA to operate
Medicare insured groups; (2) HCFA expenditures for the
agreements totalled $1.1 million over the last 8 years; (3) all
the agreements have been terminated due to concerns over the
projects' financial viability; (4) HCFA terminated one of the
projects after experiencing prolonged delays and problems with
contract negotiations; (5) another company encountered delays
in obtaining employer commitments and data needed for rate-
setting analysis; (6) the most recent group to terminate had
developed an operating plan and proposed a payment rate-setting
method before experiencing lengthy delays and problems with
payment update methodology; (7) the proposed payment
methodology would have established a base rate using 1986 to
1990 claims data and updated the rate on the basis of revised
per capita costs; and (8) in using more recent claims data,
groups would have faced financial risk, as well as additional
time and expense.
Medicare Managed Care: Growing Enrollment Adds Urgency to Fixing HMO
Payment Problem (GAO/HEHS-96-21, Nov. 8, 1995)
Enrollment of Medicare beneficiaries in HMOs has soared in
recent years, concentrated in some states and locales. This
rapid growth in enrollment highlights the urgency of correcting
Medicare's excessive payment rates to HMOs--particularly in
certain areas. Likewise, enrollment stagnation elsewhere
underscores the need to examine the causes of payment rate
disparities among states and counties. Medicare's HMO payment
method is plagued by three flaws. First, the rigidity of the
formula-based fixed payment rate does not allow Medicare to
capitalize on the competition among HMOs that, in the private
market, leads to lower rates. Second, rate adjustments for
differences in beneficiaries' health status are so imprecise
that Medicare overpays HMOs that enroll beneficiaries who are
in good health. Third, the reliance on a county's fee-for-
service health care costs to establish a payment rate produces
rates that vary considerably within market areas. GAO concludes
that a sensible approach would be to pursue three promising
strategies concurrently--foster price competition among HMOs,
improve risk adjusters' accuracy, and allow for adjustments in
the current formula to reflect market competition and HMO's
local health care costs. HCFA plans demonstration projects
using competitive bidding and improved risk adjustment but
results of a full-scale evaluation of these projects are years
away. In the interim, HCFA should promptly gather and use
valuable design and implementation data as they become
available. HCFA's legislative authority to carry out these
projects does not address managed care options explicitly,
which raises questions about HCFA's authority to mandate HMO
participation in the projects.
Medicare Managed Care Growth (GAO/HEHS-96-47R, Oct. 18, 1995)
Pursuant to a congressional request, GAO reviewed the
growth of Medicare beneficiaries in managed health care plans.
GAO noted that (1) although more than 50 percent of employees
covered by employer-provided insurance are enrolled in managed
health care plans, fewer Medicare beneficiaries are enrolled in
such plans; (2) the only managed care option Medicare offers is
HMOs and they are not uniformly available; (3) the percentage
of Medicare beneficiaries enrolled in an HMO has increased from
about 3 percent in 1987 to about 7 percent in 1995; (4)
although Medicare beneficiaries are increasingly choosing HMOs,
about 87 percent of these beneficiaries live in 10 states,
while about 55 percent live in just 2 states; and (5) only 3
states have Medicare HMO enrollment of 20 percent or more,
while 7 states have non-Medicare HMO enrollments of 30 percent
or more.
Medicare: Millions Can Be Saved by Screening Claims for Overused
Services (GAO/HEHS-96-49, Jan. 30, 1996)
Medicare contractors routinely pay hundreds of millions of
dollars in Medicare claims without first determining if the
services provided are necessary. GAO reviewed payments to
doctors for six groups of high-volume medical procedures--
ranging from eye examinations to chest X rays--that accounted
for nearly $3 billion in Medicare payments in 1994. GAO also
surveyed 17 contractors to determine if they had used medical-
necessity criteria in their claims processing to screen for
these six groups of procedures. For each of the six groups,
more than half of the 17 contractors failed to use automated
screens to flag claims for unnecessary, inappropriate, or
overused treatments. These prepayment screens could have saved
millions of taxpayer dollars now wasted on questionable
services. Problems with controlling payments for widely
overused procedures continue because HCFA lacks a national
strategy to control these payments. HCFA now relies on
contractors to focus on procedures where local use exceeds the
national average. Although this approach helps reduce local
overuse of some procedures, it is not designed to control
overuse of a procedure nationwide. GAO summarized this report
in testimony before the Congress; see Medicare: Millions Can Be
Saved by Screening Claims for Overused Services (GAO/T-HEHS-96-
86, Feb. 8, 1996), by Sarah F. Jaggar, Director of Health
Financing and Public Health Issues, before the Subcommittee on
Human Resources and Intergovernmental Relations, House
Committee on Government Reform and Oversight.
Medicare Providers' Legal Expenses (GAO/HEHS-95-214R, July 18, 1995)
GAO provided information on Medicare reimbursement of
providers' legal expenses, focusing on (1) the conditions that
Medicare imposes on provider legal expense reimbursements and
whether these conditions differ from those applied in other
government contexts, (2) the amount Medicare spends on
providers' legal expenses, and (3) whether Medicare providers
have abused current provisions covering legal expense
reimbursement. GAO noted that (1) HCFA has not specified the
conditions under which legal fees are reimbursable; (2)
Medicare decides whether providers' legal fees are reimbursable
on a case-by-case basis; (3) the provisions for reimbursing
Medicare providers' legal fees are more generous than those in
other government contexts in that providers can be reimbursed
by Medicare regardless of outcome and providers' legal expenses
are not capped; (4) in 1994, 46 HHAs had a combined total of
$6.5 million in legal expenses; and (5) HHAs are more likely to
submit claims for Medicare reimbursement and to appeal denied
cost adjustments, despite limited chances of success.
Medicare Secondary Payer Program (GAO/HEHS-95-101R, Mar. 6, 1995)
GAO provided information on and suggested language for
proposed legislation regarding the recovery of health care
costs from private insurers where Medicare is the secondary
payer. GAO noted that (1) the proposed legislation would give a
clearer statutory basis for existing Medicare regulations on
cost recovery from private insurers, which were recently
invalidated by a court ruling; (2) HHS is also preparing a
legislative proposal to address this and other Medicare issues;
(3) the government may have to refund millions of dollars in
past recoveries and forego future recoveries because of the
court ruling; and (4) the court ruling barred recoveries from
third-party administrators and claims filed past the insurers'
filing deadlines and before 1989.
Medicare Spending: Modern Management Strategies Needed to Curb Billions
in Unnecessary Payments (GAO/HEHS-95-210, Sept. 19, 1995)
Medicare's vulnerability to billions in unnecessary
payments stems from a combination of factors. First, Medicare
pays higher than market rates for some services and supplies.
For example, Medicare pays more than the lowest suggested
retail price for more than 40 types of surgical dressings.
Second, Medicare's anti-fraud-and-abuse controls do not prevent
the unquestioned payment of claims for improbably high charges
or manipulated billing codes. Third, Medicare's checks on the
legitimacy of providers are too superficial to detect the
potential for scams. Various health care management strategies
help private payers avoid these problems, but Medicare
generally does not use these strategies. The program's pricing
methods and controls over utilization, consistent with health
care financing and delivery 30 years ago, have not kept pace
with major financing and delivery changes. GAO believes that a
viable strategy for remedying the program's weaknesses would
involve adapting the health care management approach of private
payers to Medicare's public payer role. This strategy would
include (1) more competitively developed payment rates, (2)
enhanced fraud and abuse detection efforts through modernized
information systems, and (3) more rigorous criteria for
granting authorization to bill the program.
Medicare: Tighter Rules Needed to Curtail Overcharges for Therapy in
Nursing Homes (GAO/HEHS-95-23, Mar. 30, 1995)
Nursing homes and rehabilitation centers are taking
advantage of ambiguous payment rules and the lack of guidelines
to bill Medicare at inflated rates for therapy services. State
averages for physical, occupational, and speech therapists'
salaries range from about $12 to $25 per hour, but Medicare has
been charged upwards of $600 per hour. The extent of
overcharging and its precise impact on Medicare outlays are
unclear; however, billing schemes uncovered in recent years
suggest that the problem is nationwide and growing in
magnitude. Extraordinary markups on therapy can resultfrom
providers exploiting regulatory ambiguity and weaknesses in Medicare's
payment rules. Payment rules and procedures developed when the therapy
industry was much smaller and less sophisticated have proved no match
for increasingly complex business practices designed to generate
increased Medicare revenue and skirt program controls. Although the
overbilling problem has been known since 1990, no action has been taken
to close loopholes that allow payment for these overcharges.
Medigap Insurance: Alternatives for Medicare Beneficiaries to Avoid
Medical Underwriting (GAO/HEHS-96-180, Sept. 10, 1996)
Although the Medicare program covers a substantial share of
its beneficiaries' health expenses, it does require deductibles
and coinsurance that can amount to thousands of dollars a year.
Most beneficiaries obtain private insurance to supplement
Medicare when they become eligible for the program at age 65.
On occasion, beneficiaries decide to change Medigap policies
and may then become subject to medical underwriting; that is,
the insurer can take into account a person's health status or
medical history in deciding whether to sell a policy. GAO found
that few beneficiaries decide later to change their policies
and those that do have at least one alternative for changing
without being subject to medical underwriting. These
alternatives, however, are not guaranteed by federal law, and
it is possible that circumstances could change in the future.
Federal Medigap law could be amended to furnish such a
guarantee to beneficiaries who have been continuously covered
by Medigap. Such a change should not have any major effect
because it would not alter beneficiary incentives for Medigap
coverage.
Medigap Insurance: Insurers' Compliance With Federal Minimum Loss Ratio
Standards, 1988-93 (GAO/HEHS-95-151, Aug. 23, 1995)
The Medigap market grew steadily from 1988 to 1993, from
$7.3 billion to $12.1 billion. Medigap insurers' aggregate loss
ratios were relatively stable during the first 4 years of that
period. During the next 2 years, however, these ratios fell
about 10 percent, to an aggregate 75 percent for individual
policies and 85 percent for group policies. In 1991, 19 percent
of Medigap policies failed to meet loss ratio standards; this
rose to 38 percent by 1993. The premium dollars spent on such
policies increased from $320 million in 1991 to $1.2 billion in
1993. If insurers had been required to give refunds or credits
on substandard policies, as they will in the future,
policyholders would have been due about $124 million during
1992 and 1993.
MediGrant: Florida (GAO/HEHS-96-11R, Oct. 2, 1995)
Pursuant to a congressional request, GAO provided
information on how the proposed MediGrant Program will affect
Florida's federal Medicaid funding between fiscal years 1996
and 2002. GAO noted that (1) Florida state officials estimated
that Florida would receive $7.6 billion less under the proposed
MediGrant program than it does under current law; (2) between
1996 and 2002 Florida is expected to match $30.6 billion under
the current Medicaid spending law and $15.8 billion under the
MediGrant proposal; (3) the MediGrant program would phase in a
new formula by guaranteeing minimum growth rates for some
states and placing limits on the maximum growth a state could
receive each year; and (4) the MediGrant program would increase
Florida's share of federal Medicaid funding from 3.67 percent
in fiscal year 1994 to 4.13 percent in fiscal year 2002.
Michigan Financing Arrangements (GAO/HEHS-95-146R, May 5, 1995)
GAO provided information on Michigan's 1995 Medicaid
funding arrangements. GAO noted that (1) Michigan has been
among the most successful states in obtaining additional
federal Medicaid funds; (2) since fiscal year 1991, Michigan
has reduced its Medicaid costs by $1.8 billion due to a variety
of financing partnerships with medical providers; (3) most
federal matching funds paid to providers have been returned to
the state, thus reducing state appropriations; (4) although
federal legislation has curtailed certain financing practices,
Michigan has found new ways to obtain federal matching funds,
such as using provider donations to maximize federal funds and
reduce state costs; (5) Michigan's use of intergovernmental
transfers could reduce Medicaid costs by an additional $428
million in fiscal year 1995; (6) Michigan expects to obtain
over $414 million in federal matching funds in fiscal year
1996; (7) Michigan should realize a net benefit of $196.5
million in fiscal year 1995 by adjusting nursing home and
mental health Medicaid services payments; and (8) Michigan
determined that it could make additional hospital outpatient
payments of $40 million without exceeding established cost
limits for such services.
Montana's Medical Assistance Facilities (GAO/HEHS-96-12R, Oct. 2, 1995)
Pursuant to a congressional request, GAO provided
information on Montana's medical assistance facilities (MAF),
focusing on the (1) cases treated and services performed at
MAFs; (2) costs to Medicare for inpatient services provided at
MAFs compared to the costs at acute-care hospitals; and (3)
number of hospitals that might qualify as MAFs if the program
was expanded nationwide. GAO noted that (1) MAFs mainly serve
patients with uncomplicated conditions or stabilize patients
with more severe conditions before transferring them to full-
service hospitals; (2) MAFs serve as primary care providers for
Medicare beneficiaries living in rural areas; (3) Medicare
costs are generally less at MAFs than if the same patients had
been treated at non-MAFs; (4) patients who are transferred from
MAFs to acute-care hospitals increase Medicare costs, because
the two facilities receive payments for the same patient; and
(5) if the MAF or a similar program for rural hospitals in
seven other states were expanded nationwide academic
researchers estimated that although over 500 hospitals meet the
qualifying criteria for MAFs, no more than 150 hospitals would
convert to such limited service centers.
Nonphysician Specialists (GAO/HEHS-96-135R, May 29, 1996)
Pursuant to a congressional request, GAO provided
information on the policies and procedures governing the
participation of certain nonphysician health specialists in
several federal health care programs. GAO noted that (1)
although nonphysician specialists are authorized to participate
and provide services in federal health care programs,
participation requirements and allowable services vary among
and within the programs; (2) participation requirements vary as
to training, supervision, and specialty autonomy; and (3) some
agencies that administer federal health programs are more
involved in setting requirements and establishing service
parameters for nonphysician specialists than other agencies.
Patient Self-Determination Act: Providers Offer Information on Advance
Directives But Effectiveness Uncertain (GAO/HEHS-95-135, Aug.
28, 1995)
The Congress passed the Patient Self-Determination Act in
1990 to reinforce individuals' constitutional right to decide
their final health care. The act requires health care providers
to increase public awareness about the use of ``advance
directives''--a living will or health care power of attorney.
An advance directive spells out how life-support decisions
should be carried out should the patient become terminally ill
and unable to communicate his or her wishes. This report
provides information on the act's implementation and on the
effectiveness of advance directives in ensuring patient self-
determination. GAO looked at the extent to which (1)
institutional health care providers and the federal government
are complying with the act's provision, (2) the public uses
advance directives to express their end-of-life treatment
wishes, and (3) an advance directive affects a patient's
desired care.
Practice Guidelines: Managed Care Plans Customize Guidelines to Meet
Local Interests (GAO/HEHS-96-95, May 30, 1996)
The inappropriate use of medical services can be costly and
raises quality-of-care concerns. For example, a 1988 study
found that 14 percent of bypass surgeries were performed
inappropriately. To narrow the gap between current and optimal
practice, some federal agencies and other groups develop
clinical practice guidelines on the best practices for
effective and appropriate care. Managed care plans, which
employ various techniques intended to reduce inappropriate
care, are likely sites of guideline use. This report discusses
(1) the purposes clinical practice guidelines serve and (2) how
health plans make use of already published guidelines developed
by federal agencies and other groups.
Prescription Drugs and the Elderly: Many Still Receive Potentially
Harmful Drugs Despite Recent Improvements (GAO/HEHS-95-152,
July 24, 1995)
The inappropriate use of prescription drugs is particularly
hazardous for the elderly. Not only do they use more
prescription drugs than any other age group, the elderly are
more likely to take several drugs at once, increasing the
likelihood of harmful drug reactions. Furthermore, the elderly
do not eliminate drugs from their systems as efficiently as
younger patients because of decreased liver and kidney
function. GAO found that 17.5 percent of nearly 30 million
noninstitutionalized Medicare recipients aged 65 or older used
at least one drug identified as generally unsuitable for
elderly patients since safer alternative drugs exist.
Inappropriate prescription drug use can result from doctors
using outdated prescribing practices, pharmacists not doing
drug utilization reviews, and patients not telling their
doctors and pharmacists about all the drugs they are taking.
Recent initiatives are seeking to address this problem. Federal
and state efforts have encouraged the development and
dissemination of detailed information on the effect of
prescription drugs on the elderly, and the medical community is
urging doctors to increase their knowledge of geriatrics and
elderly clinical pharmacology. At the same time, drug
utilization review systems now allow prescriptions to be
screened before they are filled to identify potential problems,
such as adverse drug interactions or inappropriate dosage
levels. Changes in the health care delivery system may also
help reduce inappropriate use of prescription drugs. For
example, managed care plans, through the use of controls such
as a ``gatekeeper,'' could potentially improve the coordination
of drug therapies for newly enrolled elderly patients.
Prescription Drugs and Medicaid: Automated Review Systems Can Help
Promote Safety, Save Money (GAO/AIMD-96-72, June 11, 1996)
Inappropriate use of prescription drugs can lead to drug-
induced illness, hospitalization, and even death. Inappropriate
drug use can also prove expensive for the Medicaid program. As
a result, the Congress mandated that states establish
utilization review programs--called prospective reviews--to
review Medicaid prescriptions before drugs are dispensed.
Automated prospective drug utilization review systems are
proving a low-cost way for states to help both doctors and
pharmacies safeguard Medicaid recipients from potentially
harmful medical reactions. Although the main emphasis of these
systems--appropriately--has been safety, both safety benefits
and dollar savings accrue from their use. Because results vary
on the basis of how such systems are administered, it is
important that states share their experiences. Absent any
analysis of data from the Iowa demonstration project or
anyconcerted effort by HCFA to collect and share other states'
experiences, states have had only limited access to both safety and
cost data--information that is critical to informed decisionmaking and
to maximizing the effectiveness and efficiency of automated prospective
drug utilization review systems.
Preventing Abusive Medicare Billing (GAO/HEHS-95-260R, Sept. 5, 1995)
GAO discussed its recommendations for preventing abusive
billing practices for therapy services furnished to nursing
home residents who are covered by Medicare and whether the
recommendations can be implemented legislatively. GAO noted
that (1) Medicare law could be amended to require HHS to
establish the requirements recommended as well as a higher
limit on the amount that Medicare will recognize as reasonable
for therapy services; (2) expense claim limits could be set at
the amount established under Medicare's part B fee schedules
for therapy services; (3) establishing an upper limit would
partially define billable units of service, since the procedure
codes for occupational and speech therapy do not define the
amount of time the codes cover; and (5) proposals have been
made to require nursing homes to bill for the services provided
to their residents, whether payment is sought from part A or
part B fee schedules.
Private Health Insurance: Millions Relying on Individual Market Face
Cost and Coverage Trade-Offs (GAO/HEHS-97-8, Nov. 25, 1996)
Most Americans obtain health insurance coverage through
their jobs or through government programs like Medicare and
Medicaid. About 10.5 million Americans, however, purchased
private health insurance for themselves or their families in
1994. The family farmer, the recent college graduate, the early
retiree, and the employee of a company that does not offer
health insurance coverage are all examples of persons who are
often not covered in a voluntary, employment-based insurance
market. Integrating the individual market into health insurance
reform proposals has been a thorny issue at both the federal
and state level, in part because of the paucity of information
on the nature of this market and the characteristics of its
participants. This report discusses the (1) size of the
individual market, recent trends in it, and the demographic
characteristics of its participants; (2) market structure,
including how persons access the market, the prices and other
characteristics of health plans offered, and the number of
individual carriers offering plans; and (3) insurance reforms
and other measures states have taken to improve individuals'
access to health insurance.
Psychiatric Hospital Oversight (GAO/HEHS-96-132R, May 24, 1996)
Pursuant to a congressional request, GAO reviewed federal
and state oversight of state-operated and private psychiatric
hospitals. GAO noted that (1) as of August 1995, 702
psychiatric hospitals were certified to participate in Medicare
and Medicaid; (2) to become certified for participation in
Medicare and Medicaid, psychiatric hospitals must satisfy
general hospital requirements for health and safety, and
special psychiatric hospital requirements for active treatment;
(3) hospital medical records must reflect the degree of active
treatment and hospitals must have qualified staff to evaluate
and treat patients; (4) HCFA requires states to conduct surveys
of psychiatric hospitals to determine whether they satisfy
certification requirements; (5) surveys of psychiatric
hospitals include examinations of hospital and patient records,
direct observations of patients, and interviews with staffs and
patients; (6) as of August 1995, most certified psychiatric
hospitals satisfied HCFA requirements for medical records and
staffing; and (7) the failure to evaluate a patient's strengths
when developing a treatment plan, specify each patient's
treatment goals, and indicate the methods of treatment were the
most common deficiencies cited in surveys of psychiatric
hospitals that failed to satisfy HCFA certification
requirements.
Public Health: A Health Status Indicator for Targeting Federal Aid to
States (GAO/HEHS-97-13, Nov. 13, 1996)
Premature mortality is the best single proxy for reflecting
differences in the health status of states' populations as
measured by both the Healthy People 2000 indicators and the
ReliaStar index. GAO's analysis showed that using premature
mortality to distribute federal funding for core public health
functions would systematically target federal assistance to
states on the basis of their populations' rates of mortality,
disease incidence, and risk for mortality and morbidity.
Several other variables, including the proportion of states'
populations that are poor or minorities, were also found to be
correlated with health status differences as measured by the
Healthy People 2000 indicators and the ReliaStar index.
However, including these variables along with premature
mortality did not significantly enhance GAO's ability to
differentiate the health status of state populations. Moreover,
improving the targeting of funds beyond that obtained by using
premature mortality alone would require using several
additional variables, which would add to the complexity of the
allocation formula.
Skilled Nursing Facilities: Approval Process for Certain Services May
Result in Higher Medicare Costs (GAO/HEHS-97-18, Dec. 20, 1996)
Skilled nursing facilities provide posthospital care for
people who need more care than is available in the home.
Medicare payments to these facilities have grown rapidly, from
$456 million in 1983 to nearly $11 billion in 1996. The number
of facilities that have sought and been granted payments higher
than those normally allowed by Medicare has also grown, from a
total of 80 during fiscal years 1979-92 to 552 in fiscal year
1995. The skilled nursing facility industry contends that the
higher payments are justified because these facilities care for
more complex and costly patients than they did in the past.
However, GAO did not find that skilled nursing facilities that
collected the higher fees had a larger proportion of patients
requiring complex care than did other facilities. Moreover, in
the area of therapy, which could be indicative of complex care
needs, GAO found no major differences in the amount and types
of therapy provided. Although the number of skilled nursing
facilities granted exceptions to routine cost limits under
Medicare soared from 62 in fiscal year 1992 to 552 in 1995, the
Health Care Financing Administration's review process for
exception requests does not ensure that facilities actually
provide atypical services to their Medicare patients. In
addition, the patient-specific data obtained from requesting
skilled nursing facilities generally are not used to assess
whether the Medicare beneficiaries need or receive atypical
services.
State Medicaid Financing Practices (GAO/HEHS-96-76R, Jan. 23, 1996)
Pursuant to a congressional request, GAO provided
information on state Medicaid financing arrangements in
Michigan, Tennessee, and Texas. GAO noted that (1) until HCFA
ruled in 1985 that states could use Medicaid provider donations
to reduce their share of Medicaid expenditures, states could
only use provider donations for the cost of training
administrative personnel; (2) Michigan raised $684 million for
its Medicaid program through hospital donations and federal
matching funds in fiscal years 1991 through 1993, allowing it
to fund $566 million in additional Medicaid payments; (3) in
1993, Tennessee required certain medical providers to pay a
$2,600 tax on their nursing home beds and a 6.75-percent tax on
services, but it discontinued the hospital services tax in 1994
when it implemented the TennCare program; (4) Tennessee earned
$458 million from nursing home and hospital taxes in fiscal
year 1993 and received $954 million in federal matching funds,
which accounted for over half of its 1993 Medicaid spending;
(5) the Congress enacted legislation in 1993 that restricted
state financing arrangements by limiting disproportionate share
hospital (DSH) program payments, causing states to modify their
DSH programs and overall DSH payments to decline; and (6)
despite the 1993 legislation, states were able to use
intergovernmental transfers and other creative funding
arrangements to reduce their share of Medicaid costs.
HOUSING AND COMMUNITY DEVELOPMENT ISSUES
Community Development: Status of Urban Empowerment Zones (GAO/RCED-97-
21, Dec. 20, 1996)
The Empowerment Zone and Enterprise Community Program
targets federal grants to distressed urban and rural
communities for social services and community redevelopment and
provides tax and regulatory relief to attract or retain
businesses in distressed communities. This report focuses on
six urban empowerment zones that receive most of the program's
funds--Atlanta, Baltimore, Chicago, Detroit, New York, and
Philadelphia/Camden. GAO discusses the (1) status of the
program's implementation in the urban empowerment zones,
including the extent to which public housing officials and
residents have been involved; (2) factors that participants
believe have either helped or hindered efforts to carry out the
program; and (3) plans for evaluating the program.
Housing Counseling Demonstration Program (GAO/RCED-96-238R, Sept. 16,
1996)
The National Affordable Housing Act of 1990 required GAO to
report on the effectiveness of a U.S. Department of Housing and
Urban Development prepurchase and foreclosure-prevention
counseling demonstration program. This counseling was intended
to (1) reduce defaults and foreclosures on single-family
mortgages insured by the Federal Housing Administration (FHA),
(2) encourage responsible and prudent use of such mortgages,
(3) help homeowners with FHA mortgages keep their homes, and
(4) encourage the availability and expansion of home ownership
through the FHA mortgage insurance program. The act required
that the demonstration program, which was funded from September
30, 1992, to September 30, 1994, include a comparison of three
locations where the counseling was provided (target areas) and
three similar locations where counseling was not provided
(control areas).
Several implementation problems precluded GAO from
assessing the impact of the program. Specifically, target and
control areas were not comparable, the counseling intervention
was not always implemented properly, and the program was
geographically more limited than originally planned.
Consequently, valid data does not exist upon which to base a
study for determining whether a permanent program of mandatory
counseling would be effective in reducing defaults and
foreclosures.
HUD-Assisted Renters (GAO/RCED-95-167R, May 18, 1995)
GAO provided information on the Department of Housing and
Urban Development's (HUD) rental assistance programs, focusing
on the potential for assisted households to move toward or
achieve economic self-sufficiency. GAO noted that based on
samples of 1989 data (1) HUD-assisted renters' median age was
50 years, with 29 percent 34 years or younger, 36 percent
between the ages of 35 and 64, and 35 percent 65 years or
older; (2) the elderly and the disabled, who constituted about
49 percent of HUD-assisted households, had limited potential
for achieving self-sufficiency; (3) 45 percent of assisted
households had children, with 12 percent having three or more
children; (4) about 55 percent of the households were headed by
single parents; (5) single parents needed child care and other
services to participate in training or employment programs; (6)
about 36 percent of the heads of assisted households had
graduated from high school, another 18 percent had 1 or more
years of college, and 21percent had fewer than 8 years of
schooling; (7) at least 45 percent of HUD-assisted renters needed
additional education or training to become self-sufficient; (8) the
renters' median income was $7,320; (9) about 7 percent of the renters
had incomes of $20,000 or more; (10) only 40 percent of the households
reported income from wages or salaries; and (11) a 3-member family
renting a 2-bedroom apartment would need an annual income ranging from
$18,396 to $36,264 to become economically independent of the housing
program.
HUD Management: Greater Oversight Needed of FHA's Nursing Home
Insurance Program (GAO/RCED-95-214, Aug. 25, 1995)
HUD has insured private lenders against financial losses
arising from defaults on mortgages for nursing homes and
retirement service centers. Although HUD officials believe that
the program has enabled the agency to assist populations or
areas that are not well served by the private sector, GAO found
that the nursing home program has not been targeted to specific
populations or communities and that HUD does not collect or
analyze information on whom the program is servicing. The
Federal Housing Administration (FHA) has not completely
assessed the financial performance of the nursing home and
retirement service center programs. Available data indicate
that the nursing home program has incurred losses of $187
million, adjusted for inflation, during its 35-year history.
Additionally, FHA's fiscal year 1994 loan loss reserves
anticipate future losses equivalent to about 19 percent of the
$3.7 billion balance of nursing home loans in the portfolio as
of September 1994. HUD data show that about 46 percent of the
retirement service center's total portfolio of about $1.4
billion had defaulted and resulted in FHA insurance claims as
of September 1994. GAO doubts whether HUD will be able to
effectively manage the nursing home and retirement service
center programs in the near future.
Information Technology: Streamlining FHA's Single Family Housing
Operations (GAO/AIMD-97-4, Oct. 17, 1996)
The Secretary of Housing and Urban Development has proposed
a major overhaul of the agency's programs and operations during
the next several years. One proposal is to cut staff at FHA by
more than 50 percent by the year 2000. Information technology
figures prominently in FHA's plans to streamline its single
family operations, boost efficiency, and meet mandated staff
reductions. Thus far, the planned actions are consistent with,
but are not as extensive as, efficiency improvements taken by
leading mortgage industry organizations. FHA's streamlining
efforts, however, are in the early stages and, as other efforts
continue, FHA will be deciding on specific operational changes,
information technology applications, and management controls
that will determine the efficiency and effectiveness of its
operations and the achievement of staff reductions. In doing
so, it can use the recently enacted Information Technology
Management Reform Act of 1996 to establish an effective
framework for making these information technology decisions.
Multifamily Housing: Effects of HUD's Portfolio Reengineering Proposal
(GAO/RCED-97-7, Nov. 1, 1996)
About 8,600 privately owned multifamily properties with
federally insured mortgages totaling nearly $18 billion receive
federal rental subsidies for all or some of their apartments
under the Department of Housing and Urban Development's (HUD)
Section 8 program. For subsidized apartments, HUD pays the
difference between the rent and 30 percent of the household's
income. The rents at many properties exceed market levels,
resulting in high subsidies. To reduce costs and address other
problems, HUD has proposed adjusting the rents to market levels
and writing down mortgages as needed to allow the properties to
operate at market rents. In essence, HUD's proposal recognizes
a reality that has persisted for some time--namely, that many
of the properties in the insured Section 8 portfolio are worth
far less than their mortgages suggest. This report examines the
(1) problems affecting the properties in HUD's insured Section
8 portfolio and HUD's plans for addressing them, (2) results
and reasonableness of a study done by Ernst & Young assessing
the effects of HUD's proposal on the properties in the
portfolio, and (3) key issues facing the Congress as it
assesses HUD's proposal.
Public Housing: Partnership Can Result in Cost Savings and Other
Benefits (GAO/RCED-97-11, Oct. 17, 1996)
The Congress is considering giving the nation's 3,300
public housing authorities greater flexibility in managing
their properties and in operating public and assisted housing
for more than 4 million households. This greater discretion is
expected to strengthen the long-term viability of public and
assisted housing and allow the public housing authorities to
better meet the needs of local communities. Public housing
authorities have begun establishing partnerships with public
and private sector groups to help stretch limited financial
resources. Some partnerships have generated quantifiable cost
savings, while others have produced nonmonetary benefits, such
as improved social services, that would not have been possible
without the partnership. This report describes four types of
arrangements that public housing authorities have established
and provides the views of public housing authority officials on
the advantages of these arrangements.
Rural Housing Programs: Opportunities Exist for Cost Savings and
Management Improvement (GAO/RCED-96-11, Nov. 16, 1995)
The Agriculture Department's Rural Housing and Community
Development Service provides about $2.85 billion each year for
rural housing loans. As of June 1995, the Service had an
outstanding single-family and multifamily housing loan
portfolio of about $30 billion, which represented a significant
federal investment in affordable housing for the rural poor.
The largest portion of the loan portfolio is for single-family
direct and guaranteed mortgage loans that are made to families
or individuals who are without adequate housing and who are
unable to obtain loans from private lenders at reasonable
costs. Rural multifamily rental housing loans, made to finance
apartment-style housing or to buy and rehabilitate existing
rental units, make up the rest of the portfolio. This report
provides information on the Service's single- and multifamily
housing loan programs and discusses suggestions made by GAO and
others that could yield cost savings or improve management in
these programs.
INCOME SECURITY ISSUES
Buyout Recipients' Compliance with Reemployment Provisions (GAO/GGD-97-
7R, Oct. 3, 1996)
In Reemployment of Buyout Recipients (GAO/GGD-96-102R), GAO
identified 68 persons who took a buyout to leave government,
were reemployed as civil servants, and also were required to
take certain steps to satisfy reemployment requirements. On the
basis of information from Office of Personnel Management (OPM)
data and interviews with personnel officials at the affected
agencies, GAO concluded in this report that 11 of the 68
individuals were in apparent violation of the reemployment
requirements, while 45 were not. GAO could not determine
whether the remaining 12 were in violation because of
inconsistencies between OPM and agency data. GAO will refer
information about the 11 individuals in apparent violation of
reemployment requirements and has already referred the 12 whose
compliance was uncertain to the appropriate Office of Inspector
General (OIG). GAO will report on the status of the OIG's
investigations of the 23 cases and whether agencies had
adequate internal controls to ensure compliance with buyout
repayment requirements. [This was subsequently reported in GAO/
GGD-98-12, Jan. 26, 1998.]
Combined Fund Update (GAO/HEHS-95-166R, May 25, 1995)
GAO reviewed the United Mine Workers of America (UMWA)
Combined Benefit Fund, focusing on the fund's (1)
beneficiaries, expenses, and revenues; and (2) Medicare
reimbursement arrangements. GAO noted that (1) as of October 1,
1994, the fund had 96,700 beneficiaries, about three-quarters
of whom were coal industry operators; (2) 29 firms terminated
their contributions to the fund between October 1994 and March
1995, which necessitated the reassignment of 3,114
beneficiaries; (3) the fund had billed all operators about $162
million for fiscal year 1995 premiums; (4) the fund's Medicare
per capita reimbursement rate was renegotiated and reduced for
the year beginning July 1994, which makes it unlikely that
future annual surpluses will occur; and (5) overall annual
operating deficits are expected to begin in 1995, which would
eliminate the current surplus by 2003.
Combined Fund Analysis (GAO/HEHS-95-230R, Aug. 4, 1995)
GAO reviewed two studies of the UMWA Combined Benefit Fund.
GAO noted that (1) the consultants' models projected widely
differing financial results for the UMWA Combined Benefit Fund;
(2) the models' expense estimates for 1995 differed by about
$16 million; (3) one of the models underestimated the UMWA
fund's 1995 net expenses by approximately $3 million; (4) one
consultant based its medical cost inflation assumptions on the
fund's past and current efforts to contain cost growth in
prescription drugs; (6) the other consultant relied on the
Medicare trust fund's projections of medical inflation and
adjusted these estimates to reflect the fund's past
experiences; and (7) the later assumptions may be more
reasonable and may be more accurate in predicting the fund's
status beyond 1995.
Congressional Retirement Costs (GAO/GGD-96-24R, Oct. 12, 1995)
Pursuant to a congressional request, GAO provided
information on the proposal to change the congressional
retirement system, focusing on (1) the cost of congressional
retirement benefits; (2) the potential savings from the
proposal; (3) how private sector retirement systems compare
with the congressional retirement system; and (4) the extent to
which private sector employers are replacing defined benefit
pension plans with defined contribution plans. GAO noted that
(1) the estimated cost of providing future retirement benefits
to 1994 congressional members would total $14,327,224; (2) over
a 5-year period, the cost of providing retirement benefits
would total $71.5 million; (3) if the proposal were enacted, it
would significantly reduce the cost of member retirement
programs; (4) the cost of providing retirement benefits to 1994
congressional staff members would total $116.5 million; (5)
although federal employees receive greater benefit amounts
under the Civil Service Retirement System (CSRS) than
nonfederal employees before age 62, they receive smaller
amounts after age 62 when social security benefits are
available to nonfederal employees; and (6) the private sector
does not appear to be moving toward replacing defined benefit
plans with defined contribution plans.
CSRS Funding (GAO/GGD-95-200R, Apr. 3, 1995)
GAO reviewed information on the funding status of the Civil
Service Retirement System. GAO noted that (1) the system's
unfunded liability is not a problem that needs to be fixed to
avoid a steep increase in outlays from the Treasury or
increases in the deficit and (2) there should be sufficient
assets in the retirement fund to cover benefit payments to all
current and future retirees.
D.C. Disability Retirement Rate (GAO/GGD-95-133, Mar. 31, 1995)
The federal government makes annual payments to the
District of Columbia retirement fund for police officers and
firefighters. To encourage the District government to control
disability retirement costs, these payments must be reduced
when the disability retirement rates exceed a certain limit.
GAO concludes that no reduction is required in the fiscal year
1996 payment to the fund.
District's Workforce: Annual Report Required by District of Columbia
Retirement Act (GAO/GGD-96-95, Mar. 29, 1996)
The federal government makes annual payments to the
District of Columbia retirement fund for police officers and
firefighters. To encourage the District government to control
disability retirement costs, these payments must be reduced
when disability retirement rates exceed a certain limit. GAO
concludes that no reduction is required in the fiscal year 1997
payment to the fund.
Federal Employees' Compensation Act: Issues Associated With Changing
Benefits for Older Beneficiaries (GAO/GGD-96-138BR, Aug. 14,
1996)
The Federal Employees' Compensation Act (FECA) now allows
beneficiaries who are at or beyond retirement age to receive
worker's compensation benefits. Possible changes to the
legislation would reduce these benefits. This briefing report
provides (1) a profile of beneficiaries on the long-term FECA
rolls, (2) views of proponents and opponents of changing FECA
benefits for older beneficiaries, and (3) questions and issues
that the Congress might consider if crafting benefit changes.
Federal Grants: Design Improvements Could Help Federal Resources Go
Further (GAO/AIMD-97-7, Dec. 18, 1996)
Grants-in-aid are payments from the federal government to
state and local governments to help them finance various
activities, such as public assistance, highway construction,
and education. In addition, lesser-known grant programs help
finance public libraries, efforts to restore sport fish,
programs to promote boating safety, and other activities. In
fiscal year 1995, the federal government earmarked $225 billion
for more than 600 grant programs--about 15 percent of all
federal spending. This report focuses on the extent to which
the grant system meets two goals frequently cited by public
finance experts: (1) encouraging the states to use federal
dollars to supplement rather than replace their own spending on
nationally important activities and (2) targeting grant funding
to states with relatively greater programmatic needs and fewer
fiscal resources.
Federal Pensions: Thrift Savings Plan Has Key Role in Retirement
Benefits (GAO/HEHS-96-1, Oct. 19, 1995)
As of September 1994, about 940,000 federal workers covered
by the Federal Employees Retirement System (FERS) were
voluntarily contributing an average of 5.7 percent of their
salaries to the Thrift Savings Plan (TSP). Most of the
remaining 300,000 FERS-covered workers who were not
contributing were in the lower pay ranges. Lower-paid workers
who were contributing were doing so at lower rates than higher-
paid workers--an average of 4.4 percent of their salaries.
However, lower-paid workers may achieve satisfactory retirement
income levels even with low contribution rates because Social
Security benefits are proportionately greater for them than for
higher-paid workers. Higher-paid workers need to defer at least
5 percent of their salaries throughout their careers--if not
more--to achieve retirement income of 60 to 80 percent of their
preretirement salaries. Educating FERS workers can play a key
role in their making wise preretirement investment choices.
Although TSP materials discuss the plan's financial aspects,
they do not explicitly discuss how TSP can help workers covered
by FERS achieve their retirement income goals. The TSP Board is
seeking legislation that would enable employees to invest in a
domestic small capitalization fund and an international stock
fund. GAO found that these two additions would make TSP's
investment options more closely resemble those in similar
private sector plans.
Federal Retirement: Benefits for Members of Congress, Congressional
Staff, and Other Employees (GAO/GGD-95-78, May 15, 1995)
The retirement benefits provided by the Civil Service
Retirement System for Members of Congress are generally more
generous than those provided for other federal employees. The
major differences are found in the eligibility requirements for
retirement and the formulas used to calculate benefits. The
Member benefit formula applies to congressional staff, but they
are covered by the general employee retirement eligibility
requirements. Law enforcement officers and firefighters may
retire earlier than general employees and are covered by a more
generous benefit formula than are general employees. Under the
Civil Service Retirement System, the provisions for air traffic
controllers fall between those for law enforcement officers and
firefighters and those for general employees. Many of the
advantages afforded to Members of Congress and congressional
staff under the Civil Service Retirement System were continued
under the Federal Employees Retirement System, which covers
workers hired in 1984 and thereafter. But under the Federal
Employee Retirement System, provisions for law enforcement
officers, firefighters, and air traffic controllers are very
similar to provisions for Members. GAO summarized this report
in testimony before the Congress; see Congressional Retirement
Issues (GAO/T-GGD-95-165, May 15, 1995), by Johnny C. Finch,
Assistant Comptroller General for General Government Programs,
before the Subcommittee on Post Office and Civil Service,
Senate Committee on Governmental Affairs.
Food Stamp Program: Achieving Cost Neutrality in Minnesota's Family
Investment Program (GAO/RCED-96-54, Feb. 12, 1996)
In 1994, Minnesota began a 5-year federally authorized
welfare reform project known as the Minnesota Family Investment
Program. Aimed at simplifying the welfare system, the project
consolidates the food assistance and the cash benefits provided
by three programs--Aid to Families With Dependent Children, the
Food Stamp Program, and Minnesota's Family General Assistance
Program--into a single monthly payment. The Food Stamp Act of
1977 requires that the federal government spend no more for
this project's food assistance component in any fiscal year
than it would have spent for the Food Stamp Program. That is,
the project must be cost neutral. To ensure cost neutrality,
the act requires the Agriculture Department and the state of
Minnesota to agree upon methodologies for estimating what the
costs of the Food Stamp Program for both benefits and
administration would have been had there been no project. This
report (1) describes the methodologies that Minnesota agreed to
use for estimating Food Stamp Program costs that would have
been incurred if the project had not been implemented; (2)
determines if Minnesota implemented these methodologies; (3)
assesses the reasonableness of these methodologies, as
implemented, for estimating the cost of the Food Stamp Program
for fiscal year 1994; and (4) compares the payments that would
have been paid to Minnesota using the agreed-upon methodologies
with the actual payments in fiscal year 1994.
Means-Tested Programs (GAO/HEHS-95-94R, Feb. 24, 1995)
GAO provided information on welfare reform proposals to
simplify means-tested public assistance programs. GAO noted
that (1) welfare services should be easily accessible to all
who seek assistance; (2) there is no integrated strategy to
unify these programs to address the interrelated needs of
individuals and families; (3) despite efforts to better
coordinate federal programs, conflicting requirements make it
difficult for program staff to coordinate activities and share
resources; and (4) program integration could be facilitated by
reducing or eliminating federal program barriers and
reengineering the welfare delivery process.
Military Retirement: Possible Changes Merit Further Evaluation (GAO/
NSIAD-97-17, Nov. 15, 1996)
Payments to military retirees and their survivors totaled
$29 billion in fiscal year 1996. Various factors, including the
end of the Cold War, defense downsizing, changes in civilian
retirement systems, and increasing federal budgetary
constraints, have raised questions about whether the military
retirement system today best meets the needs of the Pentagon
and members of the armed forces. A number of analysts,
including several who participated in a roundtable discussion
convened by GAO, believe that fundamental changes to the
military retirement system could increase its effectiveness or
reduce costs by yielding a force of different composition and
size than exists today. The suggestions of the GAO panel, which
included Defense Department experts and compensation analysts,
ranged from earlier vesting of retirement benefits to more
sweeping reforms, such as placing military personnel under a
system similar to the Federal Employees Retirement System.
Older American Act Funding Formula (GAO/HEHS-96-137R, Apr. 24, 1996)
Pursuant to a congressional request, GAO provided
information on how proposed changes to the funding formula for
title III of the Older Americans Act would affect equity in
state funding and per-person-in-need income. GAO found that (1)
the proposed formula changes would improve funding equity and
target more aid to the elderly in the oldest age groups and
low-income states; (2) the formula changes would not affect
small states that are guaranteed at least 0.5 percent of the
funds made available for state distribution; (3) the changes
would reduce cross-state disparities, increase funding for
states whose funding is below the national average, and
decrease funding for those states whose funding is above the
average; and (4) funding disparities could be further reduced
if minority status and poverty were included in the formula
changes.
PASS Program: SSA Work Incentive for Disabled Beneficiaries Poorly
Managed (GAO/HEHS-96-51, Feb. 28, 1996)
The Social Security Administration (SSA) is poorly managing
a small but growing program to encourage disability
beneficiaries to seek employment. The plan for achieving self-
support (PASS) program, established in 1972, is currently
small--only about 10,300 persons participated in December
1994--but the number of participants has swelled more than 5-
fold during the past 5 years as awareness of the program has
increased and millions more disabled beneficiaries have become
eligible to participate.The PASS program is vulnerable to abuse
because of vague guidelines, and its impact on employment is unknown
because SSA does not collect basic data on participants and their
employment. In addition, SSA top management has not adequately
considered the potential problems posed by professional PASS preparers,
whose fees--as much as $800--are often included as PASS expenses. SSA
is trying to address some of these internal control weaknesses, but it
cannot guarantee today that taxpayer dollars are being well spent.
PBGC (GAO/AIMD-95-225R, Aug. 24, 1995)
GAO reviewed the Pension Benefit Guaranty Corporation's
(PBGC) accounting procedures and internal controls that
warranted management's attention as of September 30, 1994. GAO
noted that PBGC (1) used evidence about significant
transactions that occurred after year-end in assessing its
year-end contingent liabilities; (2) misclassified several
pension plans based on their prior year classifications; (3)
placed greater emphasis on bond ratings and debt-equity ratios
in classifying pension plans; (4) had financial statements that
did not disclose factors that represented high contingent
liability risks; (5) did not adequately disclose the monetary
effects that actuarial assumptions had on the amounts
disclosed; (6) did not provide all available information about
its efforts to recover amounts from sponsors of terminated
plans in its financial statements; (7) incorrectly recorded its
estimated losses; (8) did not provide adequate documentation in
its Single Employer Program's Statement of Cash Flows; (9)
inconsistently reviewed its financial assistance to
multiemployer plans; (10) had yet to evaluate the effectiveness
of its ratio screens in identifying troubled plans; (11)
incorrectly listed 16 multiemployer plans as inactive in its
Premium Processing System; (12) incorrectly allocated some of
its losses to the Multiemployer Program; and (13) had not fully
implemented its new computerized premium accounting system,
disaster recovery plan, and software changes.
Pension COLAs (GAO/HEHS-95-219R, Aug. 11, 1995)
GAO provided information on the frequency and
characteristics of cost-of-living adjustments (COLA) that
retirees receive from public and private pension plans. GAO
noted that (1) Social Security and federal pension plans
incorporate automatic, annual COLAs; (2) over half the states
reporting to the Bureau of Labor Statistics provide automatic
COLAs annually, generally capped between 3 and 5 percent; (3)
the remaining states mainly provide ad hoc COLAs, although the
number of states granting ad hoc COLAs has gradually decreased
since 1987, due to lower inflation; (4) ad hoc COLAs in private
pension plans occur less frequently than automatic COLAs in the
public sector, and the plans often specify a maximum increase;
(5) a number of factors, such as union negotiations, affect
employers' decisions to provide COLA increases; (6) COLA
provisions vary widely among industries, ranging from 3 percent
of pension plans in the retail sector to over 60 percent in the
transportation industry; and (7) ad hoc adjustments to private
sector pension benefits have declined in recent years from over
50 percent to under 10 percent of plans.
Private Pensions: Most Employers That Offer Pensions Use Defined
Contribution Plans (GAO/GGD-97-1, Oct. 3, 1996)
In response to congressional interest in possibly changing
the structure of federal employee retirement plans, this report
provides information on the approaches that private sector
employers are using to provide their employees with retirement
benefits and the extent to which these approaches may be
changing. GAO describes (1) the numbers and types of pension
plans sponsored nationwide by private employers during 1984 to
1993, (2) the proportions of total contributions made to these
plans by employers and employees, (3) the average
administrative expense for the plans, and (4) the explanations
provided in retirement literature on why employers might decide
to sponsor a particular type of pension plan.
Proposed Pension Reversions (GAO/HEHS-96-54R, Oct. 24, 1995)
Pursuant to a congressional request, GAO provided
information on pension plan underfunding, focusing on a
proposed legislative provision that would allow companies to
transfer excess assets out of their defined benefit pension
plans for any purpose. GAO noted that (1) current and
termination liabilities are measures of liabilities that a plan
has accrued as of its valuation date, and each relies on
different assumptions and yields very different estimates; (2)
plans that are significantly funded over their current
liability can lose plan funding rapidly due to bankruptcy,
early retirements, or a decline in interest rates; (3)
participants can lose benefits when a plan is terminated
because the Pension Benefit Guaranty Corporation (PBGC)
generally does not insure all benefit amounts; (4) companies
may not transfer or obtain excess assets from a defined benefit
plan under current law, but some transfers may be permissible
if the plans merge and participants' benefits are not reduced;
(5) it is unclear whether the transfer of excess plan assets
would release capital for investment; and (6) although the
proposed provision would allow withdrawal of overfunded assets,
plan sponsors may be required to make larger cash contributions
in the future.
Public Pensions: Section 457 Plans Pose Greater Risk Than Other
Supplemental Plans (GAO/HEHS-96-38, Apr. 30, 1996)
Millions of state and local government employees are trying
to increase their future retirement benefits by deferring some
of their wages to supplemental pension plans, known as salary
reduction arrangements or plans. The amount deferred or
contributed to these plans, however, may be at risk. Recent
media stories have recounted instances of imprudent investment,
improper use of plan funds by sponsors, and possible seizure of
plan funds by sponsoring governments' creditors. This report
examines the risks of financial loss inherent in such plans and
discusses whether the provisions of such plans treat
participants comparably. See also Public Pensions: Summary of
Federal Pension Plan Data (GAO/AIMD-96-6, Feb. 16, 1996) and
Public Pensions: State and Local Government Contributions to
Underfunded Plans (GAO/HEHS-96-56, Mar. 14, 1996).
Public Pensions: State and Local Government Contributions to
Underfunded Plans (GAO/HEHS-96-56, Mar. 14, 1996)
State and local governments with underfunded pension plans
risk tough budget choices in the future if they do not make
progress toward full funding. Their taxpayers will face a
liability for benefits earned by current and former government
workers, forcing these governments to choose between reducing
future pension benefits or raising taxes. Funding of state and
local pension plans has improved significantly since the 1970s.
After adjusting for inflation, the amount of the unfunded
liability has been cut in half. Still, in 1992, 75 percent of
state and local government pension plans in the Public Pension
Coordinating Council survey were underfunded; 38 percent were
less than 80 percent funded. Sponsors of slightly more than
half of the plans in the survey made contributions on schedule
to pay off any unfunded liability. One-third of the pension
plans, however, were underfunded in 1992 and were not receiving
the actuarially required sponsor contributions. Of all plans
with complete data, one-fifth were underfunded and were not
receiving full contributions in both 1990 and 1992. See also
Public Pensions: Summary of Federal Pension Plan Data (GAO/
AIMD-96-6, Feb. 16, 1996) and Public Pensions: Section 457
Plans Pose Greater Risk Than Other Supplemental Plans (GAO/
HEHS-96-38, Apr. 30, 1996).
Public Pensions: Summary of Federal Pension Plan Data (GAO/AIMD-96-6,
Feb. 16, 1996)
This report--one in a series of three reports on the status
of public pension plan funding--provides summary data on
federal government pension plans. The other two reports in the
series address state and local government pension plans. GAO
focuses on federally sponsored defined benefit and defined
contribution plans. See also Public Pensions: State and Local
Government Contributions to Underfunded Plans (GAO/HEHS-96-56,
Mar. 14, 1996) and Public Pensions: Section 457 Plans Pose
Greater Risk Than Other Supplemental Plans (GAO/HEHS-96-38,
Apr. 30, 1996).
Reemployment of Buyout Recipients (GAO/GGD-96-102R, June 14, 1996)
As part of its downsizing efforts, the federal government
has offered employees of various federal agencies incentive
payments, or buyouts, to leave federal employment through
voluntary separations. Pursuant to a congressional request, GAO
reviewed agencies' use of buyout authority and whether agencies
subsequently reemployed buyout recipients as civil servants or
government contractors. Using the Office of Personnel
Management's (OPM) data, GAO determined that governmentwide
agencies paid 87,743 buyouts from January 1993 through June 30,
1995. However, GAO could not determine the total number of
employees who were eligible to receive buyouts. Of the 87,743
buyout recipients, agencies rehired 394 as civil servants.
However, it is not clear how many were reemployed as federal
contractors. The limited available data suggest the practice
was not used extensively. Reemployment of buyout recipients as
civil servants or contractors is not prohibited, but, under
certain circumstances, buyout recipients are required to take
steps to satisfy reemployment provisions. Of the 394 buyout
recipients reemployed as civil servants, GAO identified 68
cases in which these reemployment provisions applied. Finally,
through a survey of National Aeronautics and Space
Administration and Department of Transportation units,
respondents reported that they had management controls designed
to prevent reemployment abuses.
Service Corps of Retired Executives (GAO/RCED-95-127R, Mar. 10, 1995)
GAO provided information on the Small Business
Administration's Service Corps of Retired Executives Program
(SCORE), focusing on how SCORE (1) determines budget
allocations for regional locations; (2) officials view the
fairness of the allocations; and (3) meets the needs of rural
communities. GAO noted that (1) SCORE regional budget
allocations are based primarily on historical trends in actual
expenditures; (2) SCORE officials stated that their areas
receive a fair share of SCORE funds, given the small size of
the total budget; and (3) to meet the needs of rural
communities, SCORE uses approaches such as waiving the
guidelines for the number of volunteers needed to start a
chapter and using persons or funds from larger chapters to
subsidize rural chapters.
Social Security Administration: Effective Leadership Needed to Meet
Daunting Challenges (GAO/HEHS-96-196, Sept. 12, 1996)
With a staff of 64,000, SSA runs the nation's largest
federal program--Social Security--as well as the largest cash
welfare program--the Supplemental Security Income (SSI)
program. SSA's expenditures totaled $363 billion in fiscal year
1995, nearly one-fourth of the $1.5 trillion federal budget.
SSA programs touch the lives of nearly every American,
providing benefits to the retired, the disabled, and their
dependents and survivors. This report, which is based on July
1995 testimony before the Congress (GAO/T-OCG-96-7), discusses
SSA's progress in meeting the challenges of managing for
results and accountability; funding future retirement benefits;
rethinking SSI fraud, waste, and abuse; handling increasing
workloads with fewer resources; and establishing effective
leadership.
Social Security Administration: Leadership Challenges Accompany
Transition to an Independent Agency (GAO/HEHS-95-59, Feb. 15,
1995)
In 1994, the Congress passed legislation making the Social
Security Administration (SSA) an independent agency. As part of
the transition, GAO was required to evaluate the interagency
agreement for transferring personnel and resources from HHS to
SSA. GAO concluded that the two agencies have developed an
acceptable methodology for identifying the functions;
personnel; and other resources, such as furniture and computer
equipment, to be transferred to an independent SSA. They have
also made good progress toward completing the initiatives
necessary for SSA to be a fully functional independent agency
by March 31, 1995. However, SSA will continue to face serious
policy and management challenges, including the long-range
shortfall in funds to pay future Social Security benefits.
Also, questions have been raised by GAO and others about the
future growth of the Disability Insurance (DI) program and
recent increases in Supplemental Security Income (SSI)
benefits.
Social Security: Telephone Access Enhanced at Field Offices Under
Demonstration Project (GAO/HEHS-96-70, Feb. 23, 1996)
The Social Security Administration (SSA) runs a nationwide
toll-free telephone number and is testing enhanced local office
telephone service at selected offices. In February 1995, SSA
began installing new telephone equipment, called automated
attendant and voice mail, at 30 of its 800 nationwide field
offices that list their telephone numbers in local telephone
directories. The equipment was installed in different
configurations. Telephone access--calls reaching an SSA
employee with the caller spending less than 2 minutes on hold--
improved 23 percent under one of the configurations being
tested by SSA. In addition, busy signals dropped by more than
55 percent. Staffing, however, did not increase, and many
callers reaching SSA did spend some time on hold before
reaching an SSA representative. SSA field office staff viewed
the installation of voice mail equipment at their desks as
having a very positive effect on office efficiency and public
service. SSA has not yet completed its two internal evaluations
of the demonstration project. GAO concludes that the technology
tested in the demonstration projects has the potential to
further SSA's public service goals. Public reaction and the
effect on operations, however, will need to be considered as
SSA weighs the costs and the benefits of this technology.
Social Security: Union Activity at the Social Security Administration
(GAO/HEHS-97-3, Oct. 2, 1996)
The Social Security Administration (SSA), like other
federal agencies and some private sector firms, pays for
approved time spent by its employees on union activities. SSA
has a special fiduciary responsibility to effectively manage
and maintain the integrity of the social security trust funds
from which most of these expenses are paid. In a time of
shrinking budgets, it is crucial that SSA, as well as other
agencies, evaluate how resources are being spent and have
reliable monitoring systems to support this evaluation. To
ensure accurate tracking of time spent on union activities and
the staff conducting these activities, SSA has developed and is
testing a new time-reporting system for its field offices and
teleservice centers. GAO believes that the new system should be
implemented agencywide. With an improved agencywide system, SSA
management should have better information on where its money is
being spent.
SSA Benefit Statements: Well Received by the Public But Difficult to
Comprehend (GAO/HEHS-97-19, Dec. 5, 1996)
SSA in 1995 began sending statements--called Personal
Earnings and Benefit Estimate Statements--automatically to
workers who had reached age 60. By fiscal year 2000, these
statements will reach an estimated 123 million people
annually--almost every U.S. worker aged 25 and older. These
six-page statements provide workers with information on their
yearly earnings on record at SSA, information on their
eligibility for social security retirement and other benefits,
and estimates of these benefits. Experts agree that SSA's
approach is generally reasonable, and feedback suggests that
the public generally finds the statements to be helpful in
retirement planning. However, GAO believes that the statements
could benefit from extensive revisions. Specifically, the
statements need a better layout and design and simpler
explanations. SSA will need to start now to complete these
changes by its 1999 redesign target date because the agency
will require time to collect data and test alternatives.
SSA Disability: Program Redesign Necessary to Encourage Return to Work
(GAO/HEHS-96-62, Apr. 24, 1996)
During the past decade, the number of persons receiving
benefits from Social Security's DI and SSI programs increased
70 percent because of program changes and economic and
demographic factors. These programs, which provide assistance
to persons with disabilities until they return to work, if that
is possible, provided $53 billion in cash benefits to 7.2
million people in 1994. Advances in technology, such as
standing wheelchairs and synthetic voice systems, and the
medical management of some physical and mental disabilities
have allowed some persons to work. Moreover, there has been a
greater trend toward inclusion of and participation by people
with disabilities in the mainstream of society. Yet both
programs have done little to identify recipients who might
benefit from rehabilitation and employment assistance and
ultimately return to work.
SSA Overpayment Recovery (GAO/HEHS-96-104R, Apr. 30, 1996)
Pursuant to a congressional request, GAO reviewed how SSA
recovers overpayments of benefits. GAO found that (1) the
amount of SSI, RSI, and DI payments that SSA withholds to
recoup overpayments is not upwardly adjusted with cost-of-
living increases in the many cases in which the withholding is
based on a fixed dollar amount negotiated with the beneficiary,
as opposed to a fixed percentage of the recipient's monthly
income or monthly benefit amount; (2) basing the withholding on
a percentage instead of a dollar amount would accelerate the
recovery of overpayments without imposing an undue burden on
recipients or causing excessive administrative costs; (3)
accelerating recoveries while recipients are still receiving
benefits improves the chance of collecting overpayments; (4)
SSA administrative costs would likely increase only in the
first year of implementation; and (5) the cost of notifying
recipients of the new withholding procedures would be
negligible, because SSA already notifies recipients when
overpayments occur.
Social Security: Issues Involving Benefit Equity for Working Women
(GAO/HEHS-96-55, Apr. 10, 1996)
When the social security program was established in the
1930s, less than 15 percent of married women held paying jobs
outside the home; today, about 60 percent of married women are
paid workers. Despite the movement of women into the labor
market, the social security benefit structure has remained
essentially unchanged over the years. The fairness of the
benefit structure has come under increasing scrutiny,
especially as it affects women who have earned benefits in
their own right. For example, a two-earner couple will receive
lower combined benefits in retirement than an otherwise
identical one-earner couple. And, a married woman who works and
pays social security taxes might not, because of the dual
entitlement limitation, receive higher benefits than if she had
never worked and received only a spousal benefit. Several
proposals seek to remedy these inequities. These include two
broad proposals--``earnings sharing'' and a ``double-decker''
plan--and several narrower proposals, such as reducing spousal
benefits. None of the measures has been adopted, however,
partly because they would either boost program costs or reduce
benefits for some beneficiaries. Their enactment could also
impose a large administrative burden on SSA.
Social Security Disability: Backlog Reduction Efforts Under Way;
Significant Challenges Remain (GAO/HEHS-96-87, July 11, 1996)
SSA runs the nation's largest programs providing cash
benefits to people with severe long-term disabilities. The
number of persons receiving either Disability Insurance (DI) or
SSI benefits has soared during the past decade. At the same
time, SSA has struggled to deal with unprecedented growth in
appeals of its disability decisions and the resulting backlog
of cases awaiting hearing decisions. Processing delays stemming
from a backlog of more than half a million appealed cases have
created hardships for disability claimants, who often wait more
than a year for final disability decisions. This report
discusses (1) factors contributing to the growth in appealed
cases, (2) SSA initiatives to reduce the backlog, and (3) long-
term steps that need to be taken to make the disability appeals
process more timely and efficient.
Social Security Trust Funds (GAO/AIMD-96-30R, Dec. 12, 1995)
Pursuant to a congressional request, GAO reviewed the
Secretary of the Treasury's actions during the 1995 debt
ceiling crisis, focusing on whether the Department of the
Treasury followed normal investment and redemption policies
regarding the Social Security trust funds. GAO noted that
Treasury records show that the Secretary followed normal
investment and redemption policies for all transactions
affecting the trust funds between November 1, 1995, and
December 8, 1995.
SSI Disability Issues (GAO/HEHS-95-154R, May 11, 1995)
GAO provided information on several SSI issues related to
(1) SSI outreach activities; (2) the status of continuing
disability reviews involving interpreter fraud; (3) the
function of referral and monitoring agencies (RMA) in
overseeing the drug addict and alcoholic populations; and (4)
the number of drug and alcohol addicts in treatment. GAO noted
that (1) very few SSI outreach activities are targeted to drug
addicts and alcoholics; (2) SSA has not requested funding for
SSI outreach for fiscal years 1993 through 1996; (3) in two
states, SSA continuing disability reviews are yielding a high
rate of initial benefit terminations, of which about 60 percent
have been appealed; (4) SSA is developing an interpreter
database to understand the extent of the fraud problem; (5)
RMAs assess beneficiaries' treatment needs, make treatment
referrals, monitor beneficiaries' compliance with treatment,
and report their compliance status to SSA; (6) RMAs do not
conduct SSI outreach activities; (7) only 1 in 6 addicted
beneficiaries are in required treatment, mainly due to the lack
of RMA funding to monitor beneficiaries' treatment; and (8) in
fiscal year 1996, the administration is requesting $195 million
for RMA monitoring activities, which is a significant increase
over 1990 through 1993 levels.
Supplemental Security Income: Administrative and Program Savings
Possible by Directly Accessing State Data (GAO/HEHS-96-163,
Aug. 29, 1996)
The Supplemental Security Income program, which provides
cash benefits to the aged, the blind, and the disabled, could
be run more efficiently. More importantly, millions of dollars
in overpayments could be prevented or detected quickly if
information were available on-line during eligibility
assessments. GAO estimates that direct on-line access to state
computerized income information could have prevented or quickly
detected more than $131 million in overpayments caused by
unreported or underreported income nationwide in one 12-month
period. However, in SSA field offices where direct access to
computerized state information has been implemented, SSA claims
representatives did not use it to detect overpayments. The
claims representatives did use it to process claims more
efficiently, and SSA's preliminary results have shown that its
use has reduced administrative expenses. Establishing on-line
access between SSA field offices and state agency databases
would require only minimal computer programming in most states;
some states would need additional hardware, such as computer
lines.
Supplemental Security Income: Growth and Changes in Recipient
Population Call for Reexamining Program (GAO/HEHS-95-137, July
7, 1995)
The SSI program is the largest cash assistance program for
the poor and one of the fastest growing entitlement programs;
program costs have risen 20 percent annually during the last 4
years. SSI provides means-tested income support payments to
aged, blind, or disabled persons. Last year, more than 6
million people received about $25 billion in federal and state
benefits. In response to SSI's rapid growth, the Congress
passed legislation limiting drug addicts' benefits, and this
year it is considering further restrictions for these
recipients as well as for children and noncitizens. This report
provides an overview of the SSI program and its recent history.
Specifically, it examines factors contributing to caseload
growth and changes in the characteristics of SSI recipients.
Supplemental Security Income: SSA Efforts Fall Short in Correcting
Erroneous Payments to Prisoners (GAO/HEHS-96-152, Aug. 30,
1996)
Despite SSA procedures to detect supplemental security
income recipients in county and local jails, GAO found that $5
million had been erroneously paid to prisoners in the jail
systems it reviewed. SSA had been unaware of many of these
payments and, therefore, had made no attempt to recover them.
Various factors contributed to these payments. First, SSA field
offices have not been obtaining information regularly on
prisoners in county and local jails. Second, the supplemental
security income recipient--or the person or organization
designated to receive payments on the recipient's behalf--has
not been reporting the incarceration, as required. Third, SSA
sometimes falls short in periodically reviewing--either by mail
or interview--a recipient's continued financial eligibility for
supplemental security income. Under a new SSA initiative, field
offices will be required to obtain prisoner information from
county and local jails, and SSA plans to monitor field office
compliance with this requirement. It is too early to tell,
however, whether this initiative will be successful.
Supplemental Security Income: Some Recipients Transfer Valuable
Resources to Qualify for Benefits (GAO/HEHS-96-79, Apr. 30,
1996)
Existing law does not prohibit people from transferring
resources to qualify for benefits under the SSI program--the
largest cash assistance program for the poor and one of the
fastest growing entitlement programs. Between 1990 and 1994,
3,505 SSI recipients transferred resources, including cash,
houses, land, and other items, valued at $74 million. Reported
resource transfer values ranged as high as $800,000; most
transfers fell between $10,000 and $25,000. The total amount of
resources transferred, however, is likely to be larger than
GAO's estimate because SSA is not required to verify the
accuracy of resource transfer information, which is self-
reported by individuals. Moreover, because the information is
self-reported, SSA is unlikely to detect unreported transfers.
Without a transfer-of-resource restriction, GAO estimated the
3,505 SSI recipients who reported transferring resources to
qualify for benefits would receive nearly $8 million in SSI
benefits during the 24 months after they transferred resources.
Many of these recipients also could have received Medicaid
acute-care benefits at an annual value of between $2,800 and
$5,300 per recipient. GAO estimated that from 1990 through
1995, SSA could have saved $14.6 million with a transfer-of-
resource restriction similar to that used for Medicaid which
delays individuals' date of eligibility for benefits. Such a
restriction could also boost the public's confidence in the
program's integrity.
Thrift Savings Plan (GAO/HEHS-96-66R, Nov. 14, 1995)
Pursuant to a congressional request, GAO reviewed (1) why
the Congress replaced CSRS with FERS; and (2) the Federal
Retirement Thrift Investment Board's response to the GAO
recommendation concerning the inclusion of participant
information on contributions to TSP retirement accounts. GAO
noted that (1) the Congress replaced CSRS with FERS to provide
federal employees with a retirement benefit that included a
Social Security payment, a basic FERS annuity, and payments
from amounts accumulated in a TSP account; and (2) the board
did not implement the recommendation because it believed that
it would be violating its fiduciary duty to TSP participants
and misusing its funds.
Welfare Benefits: Potential to Recover Hundreds of Millions More in
Overpayments (GAO/HEHS-95-111, June 20, 1995)
Under welfare reform legislation being considered by the
Congress, resources for helping poor families may become
increasingly limited--making it critical that only those who
are eligible for benefits receive them. In 1992, benefit
overpayments in three welfare programs--Aid to Families With
Dependent Children (AFDC), Food Stamps, and Medicaid--totaled
$4.7 billion, or about 4 percent of the total benefits paid.
Moreover, nationwide recovery of these benefits was relatively
low. This report discusses (1) what states are doing to recover
benefit overpayments, what the more effective practices are,
and what states could do better and (2) what the federal
government could do to help states recover more overpayments.
Welfare Programs: Opportunities to Consolidate and Increase Program
Efficiencies (GAO/HEHS-95-139, May 31, 1995)
The federal government provides billions of dollars in
public assistance each year through an inefficient welfare
system that is increasingly cumbersome for program
administrators to manage and difficult for eligible clients to
access. Program consolidation may be one strategy to reduce the
inefficiency of the current system of overlapping and
fragmented programs. This report (1) describes low-income
families' participation in multiple welfare programs, (2)
examines program inefficiencies, such as program overlap and
fragmentation, and (3) identifies issues to consider in
deciding whether and to what extent to consolidate welfare
issues. Regardless of how the welfare system is restructured,
ensuring that federal funds are used efficiently and that
programs focus on outcomes remains important. Without a focus
on outcomes, concerns about the effectiveness of welfare
programs will not be adequately addressed.
Welfare Reform: Implications of Proposals on Legal Immigrants Benefits
(GAO/HEHS-95-58, Feb. 2, 1995)
GAO found that the percentage of immigrants receiving
public assistance--specifically SSI or AFDC--is higher than the
percentage of citizens receiving these benefits. Six percent of
all immigrants receive benefits compared with 3.4 percent of
all citizens. Most immigrant recipients live in four states:
California, New York, Florida, and Texas; more than one-half of
all immigrant recipients live in California. Between 1983 and
1993, the number of immigrants receiving SSI more than
quadrupled, increasing from 151,000 to 683,000. During this
period, immigrants grew from about 4 percent of all SSI
recipients to more than 11 percent. As a percentage of all
adult AFDC recipients, immigrants grew from about 5 percent to
8 percent. In all, immigrants received an estimated $3.3
billion in SSI benefits and $1.2 billion in AFDC benefits in
1993. Most immigrant recipients are lawful permanent residents
or refugees, but other characteristics of immigrants receiving
SSI and AFDC vary. For example, the number of immigrants
receiving SSI aged benefits--available to those 65 years and
older--has increased dramatically. According to the
Congressional Budget Office, a welfare reform proposal now
before the Congress (H.R. 4) would save $9.2 billion from the
SSI program and $1 billion from the AFDC program over 4 years.
GAO estimates that 522,000 SSI recipients and 492,000 AFDC
recipients would become ineligible for benefits under H.R. 4.
401(k) Pension Plans: Many Take Advantage of Opportunity to Ensure
Adequate Retirement Income (GAO/HEHS-96-176, Aug. 2, 1996)
Many workers fill the gap between social security and an
adequate retirement income with pension benefits, and one in
four workers with pension coverage participates in a 401(k)
program. GAO found, among other survey results, that workers
with higher incomes and college educations tended to contribute
more to 401(k) plans than others and women tend to invest more
conservatively than do men. Also, higher-income workers and
better-educated workers with 401(k) pension plans tend to
contribute a larger percentage of their salaries to their
pension accounts and to invest their pension funds in higher-
yielding assets than do other 401(k) plan participants.
Consequently, although many workers will have enough retirement
income, some workers, especially those with less education and
lower incomes, risk inadequate retirement incomes.
veterans' and dod issues
Defense Health Care: Effects of Mandated Cost Sharing on Uniformed
Services Treatment Facilities Likely to Be Minor (GAO/HEHS-96-
141, May 13, 1996)
The establishment of uniform benefits and cost sharing for
DOD beneficiaries is a key component of the TRICARE program--
DOD's new nationwide managed health care program--and is
something that GAO and others have long advocated. Such
uniformity would, in GAO's view, eliminate inequities and
confusion that now exist among beneficiaries of military health
plans. Although adopting TRICARE cost shares may cause some
minor adverse selection for the Uniformed Services Treatment
Facilities (USTF), there should be no lasting negative
financial impact on the USTFs. Moreover, the new cost shares,
which are similar to HMOs, are appropriate for the risks to be
borne by the USTFs and will likely make the USTF population
more similar to DOD's general beneficiary population. DOD's
current USTF capitation methodology takes into account and
allows for adjusted reimbursement levels for such higher costs
that result from changes in the enrollee cost shares and
population characteristics.
Defense Health Care: Issues and Challenges Confronting Military
Medicine (GAO/HEHS-95-104, Mar. 22, 1995)
DOD's military health care system provides medical services
and support both in peacetime and in war to members of the
armed forces and their families, as well as to retirees and
survivors. Post-Cold War planning scenarios, efforts to reduce
the overall size of the military, federal budget cuts, and base
closures and realignments have focused attention on the size of
DOD's health care system, its makeup, how it operates, whom it
serves, and whether its missions can be carried out in a more
cost-effective way. This report describes the Military Health
Services System, past problems faced by DOD as it ran the
system and efforts to solve those problems, and the management
challenges now confronting DOD. GAO summarized this report in
testimony before the Congress; see Defense Health Care: DOD's
Managed Care Program Continues to Face Challenges (GAO/T-HEHS-
95-117, Mar. 28, 1995), by David P. Baine, Director of Federal
Health Care Delivery Issues, before the Subcommittee on
Military Personnel, House Committee on National Security.
Defense Health Care: Medicare Costs and Other Issues May Affect
Uniformed Services Treatment Facilities' Future (GAO/HEHS-96-
124, May 17, 1996)
Since fiscal year 1994, the Congress has appropriated
nearly $1 billion for USTF to deliver health care to what now
totals 124,000 beneficiaries. In recent years, the Congress has
grown concerned about the rising cost to treat USTF members, in
part because some members retain dual eligibility and
unrestricted access to other government health care services,
such as Medicare and DOD hospitals. The Congress directed DOD
in 1991 to reform the USTF program by introducing a managed
care program. As DOD begins to implement its new nationwide
managed care program--TRICARE--questions about the program's
future persist. This report discusses (1) whether unnecessary
costs result from USTF members' use of other federally funded
health care sources and (2) other issues that need to be
considered as the Congress deliberates reauthorization of the
USTF program.
Defense Health Care: New Managed Care Plan Progressing, But Cost and
Performance Issues Remain (GAO/HEHS-96-128, June 14, 1996)
The DOD health care system, which costs $15 billion
annually, is undergoing sweeping reform. Through TRICARE, DOD
is trying to improve access to care among its 8.3 million
beneficiaries while containing costs. How well DOD implements
and operates TRICARE may define and shape military medicine for
years to come. Because of TRICARE's complexity, scale, and
impact on beneficiaries, GAO reviewed the program, focusing on
(1) whether DOD's experiences with early implementation yielded
the expected results, (2) how early outcomes may affect costs,
and (3) whether DOD has defined and is capturing data needed to
manage and assess TRICARE's performance. GAO concludes that
despite initial confusion among beneficiaries arising from
marketing and education problems, as well as problems with the
compatibility of computer systems, early implementation of
TRICARE is progressing consistent with congressional and DOD
goals. However, the success of DOD's efforts to implement
resource-sharing agreements and utilization management is
critical to containing health care costs. DOD also needs to
gather enrollment and performance data so that it and the
Congress can assess TRICARE's success in the future.
Defense Health Care: Problems with Medical Care Overseas Are Being
Addressed (GAO/HEHS-95-156, July 12, 1995)
The American military presence in Europe has declined
dramatically since 1989. The active duty population has been
cut by 57 percent--from 332,000 to 138,000. At the same time,
the military health services systems has also been
substantially reduced. Many beneficiaries have expressed
concern about their reduced access to health care from military
medical facilities overseas and are dissatisfied with the care
they receive from host nation providers. This report discusses
(1) the availability of health care in military facilities, (2)
any obstacles to providing that care, (3) the experiences of
beneficiaries who have used host nation providers as an
alternative to military health care, and (4) whether DOD is
addressing service delivery problems and beneficiary concerns.
To develop this information, GAO visited 15 military
communities in Germany and northern Italy, where many of the
beneficiary complaints about medical and dental care
originated.
Neoplasms in Persian Gulf Veterans (GAO/PEMD-96-15R, June 21, 1996)
Pursuant to a congressional request, GAO reviewed
Department of Veterans Affairs' (VA) data on the frequency of
abnormal tissue growths among Persian Gulf War veterans and
other military personnel. GAO noted that (1) VA data show that
Persian Gulf War veterans have a neoplasm-diagnosis rate that
is more than three times higher than that of nonwar veterans;
(2) the higher neoplasm rate for war veterans may be due to
causes other than service in the Persian Gulf, such as war
veterans seeking VA hospital treatment more often than nonwar
veterans; (3) the rate of surgical procedures for the two
groups is not significantly different, which could mean that
war veterans' neoplasms are not as serious as those diagnosed
among nonwar veterans; and (4) analyzing alternative
explanations for war veterans' neoplasm rates would require
extensive statistical analysis and professional judgment.
Proposed VA Hospital at Travis Air Base (GAO/HEHS-95-268R, Sept. 19,
1995)
GAO provided information on the proposed construction of a
Department of Veterans Affairs (VA) hospital at Travis Air
Force Base in Fairfield, California, focusing on (1) reasons
that the project cost estimate was higher than VA originally
proposed to the Congress and (2) where veterans living in the
Travis facility target area currently receive medical care. GAO
noted that (1) the project cost estimate increased because VA
believed it needed to construct and renovate more space than
originally anticipated; (2) many veterans in the Travis target
area currently receive hospital care at VA medical centers in
the northern California and Nevada areas; and (3) although
veterans' use of VA medical centers decreased in fiscal years
1992 and 1993, the reason for the decrease was unclear.
Readjustment Counseling Service: Vet Centers Address Multiple Client
Problems, But Improvement Is Needed (GAO/HEHS-96-113, July 17,
1996)
VA operates 205 community-based facilities known as Vet
Centers to help veterans make a successful transition from
military to civilian life. Vet Center counselors reported
visiting with about 138,000 veterans during fiscal year 1995,
84,000 of whom were new to Vet Centers. Most veterans do not
establish long-term relationships with Vet Center counselors;
however, those who do represent a core group who use services
over extended periods for serious psychological problems, such
as post-traumatic stress disorder. Other veterans usually visit
Vet Center counselors only once or twice for social concerns,
such as employment or benefit needs.
Substance Abuse Treatment: VA Programs Serve Psychologically and
Economically Disadvantaged Veterans (GAO/HEHS-97-6, Nov. 5,
1996)
About 25 percent of all Department of Veterans Affairs (VA)
patients discharged from inpatient settings in fiscal year 1995
were diagnosed with alcohol or drug abuse problems. VA
estimates that it spent $2 billion--or about 12 percent of its
total health care budget in fiscal year 1995--to treat veterans
with substance abuse disorders. The VA health care system is
now evaluating what services to offer and where to provide
them. VA's new organizational structure, called the Veterans
Integrated Service Network, replaces VA's central office and
regional structure with 22 networks of hospitals and clinics.
VA expects this consolidation and realignment to boost
efficiency by trimming management layers, eliminating
duplicative medical services, and making better use of
available public and private resources. This report provides
information on the (1) characteristics of veterans who receive
substance abuse treatment, (2) services that VA offers to
veterans with substance abuse problems, (3) methods that VA
uses to monitor the effectiveness of its substance abuse
treatment programs, (4) community services available to
veterans who suffer from substance abuse disorders, and (5)
implications of changing VA's current methods for delivering
substance abuse treatment.
VA Clinic Funding (GAO/HEHS-95-273R, Sept. 19, 1995)
GAO provided information on how two VA medical centers
financed their new free-standing primary care clinics to
improve veterans' access to health care services. GAO noted
that (1) the two centers have financed their 4 new clinics from
savings derived from local management initiatives to improve
operating efficiency; (2) the centers plan to open 10 more
clinics over the next several years that will also be financed
from other cost-saving initiatives; (3) the centers have
contracted with predominantly rural clinics to provide primary
care to veterans; (4) the yearly contract costs for the current
and future clinics are expected to be less than $2 million; (5)
cost savings have been derived from inpatient ward
consolidations, patient utilization reviews, health education
classes, service contract modifications, and staff reductions;
and (6) the new clinics are expected to reduce veterans' use of
fee-for-service private care and reimbursements for travel
expenses to VA medical facilities.
VA Health Care: Better Data Needed to Effectively Use Limited Nursing
Home Resources (GAO/HEHS-97-27, Dec. 20, 1996)
VA reported spending $1.6 billion in fiscal year 1995 on
nursing home care for nearly 80,000 veterans--about 14 percent
of the estimated demand by veterans for such care. VA provides
nursing home care in its own facilities, contracts with
community nursing homes, and pays state veterans' homes part of
the cost to care for veterans. All veterans are eligible for
nursing home care essentially on a first-come, first-served
basis within VA's budget constraints. As the number of veterans
aged 65 and older increases to 9.3 million by the year 2000,
the demand for nursing home care will likely rise. The funds
for VA nursing home care, however, are expected to be limited.
This report provides information on the (1) distribution of
veterans in VA, community, and state nursing homes; (2) costs
to VA for these nursing homes; (3) factors affecting VA's use
of community and state veterans' nursing homes; and (4)
relative quality of the care provided by VA, community, and
state veterans' homes.
VA Health Care: Effects of Facility Realignment on Construction Needs
Are Unknown (GAO/HEHS-96-19, Nov. 17, 1995)
As part of the fiscal year 1996 budget, the President
requested $524 million for major VA construction projects.
These projects include the construction of two new VA medical
facilities and major renovations at seven existing facilities.
This report discusses how the projects are expected to benefit
veterans and the relationships between the proposed projects
and VA's recent efforts to realign all of its facilities into a
new service network. GAO also discusses the potential effects
of funding delays on VA's construction award dates and costs.
VA Health Care: Exploring Options to Improve Veterans' Access to VA
Facilities (GAO/HEHS-96-52, Feb. 6, 1996)
Since its creation in 1930, VA's health care system has
become one of the nation's largest networks of direct delivery
health care providers, with 173 hospitals and 376 outpatient
clinics nationwide. But because public and private health
insurance programs have also grown, most veterans now have
alternatives to VA health care. Many veterans indicate that
they use private providers because they live too far from VA
hospitals or outpatient clinics. VA has recently encouraged its
facilities to improve veterans' access to VA health care. This
report discusses (1) characteristics of recent users of VA
medical facilities; (2) the geographic accessibility of VA and
private medical facilities that provide standard benefits; and
(3) options that VA facilities might want to consider to
improve the accessibility of VA health care, such as locating
new medical facilities closer to where veterans live and
contracting with private providers.
VA Health Care: How Distance From VA Facilities Affects Veterans' Use
of VA Services (GAO/HEHS-96-31, Dec. 20, 1995)
Living within 5 miles of a VA Hospital or outpatient clinic
significantly increases the likelihood that veterans will use
VA health care services. Although most veterans live within 25
miles of a VA hospital or outpatient clinic, use of VA
facilities declines significantly among veterans living more
than 5 miles from a VA facility. Only about 11 percent of
veterans live within 5 miles of a VA hospital providing acute
medical and surgical care and 17 percent within 5 miles of a VA
outpatient clinic. Use of VA health care services does not
decline with distance as rapidly among veterans receiving VA
compensation or pension payments. Even those veterans with a
service-connected disability who live more than 100 miles from
a VA outpatient clinic are more likely to avail themselves of
VA outpatient services than are higher-income veterans with
nonservice-connected disabilities who live within 5 miles of a
VA outpatient clinic. Other factors that may contribute to
differences in the use of VA services include broader
eligibility and entitlement to outpatient care for service-
connected and low-income veterans, veterans' ages, and
differences in available resources.
VA Health Care: Issues Affecting Eligibility Reform Efforts (GAO/HEHS-
96-160, Sept. 11, 1996)
Pursuant to a congressional request, GAO reviewed various
proposals that would simplify and expand eligibility for
veterans' health care benefits. GAO found that (1) eligibility
requirements for veterans' health care benefits have become
increasingly complex and a source of frustration to veterans,
VA physicians, and administrators; (2) VA does not have a
defined or uniform benefits package and cannot ensure the
availability of covered services; (3) VA physicians sometimes
must decide to either deny needy veterans noncovered services
or ignore the law and provide the noncovered services free of
charge; (4) VA health care eligibility reform could expand the
types of services provided and allow veterans lacking
supplemental insurance access to needed services; (5) the four
legislative proposals reviewed could more than double the
demand for VA outpatient services, cause VA to ration care, and
force VA to seek larger appropriations to preserve its safety-
net mission; (6) alternative approaches including limiting the
number of eligible veterans and range of benefits added or
increasing cost sharing could preserve VA's ability to provide
specialized services; (7) although the American Legion proposal
incorporates all three of these approaches and is a basis for
future reform proposals, changes need to be made to reduce the
number of veterans covered, exempt VA from most federal
contracting laws, and designate VA as a Medicare provider; and
(8) one option to reduce the number of veterans who would be
eligible under the proposal and target those veterans who have
low incomes and lack supplemental insurance, would be to limit
VA benefits for veterans with no service-related disabilities.
VA Health Care: Improving Veterans' Access Poses Financial and Mission-
Related Challenges (GAO/HEHS-97-7, Oct. 25, 1996)
VA runs one of the nation's largest health care delivery
systems, including more than 170 hospitals and nearly 400
clinics, over one-half of which are free-standing clinics.
Veterans must often travel long distances, however, to receive
care at these facilities. VA has a policy encouraging its
hospitals to improve access to care for eligible veterans. As a
result, many hospitals have either planned or established new,
free-standing outpatient clinics, known as ``access points.''
Access points provide primary care to veterans and generally
refer those needing specialized services or inpatient stays to
VA hospitals. This report examines VA's policy for establishing
access points. GAO discusses the legal, financial, and mission-
related implications of VA's efforts to establish access
points.
VA Health Care: Need for Brevard Hospital Not Justified (GAO/HEHS-95-
192, Aug. 29, 1995)
VA assumed control of the former Naval Hospital in Orlando,
Florida, in June 1995. VA plans to convert the hospital into a
nursing home while continuing to operate an existing outpatient
clinic. VA also plans to build a new hospital and nursing home
in Brevard County, 50 miles from Orlando. GAO concludes that
VA's conversion of the former Orlando Naval Hospital into a
nursing home and construction of a new hospital and nursing
home in Brevard County is not the most prudent and economical
use of its resources. These construction projects are based on
questionable planning assumptions that may result in the
unneeded expenditure of federal dollars. Specifically, VA did
not adequately consider the availability of hundreds of
community nursing home beds and unused VA hospital beds as well
as potential decreases in future demand for VA hospital beds.
VA could achieve its goals in Central Florida by using existing
capacity.
VA Health Care: Opportunities for Service Delivery Efficiencies Within
Existing Resources (GAO/HEHS-96-121, July 25, 1996)
VA, which operates one of the nation's largest health care
systems, faces increasing pressure to contain or reduce
spending as part of governmentwide efforts to balance the
budget. This report discusses ways VA could operate more
efficiently and reduce the resources needed to meet the needs
of veterans in what is commonly referred to as the mandatory
care category. GAO addresses (1) VA's forecasts of future
resource needs, (2) opportunities to run VA's system more
efficiently, (3) differences between VA and the private sector
in efficiency incentives, and (4) recent VA efforts to
reorganize its health care system and create efficiency
incentives. GAO concludes that successful implementation of a
range of reforms, coupled with reduced demand for services,
could save the VA health care system billions of dollars during
the next 7 years. The success of these efforts, however,
depends on introducing efficiency incentives at VA that have
long existed in the private sector.
VA Health Care: Opportunities to Significantly Reduce Outpatient
Pharmacy Costs (GAO/HEHS-97-15, Oct. 11, 1996)
All pharmacies run by VA provide medications and medical
supplies that are available over the counter through other
local outlets. The most frequently dispensed over-the-counter
products include (1) medications, such as aspirin and insulin;
(2) dietary supplements, including Sustacal and Ensure; and (3)
medical supplies, such as alcohol prep pads, lancets, and
glucose test strips. Unlike VA, public and private health plans
cover few, if any, over-the-counter products for their
beneficiaries. VA pharmacies dispensed over-the-counter
products more than 15 million times during fiscal year 1995 at
an estimated cost of $165 million, including handling costs of
$48 million. VA recovered about $7 million through veterans'
copayments, or about four percent of its total over-the-counter
costs. Although many veterans shared a modest portion of the
costs and some paid the full amount, most veterans paid
nothing. GAO suggests several ways that VA could cut costs
associated with dispensing over-the-counter products or boost
revenues from copayments. First, VA could more narrowly define
when to provide over-the-counter products. Second, VA could
more efficiently dispense over-the-counter products and collect
copayments. Third, VAfacilities could further reduce the number
of over-the-counter products available to veterans on an outpatient
basis. Finally, the Congress could expand copayment requirements.
VA Health Care: Physician Peer Review Identifies Quality of Care
Problems But Actions to Address Them Are Limited (GAO/HEHS-95-
121, July 7, 1995)
Physician peer review--physicians reviewing the work of
other physicians--is crucial to ensuring that quality care is
provided to patients. An essential element of peer review is
management support for actions recommended by the peer review
process. Without such support, peer review is meaningless
because no action is taken on the peer reviewers'
recommendations. This report examines the relationship between
problem identification and problem resolution in VA physician
peer review. GAO discusses (1) how the results of VA peer
review are being used in reprivileging and disciplining doctors
with performance problems; (2) what the impediments to
effective peer review are; and (3) whether VA is taking steps
to identify, follow up on, and report to state medical boards
and the National Practitioner Data Bank on the actions of those
physicians who are not performing in accordance with
professional standards.
VA Health Care: Retargeting Needed to Better Meet Veterans' Changing
Needs (GAO/HEHS-95-39, Apr. 21, 1995)
Many veterans have health care needs that are not
adequately met through current health care programs, including
VA's health care system. About one-third of the nation's
homeless are veterans, nearly one-half of whom have serious
mental problems, suffer from substance abuse, or both. The
homeless have limited access to health care services and may
not seek medical treatment. About 38 percent of male and 25
percent of female Vietnam veterans with post-traumatic stress
disorder have not sought treatment. About 91,000 low-income,
uninsured veterans with no apparent health care options
indicated in a 1987 VA survey that they had never used VA
health facilities because they were unaware that they were
eligible or they had concerns about the quality or
accessibility of VA health care. VA cannot adequately address
many of these health care needs because (1) it relies primarily
on direct delivery of health care services in VA facilities,
(2) its complex eligibility and entitlement provisions limit
the services that veterans can obtain from VA facilities, and
(3) space and resource limitations prevent eligible veterans
from obtaining covered services. This report presents several
options for restructuring VA's health care system to enable it
to better meet the health care needs of veterans.
VA Savings Options (GAO/HEHS-95-165R, May 18, 1995)
GAO reviewed several options for achieving budgetary
savings in VA's health care system without adversely affecting
the current level of services provided to low-income or
disabled veterans. GAO noted that VA could achieve health care
cost savings by (1) shifting care from VA hospitals to
alternative settings, such as ambulatory care; (2) adopting
state veterans' home charging policies; (3) authorizing estate
recovery programs; (4) increasing copayments for health
services; (5) reducing or eliminating care for veterans with
high incomes; (6) delaying VA hospital construction projects;
(7) increasing the use of community nursing homes as an
alternative to new VA nursing homes; (8) strengthening
veterans' income verification requirements; (9) changing VA
dispensing practices for prescription drugs; (10) eliminating
the dispensing of over-the-counter drugs; (11) recovering the
full costs of services provided to nonveterans; (12)
consolidating its mail service pharmacies; (13) consolidating
underutilized services in nearby VA medical centers; (14)
suspending locality-based pay adjustments; and (15)
restructuring its ambulatory care system.
VA's Florida Network Planning (GAO/HEHS-95-160R, May 16, 1995)
GAO addressed a series of questions related to VA's
acquisition and intended use of the Naval Hospital in Orlando,
Florida. GAO noted that (1) the VA Integrated Planning Model is
based upon veterans' ages, average lengths of hospital stays,
and number of patients treated in selected medical services;
(2) VA used its model to project veterans' inpatient,
outpatient, and nursing home needs for the year 2005; (3) VA
did not consider the number of VA hospitals per square mile per
capita in making its construction planning decisions for
central Florida and significantly overestimated the number of
hospital beds it would need in 1995; (4) it is unclear why
Florida's hospital utilization rates are far below the national
rates; (5) the veteran population is expected to decline in
Florida and the nation over the next 15 years, while the total
population in these areas is expected to increase; (6) there
are waiting periods for certain elective medical treatments in
central Florida VA hospitals due to staffing reductions; and
(7) the VA Integrated Planning Model adequately accounts for
the aging nature of the veteran population.
VA Health Care: Travis Hospital Construction Project Is Not Justified
(GAO/HEHS-96-198, Sept. 3, 1996)
Pursuant to a congressional request, GAO provided
information on VA's planned construction of an outpatient
clinic and additional bed space at the David Grant Medical
Center, focusing on (1) whether the project could be adequately
justified and (2) whether there are cost-effective alternatives
to planned hospital construction. GAO found that (1) VA planned
construction of additional bed space and an outpatient clinic
at Travis Air Base appears to be unjustified; (2) VA has not
revised its construction plans to reflect the changes that have
occurred in the health care marketplace and advances in medical
practices and technology that have reduced the demand for
hospital beds in northern California; (3) VA has not considered
whether its construction plans will negatively affect
surrounding community hospitals; (4) the veteran population in
northern California is expected to decline by 25 percent
between 1995 and 2010 and may not be large enough to support a
new outpatient clinic; (5) VA is adequately meeting the health
care needs of Northern California Health Care System veterans;
(6) although VA clinics have experienced some space
constraints, they have had no problem in placing veterans
needing hospital care and using community hospitals for medical
emergencies; (7) alternatives to VA construction plans include
modifying VA hospital referral patterns, expanding use of other
military and VA hospitals, granting VA more authority to
contract for lower cost community hospital services, or
allowing it to purchase a local Air Force hospital for use as a
hospital or outpatient clinic; (8) VA Sierra Pacific Network
officials are evaluating the best way to meet veterans' future
health care needs, make better use of VA facilities, and
increase the use of private and other public facilities; and
(9) Congress' decision on whether to fund the construction plan
will significantly affect the alternatives and options that can
be implemented.
VA Health Care: Trends in Malpractice Claims Can Aid in Addressing
Quality of Care Problems (GAO/HEHS-96-24, Dec. 21, 1995)
From fiscal year 1990 to fiscal year 1994, malpractice
claims against VA medical centers have steadily increased, from
678 to 978, with payments made to claimants totaling more than
$200 million. In 1992, VA entered into an agreement with the
Armed Forces Institute of Pathology (AFIP) to analyze trends in
VA malpractice claims. VA's quality assurance staff, however,
are making only limited use of the information being developed
by AFIP. Although malpractice claim information is available
from DOD, it is not comparable to the malpractice data that VA
collects. The main reason for the lack of comparability is the
absence of a standard data collection format. Nonetheless, GAO
found that DOD information may be useful to VA to draw
comparisons in areas in which malpractice claims are being
generated, such as incidents related to surgery, diagnosis, and
medication.
Veterans' Benefits: Basing Survivors' Compensation on Veterans'
Disability Is a Viable Option (GAO/HEHS-95-30, Mar. 6, 1995)
In 1993, VA's Dependency and Indemnity Compensation (DIC)
program paid benefits totaling $2.7 billion to about 276,000
surviving spouses of service members who had died on active
duty and surviving spouses of some disabled veterans. These
benefits were paid under the Veterans' Benefits Act of 1992,
which changed the basis for DIC benefits from the military rank
of the deceased service member or veteran to a flat rate for
all surviving spouses. This report (1) estimates DIC
recipients' total income and determines the kinds and the
amounts of benefits received from other programs, (2)
determines the financial impact on surviving spouses of the
deaths of totally disabled veterans and of veterans who were
receiving supplemental payments because they had multiple
severe disabilities and could not care for themselves, and (3)
assesses alternative ways to set DIC benefits.
Veterans' Benefits: Better Assessments Needed to Guide Claims
Processing Improvements (GAO/HEHS-95-25, Jan. 13, 1995)
Slow claims processing and poor customer service have long
been recognized as serious problems for VA. As early as 1990,
VA began encouraging its regional offices to improve their
claims processing system, but processing times and backlogs
have increased rather than decreased. At the end of fiscal year
1994, nearly 500,000 claims awaited a VA decision. About 65,000
of these were initial disability compensation claims. On
average during fiscal year 1994, veterans waited more than 7
months for their initial disability claims to be decided and,
if approved, payments to begin; some waited much longer. This
report discusses VA's current plans to change regional office
claims processing and assesses VA's plans to determine the
effectiveness of those changes.
Veterans' Benefits: Effective Interaction Needed Within VA to Address
Appeals Backlog (GAO/HEHS-95-190, Sept. 27, 1995)
Veterans often wait months for VA to decide their
compensation and pension claims. In addition, the 40,000
veterans who appeal VA's decisions each year wait much longer--
more than 2 years for a final decision, according to agency
officials. GAO found that VA's appeals process is increasingly
bogged down, and the outlook for the future is not bright.
Legislation and court rulings have expanded veterans' rights
but also expanded VA's adjudication responsibilities. VA is
having difficulty integrating these responsibilities into its
already complex and unwieldy adjudication process. Since 1991,
the number of appeals awaiting board action has risen by 175
percent and the average processing time has increased by more
than 50 percent. Studies by GAO, VA, and others have
recommended the need for autonomous organizations in VA to work
together to identify and resolve problems. Yet GAO found that
problems continue to go unidentified and unresolved. Unless VA
clearly defines its adjudication responsibilities, it will be
unable to determine whether it has the resources to meet those
responsibilities and whether new solutions may be needed,
including laws amending VA's responsibilities or reconfiguring
the department.
Veterans' Benefits: VA Can Prevent Millions in Compensation and Pension
Overpayments (GAO/HEHS-95-88, Apr. 28, 1995)
Despite its responsibility to ensure accurate benefit
payments, VA continues to overpay veterans and their survivors
hundreds of millions of dollars in compensation and pension
benefits each year. VA has the ability to prevent millions of
dollars in overpayments but has not done so because it has not
focused on prevention. For example, VA does not use available
information, such as when beneficiaries will become eligible
for Social Security benefits, to prevent the overpayments from
occurring. Furthermore, VA does not systematically collect,
analyze, and use information on the specific causes of
overpayments that will help it target preventive efforts.
Veterans Compensation: Offset of DOD Separation Pay and VA Disability
Compensation (GAO/NSIAD-95-123, Apr. 3, 1995)
DOD uses separation pay to induce people to serve in the
military despite the risk of involuntary separation. The
Congress authorized special separation pay to minimize the use
of involuntary separations in the ongoing force drawdown. Pay
offsets prevent service members from receiving dual
compensation for a single period of service. Repealing offsets
for separation and disability pay would cost the federal
government an estimated $435 million for those service members
who separated during fiscal years 1995 to 1999. A repeal would
cost about $799 million if it was made retroactive to fiscal
year 1992, when the special separation pay program began.
Separation and disability pay offsets have not significantly
undermined the voluntary separation incentive. According to
DOD, the bulk of the drawdown since fiscal year 1992 has been
accomplished through voluntary separations. DOD requires the
services to inform separating service members about the offset.
Veterans' Health Care: Facilities' Resource Allocations Could Be More
Equitable (GAO/HEHS-96-48, Feb. 7, 1996)
VA confronts the challenge of equitably allocating more
than $16 billion in health care appropriations across a
nationwide network of hospitals, clinics, and nursing homes.
The challenge is made greater by the changing demographics of
veterans. Although nationally the veteran population is
declining, some veterans have relocated from the Northeast and
the Midwest to southern and southwestern states in the past
decade, offsetting veteran deaths in these states. VA has tried
for years to implement an equitable resource allocation
method--one that would link resources to facility workloads and
foster efficiency. The need for such a system has become more
urgent in recent years because of the demographic shift in
veterans and the dramatic changes in health care resulting from
increasingly limited resources. The resource allocation system
can help VA achieve this goal by forecasting workload changes
and providing comparative data on facilities' costs.
Nonetheless, VA has not taken steps to overcome several
barriers that can prevent it from acting on the data the system
produces. If the system is to live up to its potential, several
changes must be made, including linking resource allocation to
VA's strategic plan, conducting a formal review and evaluation
of facility cost variations, evaluating the basis for not
allocating funds through resource planning and management, and
using resource planning and management to overcome differences
in veterans' access to care.
Veterans' Health Care: VA's Approaches to Meeting Veterans' Home Health
Care Needs (GAO/HEHS-96-68, Mar. 15, 1996)
In fiscal year 1994, VA provided home health care to more
than 40,000 veterans at a cost of $64 million to VA and
millions more to Medicare. By providing them with home health
care, VA allows these veterans to continue living at home and
in their communities, rather than receive care in institutions.
Veterans need home health care for various reasons. Some
veterans have chronic health problems, such as heart disease,
and require periodic visits, while others have been discharged
from VA medical centers following surgery and need dressings
changed or medications administered. The number of veterans
needing home health care is expected to grow as the veteran
population ages and as VA discharges patients from its
hospitals to reduce the costs of hospitalization. This report
provides information on (1) the characteristics and the
services of the home health care programs that VA uses, (2) the
available data on program costs, and (3) the way in which VA
ensures that veterans receive quality service.
Vocational Rehabilitation: VA Continues to Place Few Disabled Veterans
in Jobs (GAO/HEHS-96-155, Sept. 3, 1996)
Pursuant to a congressional request, GAO reviewed VA's
vocational rehabilitation program, focusing on (1) the
percentage of rehabilitated veterans, (2) the services
provided, (3) the characteristics of clients served, (4) the
cost of rehabilitation, and (5) VA's efforts to improve program
effectiveness. GAO found that (1) the VA vocational
rehabilitation program continues to focus on training and
higher education, but it places few veterans in jobs; (2) from
1991 to 1995, VA rehabilitated only about 8 percent of eligible
veterans, while 51 percent continued to receive program
services; (3) those program participants with a serious
employment handicap declined from 40 percent to 29 percent over
the last 5 years and those with a 10-to-20 percent disability
increased from 34 percent to 42 percent; (4) over 90 percent of
program applicants were male and had completed high school and
almost 25 percent had taken some college courses; (5) VA spent,
on average, about $20,000 on each employed veteran and $10,000
on each program dropout; (6) over one-half of VA rehabilitation
costs were for veterans' subsistence allowances; (7) state
vocational rehabilitation agencies rehabilitated 37 percent of
eligible individuals, while the remaining individuals continued
to receive state program services; (8) the state vocational
rehabilitation programs provided a wide range of rehabilitation
services, and a majority of their clients were severely
disabled; (9) almost 60 percent of the state program applicants
were male and had completed high school, and 17 percent had
completed some college courses; (10) the state programs spent,
on average, about $3,000 on each rehabilitated client and about
$2,000 on each dropout, none of which covered clients' living
expenses; (11) VA established a design team in 1995 to improve
program effectiveness, primarily by increasing the percentage
of suitably employed veterans, improving staff job finding and
placement skills, and developing a data management system; and
(12) VA plans to implement these program changes in fiscal year
1997.
VHA's Management Improvement Initiative (GAO/HEHS-96-191R, Aug. 30,
1996)
Pursuant to a congressional request, GAO examined VA's
progress in implementing management improvement initiatives to
its health care system, administered by the Veterans Health
Administration (VHA). GAO noted that (1) VA has concentrated
its efforts on implementing those initiatives aimed at reducing
centrally funded activities while deferring most of the more
significant recommendations and (2) VA addressed the 1995 and
1996 budget reductions mainly through across-the-board cuts. In
an August 20, 1996, letter, VA commented to GAO that the agency
is making considerable progress toward implementing those
initiatives still appropriate.
[Enclosure II]
Calendar Years 1995 and 1996 Testimonies on Issues Affecting Older
Americans
GAO testified 69 times before congressional committees
during calendar years 1995 and 1996 on issues relating to older
Americans. Of these testimonies, 2 were on education and
employment, 35 on health, 3 on housing, 20 on income security,
and 9 on veterans and DOD issues.
Education and Employment Issues
Department of Labor: Rethinking the Federal Role in Worker Protection
and Workforce Development (GAO/T-HEHS-95-125, Apr. 4, 1995)
Although the Department of Labor has accomplished much over
the years, its current approaches to worker protection are
dated and frustrate both workers and employers. What is needed
is greater service orientation, improved communication, greater
access to compliance information, and expanded meaningful input
into the standard-setting and enforcement processes. By
developing alternative regulatory strategies that supplement
and even replace its current labor-intensive compliance and
enforcement approach, Labor can carry out its responsibilities
in a less costly, more effective manner. Similarly, in the
workforce development area, the government's job training
effort consists of a patchwork of federal programs with similar
goals, conflicting requirements, overlapping populations, and
questionable outcomes. The roughly $20 billion appropriated in
fiscal year 1995 for job training assistance to adults and out-
of-school youth was distributed to 15 agencies, including
Labor, and supported 163 separate programs. This situation
suggests that a major overhaul and consolidation of the
programs are needed.
Senior Community Service Employment: Program Delivery Could Be Improved
Through Legislative and Administrative Actions (GAO/T-HEHS-96-
57, Nov. 2, 1995)
The Labor Department's Senior Community Service Employment
Program finances part-time minimum-wage community service jobs
for about 100,000 poor elderly Americans. GAO found that Labor
distributes program funds through noncompetitive grants to 10
national organizations, called national sponsors, and to state
agencies. These national sponsors and state agencies, in turn,
use the grant funds to finance local employment projects run by
community service host agencies, such as libraries, nutrition
centers, and parks, that directly employ older Americans. GAO
found that the relative distribution of funds to the national
sponsors and state agencies along with Labor's method of
implementing the hold-harmless provisions have resulted in the
distribution of funds among and within states that bear little
relationship to actual need. GAO also found that, under Labor's
regulations, expenditures that GAO believes to be
administrative in nature may be charged to another cost
category, allowing grantees to exceed the statutory 15-percent
limit on administrative costs.
Health Issues
Blue Cross and Blue Shield: Change in Pharmacy Benefits Affects Federal
Enrollees (GAO/T-HEHS-96-206, Sept. 5, 1996)
Of the 400 health plans available to federal workers, the
Blue Cross and Blue Shield plan is the largest, covering nearly
42 percent of the 4 million federal enrollees. To control drug
costs, Blue Cross and Blue Shield recently began requiring
federal enrollees to pay 20 percent of the price of
prescriptions purchased at participating retail pharmacies.
Previously, federal enrollees did not have to pay anything for
prescription drugs. Enrollees may continue to receive drugs
free of charge, however, if they buy them through the plan's
mail-order program. Members of Congress and retail pharmacies
have raised concerns about the quality of mail-order services
and the effect of the change on the business of retail
pharmacies that serve plan enrollees. To provide pharmacy
services to its federal employee health plan, Blue Cross and
Blue Shield contracts with two pharmacy benefit managers (PBM):
PCS Health Systems, Inc., which provides retail prescription
drug services, and Merck-Medco Managed Care, Inc., which
provides mail-order drug services. This testimony discusses (1)
Blue Cross and Blue Shield's reasons for the benefit change,
(2) how it was implemented, (3) the change's effect on retail
pharmacies, and (4) the extent to which PCS and Merck-Medco
have met their contract requirements for services provided to
the federal health plan.
Community Health Centers: Challenges in Transitioning to Prepaid
Managed Care (GAO/T-HEHS-95-143, May 4, 1995)
As states move to prepaid managed care to control costs and
improve access for their Medicaid clients, the number of
participating community health centers continues to grow.
Medicaid prepaid managed care is not incompatible with health
centers' mission of delivering health care to medically
underserved populations. However, health centers face
substantial risks and challenges as they move into these
arrangements. Such challenges require new knowledge, skills,
and information systems. Centers lacking expertise and systems
face an uncertain future, and those in a vulnerable financial
position are at even greater risk. Today's debate over possible
changes in federal and state health programs heightens the
concern over the financial vulnerability of centers
participating in prepaid managed care. If this funding source
continues to grow as a percentage of total health center
revenues, centers must face building larger cash reserves while
not compromising services to vulnerable populations.
Consumer Health Informatics: Emerging Issues (GAO/T-AIMD-96-134, July
26, 1996)
Technology has increased the amount of health information
available to the public, allowing consumers to become better
educated and more involved in their own health care. Government
and private health care organizations rely on a variety of
technologies to disseminate health information on preventive
care, illness and injury management, treatment options, post-
treatment care, and other topics. This report discusses
consumer health informatics--the use of computers and
telecommunications to help consumers obtain information,
analyze their health care needs, and make decisions about their
own health. GAO provides information on (1) the demand for
health information and the expanding capabilities of
technology; (2) users' and developers' views on potential
systems advantages and issues surrounding systems development
and use; (3) government involvement--federal, state, and
local--in developing these technologies; and (4) the status of
related efforts by HHS. As part of this review, GAO surveyed
consumer health informatics experts and presents their views on
issues that need to be addressed when developing consumer
health information systems.
Employer-Based Health Plans: Issues, Trends, and Challenges Posed by
ERISA (GAO/T-HEHS-95-223, July 25, 1995)
As the movement for comprehensive federal health care
reform has lost steam, the focus of reform has shifted to the
states and private market. States remain concerned about the
growing number of persons lacking health coverage and about
financing health plans for poor persons. Employers have become
increasingly aggressive in managing their health plans and have
adopted various managed care plans and innovative funding
arrangements. However, ERISA effectively blocks states from
directly regulating most employer-based health plans, although
it allows states to regulate health insurers. GAO found that
nearly 40 percent of enrollees in employer-based health plans--
44 million people--are in self-funded plans. The divided
federal and state framework for regulating health plans
produces a complex set of trade-offs. Self-funded plans, which
are exempt from state regulation under ERISA, provide employers
greater flexibility to design a health benefits package that
may have been less feasible to provide under state regulation.
At the same time, however, states are unable to extend
regulations, such as solvency standards, preexisting condition
clause limits, and guaranteed issue and renewal requirements,
even indirectly, to enrollees in these self-funded plans.
Fraud and Abuse: Medicare Continues To Be Vulnerable to Exploitation by
Unscrupulous Providers (GAO/T-HEHS-96-7, Nov. 2, 1995)
Most Medicare providers try to abide by program rules and
strive to meet beneficiaries' needs. Nevertheless, Medicare is
overwhelmed in its attempts to keep pace with, much less stay
ahead of, those bent on cheating the system. GAO's recent
investigations of Medicare fraud and abuse have implicated home
health agencies, medical suppliers, pharmacists, rehabilitation
therapy companies, and clinical laboratories. They are
attracted by the high reimbursement levels for some supplies
and services, and the few barriers to entry into this lucrative
marketplace. Once engaged in these profitable activities,
exploitative providers too often escape detection because of
inadequate claims scrutiny, elude pursuit by law enforcement
authorities because of the authorities' limited resources and
fragmented responsibilities, and face little risk of speedy or
appropriate punishment.
Fraud and Abuse: Providers Excluded From Medicaid Continue To
Participate in Federal Health Programs (GAO/T-HEHS-96-205,
Sept. 5, 1996)
Although HHS' Office of Inspector General (OIG) has
excluded thousands of health care providers from state Medicaid
programs because they committed fraud or delivered poor care to
beneficiaries, weaknesses in the OIG's process could leave such
providers on the rolls of federal health programs for
unacceptable periods of time. This puts at risk the health and
safety of beneficiaries and compromises the financial integrity
of Medicaid, Medicare, and other federal health programs. The
weaknesses include (1) lengthy delays in the OIG's decision
process, even in cases where a provider has been convicted of
fraud or patient abuse and neglect; (2) inconsistencies among
OIG field offices regarding which providers will be considered
for nationwide exclusion; (3) states not informing the OIG
about providers who agree to stop participating in their
Medicaid programs even though the provider withdrew because of
egregious patient care or abusive billing practices; and (4)
how states use information from the OIG to remove excluded
providers from state programs. Because of incomplete records in
the OIG field offices, GAO could not reach a conclusion as to
the magnitude of these problems.
Health Insurance Regulation: National Portability Standards Would
Facilitate Changing Health Plans (GAO/T-HEHS-95-205, July 18,
1995)
Many Americans face discontinuity in their health care
coverage when they change employers, and others do not change
jobs because of concerns about losing health care coverage. GAO
surveyed the status of federal and state insurance reforms and
the number of individuals who would be affected by legislation
to establish national portability standards. GAO found that
federal and state laws reflect steps taken to improve the
portability of health insurance, but the possibility remains
that an individual's coverage would be reduced when changing
jobs because most private health plans still require waiting
periods before making people with preexisting conditions fully
eligible for coverage. On the basis of existing data on the
number of people who change jobs and studies on the effect of
health insurance on job mobility, GAO estimates that up to 21
million Americans would benefit from legislation waiving
preexisting condition exclusions for individuals who have
maintained continuous health care coverage.
Medicaid: Experience With State Waivers To Promote Cost Control and
Access to Care (GAO/T-HEHS-95-115, Mar. 23, 1995)
The Congress has begun reexamining the $131 billion
Medicaid program--one of the fastest growing components of both
federal and state budgets. In 1993, Medicaid cost nearly $100
billion more and served about 10 million more low-income
residents than it did a decade ago. To contain exploding costs
and enrollment, many states are seeking greater flexibility in
implementing statewide Medicaid managed care programs.
Currently, this flexibility is available only through the
waiver authority established by section 1115 of the Social
Security Act. Although many states have expressed interest in
waivers, only four states have waivers in place. Two additional
states have received federal approval, but their plans still
must be ratified by state legislatures. States face significant
challenges as they move from traditional fee-for-service
systems into managed care. Specifically, the emphasis that
states put on program implementation and oversight may affect
whether states' managed care programs successfully contain
costs while increasing access to quality health care.
Medicaid: Matching Formula's Performance and Potential Modifications
(GAO/T-HEHS-95-226, July 27, 1995)
When the Medicaid program was established in 1965, a
matching formula was developed to narrow differences likely to
arise among Medicaid programs in wealthier and poorer states.
By giving poorer states a higher federal match, it was believed
that disparities would be reduced across states in (1)
population groups and services covered in each state program
and (2) the tax burden imposed by the financing of Medicaid
relative to the size of the state's financial resources. GAO
testified that the matching formula, with its reliance on per
capita income as a measure of state wealth, has not
significantly reduced wide differences in states' Medicaid
programs or the tax burdens to support them. Large disparities
persist in the coverage of population groups and types of
services as well as in the burdens that state taxpayers bear in
financing state programs. Modifying the formula could enhance
the ability of federal payments to narrow program disparities.
Medicaid: Spending Pressures Drive States Toward Program Reinvention
(GAO/T-HEHS-95-129, Apr. 4, 1995)
The $131 billion Medicaid program is at a crossroads.
Between 1985 and 1993, Medicaid costs tripled and the number of
beneficiaries rose by more than 50 percent. Medicaid costs are
projected to rise to $260 billion, according to the
Congressional Budget Office. Despite federal and state
budgetary constraints, several states are exerting pressure to
expand the program and enroll hundreds of thousands of new
beneficiaries. The cost of expanded coverage, they believe,
will be offset by the reallocation of Medicaid funds and the
wholesale movement of beneficiaries into some type of managed
care arrangement. This testimony examines (1) federal and state
Medicaid spending, (2) some states' efforts to contain Medicaid
costs and expand coverage through waiver of federal
requirements, and (3) the potential impact of these waivers on
federal spending and on Medicaid's program structure overall.
Medicaid: Spending Pressures Spur States Toward Program Restructuring
(GAO/T-HEHS-96-75, Jan. 18, 1996)
Several factors, including federal mandates that expand
eligibility, medical price inflation, and creative financing
schemes, have boosted Medicaid costs. To contain these
expenses, 22 states have recently sought waivers from federal
regulations that limit their ability to run extensive managed
care programs. Some of these states have required the
enrollment of their acute care patients--primarily low-income
women and children--into managed care programs and have
expanded coverage to previously ineligible persons. Arizona,
which runs a Medicaid managed care program under a federal
waiver obtained more than 10 years ago, has lowered Medicaid
spending by millions of dollars. It also leads the states in
its development of information systems for collecting medical
encounter data essential for assessing quality of care.
Medicaid: State Flexibility in Implementing Managed Care Programs
Requires Appropriate Oversight (GAO/T-HEHS-95-206, July 12,
1995)
Requiring states to obtain waivers to broaden use of
managed care may hamper their efforts to aggressively pursue
cost-containment strategies. At the same time, because current
program restrictions on managed care were designed to reinforce
quality assurance, their absence requires the substitution of
appropriate and adequate mechanisms to protect both Medicaid
beneficiaries and federal dollars. Finally, the reinvestment of
managed care savings to expand Medicaid coverage to several
million additional persons suggests the need for up-front
consultation with the Congress because of (1) the heavier
financial burden such 1115 waivers may place on the federal
government and (2) the issue of whether the U.S. Treasury
should benefit from those savings.
Medicaid: Statewide Section 1115 Demonstrations' Impact on Eligibility
Service Delivery and Program Cost (GAO/T-HEHS-95-182, June 21,
1995)
The growth of Medicaid, which accounted for $142 billion in
federal and state outlays in 1994, is outpacing even the growth
of Medicare. This is happening at a time when states are
feeling pressured financially and are seeking ways to care for
their uninsured populations. In response, states are, one by
one, reinventing their Medicaid programs, using the authority
of section 1115 waivers. Named for section 1115(a) of the
Social Security Act, these waivers free states from some
Medicaid restrictions on the use of managed care delivery
systems. They also allow states to expand Medicaid-financed
coverage to persons not normally eligible for Medicaid. This
testimony presents a detailed look at Medicaid's growing
expenditures, describes states' efforts to obtain section 1115
waivers, and summarizes the expenditures forecast of programs
operating with waivers.
Medicare: Adapting Private Sector Techniques Could Curb Losses to Fraud
and Abuse (GAO/T-HEHS-95-211, July 19, 1995)
Medicare's loss of billions of dollars to fraud and abuse
could be curbed by adopting such private sector techniques as
competitive bidding, use of advanced software to detect gross
overpayments, and preferred networks to better control costs.
Medicare's losses stem from inappropriate pricing and
inadequate scrutiny of claims for payments. Further, abusive
and poorly qualified providers of medical services and supplies
continue to participate in the program. These problems are not
unique to Medicare. However, private payers are often able to
react quickly, through a variety of management approaches,
whereas Medicare's pricing methods and controls over
utilization, which were consistent with health care financing
and delivery when the program started, have not been adapted to
today's environment.
Medicare: Allegations Against ABC Home Health Care (GAO/T-OSI-95-18,
July 19, 1995)
In response to a congressional request, GAO investigated
allegations against ABC Home Health Care, a home health agency
(HHA), and its participation in the Medicare home health care
program. In the Medicare program, providers may receive
reimbursement for only those expenses that are reasonable in
amount and related to patient care for eligible patients.
Current and former employees told GAO that local ABC officer
managers directed them to alter records to make it appear that
patients continued to need home health visits. Additionally,
managers directed employees to continue visiting patients who,
in the employees' opinion, did not qualify for home health care
because they no longer met Medicare rules defining homebound
status. ABC also reportedly charged Medicare for the cost of
acquiring other HHAs by paying owners a small sum up front and
the balance in the form of salary under employment agreements,
a practice that is inconsistent with Medicare regulations for
reimbursement. Finally, according to former employees, some
managers directed employees to market ABC and its services with
the intent of charging Medicare for costs that were not
reimbursable. GAO has shared information concerning possible
illegal activities with appropriate law enforcement
authorities.
Medicare Claims Billing Abuse: Commercial Software Could Save Hundreds
of Millions Annually (GAO/T-AIMD-95-133, May 5, 1995)
With an investment of only $20 million in off-the-shelf
commercial software, Medicare could save nearly $4 billion over
5 years by detecting fraudulent claims by physicians--primarily
manipulation of billing codes. On the basis of a test in which
four commercial firms reprocessed samples of more than 20,000
paid Medicare claims, GAO estimates that the software could
have saved $603 million in 1993 and $640 million in 1994. GAO
estimates that because beneficiaries are responsible for about
22 percent of the payment amounts--mainly in the form of
deductibles and copayments--Medicare could have saved them $134
million in 1993 and $142 million in 1994. The test results
indicate that only a small portion of providers are responsible
for most of the abuses: fewer than 10 percent of providers in
the sample had miscoded claims.
Medicare: Excessive Payments for Medical Supplies Continue Despite
Improvements (GAO/T-HEHS-96-5, Oct. 2, 1995)
Despite improvements by HCFA in claims monitoring, problems
in payments for medical supplies persist. The inflexibility of
Medicare's fee schedule results in payment rates that are
higher than wholesale and many retail prices. In addition, in
the case of many part A claims, claims processing contractors
do not know what they are paying for and in the case of part B
claims, have not had a basis for questioning unreasonably high
charges. Neither type of contractor has been able to test
claims for possible duplicate payments. For these reasons,
Medicare has lost hundreds of millions of dollars in
unnecessary payments. By obtaining the legislative authority to
modify payment rates in accordance with market conditions,
requiring providers to itemize claims, and introducing the
relevant medical policies before paying for new benefits, HCFA
could reduce its dollar losses arising from medical supply
payments. Contractors could avoid paying unreasonable charges
and making duplicate payments.
Medicare: High Spending Growth Calls for Aggressive Action (GAO/T-HEHS-
95-75, Feb. 6, 1995)
The government faces strong obstacles to bringing Medicare
expenditures under control. Broad-based payment system reforms
have slowed overall spending, but Medicare growth rates remain
higher than overall inflation. And although more reforms may be
needed, their nature is the subject of much debate. There is
less dispute, however, that Medicare pays too much for some
services and supplies. Fiscal pressures have increasingly led
private and state-government payers to negotiate discounts with
providers and to manage the form and the volume of care.
Medicare has not exercised its potential market power in
similar fashion when buying some services, such as
rehabilitation therapy. GAO suggests that the government change
the reimbursement policies for these excessively costly
services to ensure that it is acting as a prudent buyer. Also,
greater vigilance over wasteful or inappropriate payments could
better protect Medicare against fraudulent and abusive billings
from providers.
Medicare: Increased Federal Oversight of HMOs Could Improve Quality of
and Access to Care (GAO/T-HEHS-95-229, Aug. 3, 1995)
This testimony discusses problems that HCFA has had
monitoring HMOs it contracts with to provide services to
Medicare beneficiaries and ensuring that they comply with
Medicare's performance standards. GAO found weaknesses in
HCFA's quality assurance monitoring, enforcement measures, and
appeal processes. Although HCFA routinely reviews HMO
operations for quality, these reviews are generally perfunctory
and do not consider the financial risks that HMOs transfer to
providers. Moreover, HCFA collects virtually no data on
services received through HMOs to enable HCFA to identify
providers who may be underserving beneficiaries. In addition,
HCFA's HMO oversight has two other major limitations:
enforcement actions are weak and the beneficiary appeal process
is slow. HCFA's current regulatory approach to ensuring good
HMO performance appears to GAO to lag behind the private
sector.
Medicare Managed Care: Enrollment Growth Underscores Need to Revamp HMO
Payment Methods (GAO/T-HEHS-95-207, July 12, 1995)
Rapid growth in the number of Medicare beneficiaries in
HMOs increases the urgency of correcting rate-setting flaws
that result in unnecessary Medicare spending. By not tailoring
its HMO capitation payment to how healthy or sick HMO enrollees
are, HCFA cannot realize the savings that private-sector payers
capture from HMOs. Two lessons can be learned from GAO's review
of ways to fix Medicare's HMO capitation payments. First, a
multipronged approach to rate setting makes sense. The large
disparities in market conditions between states call for
solutions keyed to market conditions. Second, with respect to
achieving the promise of such initiatives, details matter. How
these strategies are designed and implemented could mean the
difference between success and failure. GAO believes that in
the short term, HCFA can overcome its capitation problem by
introducing a better health status risk adjustor. HCFA should
also promptly test competitive bidding and other promising
approaches to setting HMO rates that reduce Medicare costs.
Medicare Managed Care: Program Growth Highlights Need to Fix HMO
Payment Problems (GAO/T-HEHS-95-174, May 24, 1995)
(This testimony is similar to our July 12, 1995, testimony
summarized above.)
Medicare: Millions Can Be Saved by Screening Claims for Overused
Services (GAO/T-HEHS-96-86, Feb. 8, 1996)
Medicare contractors routinely pay hundreds of millions of
dollars in Medicare claims without first determining if the
services provided are necessary. GAO reviewed payments to
doctors for six groups of high-volume medical procedures--
ranging from eye examinations to chest X rays--that accounted
for nearly $3 billion in Medicare payments in 1994. GAO also
surveyed 17 contractors to determine if they had used medical
necessity criteria in their claims processing to screen for
these six groups of procedures. For each of the six groups,
more than half of the 17 contractors failed to use automated
screens to flag claims for unnecessary, inappropriate, or
overused treatments. These prepayment screens could have saved
millions of taxpayer dollars now wasted on questionable
services. Problems with controlling payments for widely
overused procedures continue because HCFA lacks a national
strategy to control these payments. HCFA now relies on
contractors to focus on procedures where local use exceeds the
national average. Although this approach helps reduce local
overuse of some procedures, it is not designed to control
overuse of a procedure nationwide.
Medicare: Modern Management Strategies Could Curb Fraud, Waste, and
Abuse (GAO/T-HEHS-95-227, July 31, 1995)
Medicare's vulnerability to provider exploitation of its
billing system stems from a combination of factors: (1) higher
than market rates for some services, (2) inadequate checks for
detecting fraud and abuse, (3) superficial criteria for
confirming the authenticity of providers billing the program,
and (4) weak enforcement efforts. Various health care
management techniques help private payers avoid these problems,
but Medicare generally does not use these techniques. The
program's pricing methods and controls over utilization have
not kept pace with changes in health care financing and
delivery. To some extent, the predicament inherent in public
programs--the uncertain line between adequate managerial
control and excessive government intervention--helps explain
the dissimilarity in the ways in which Medicare and
privatehealth insurers run their respective ``plans.'' GAO believes
that a viable strategy for remedying the program's weaknesses consists
of adapting the health care management approach of private payers to
Medicare's public payer role. This would entail (1) more competitively
developed payment rates, (2) beefed-up fraud and abuse detection that
uses modern information systems, and (3) more rigorous criteria for
granting authorization to bill the program.
Medicare: Modern Management Strategies Needed to Curb Program
Exploitation (GAO/T-HEHS-95-183, June 15, 1995)
(This testimony is similar to our July 31, 1995, testimony
described above.)
Medicare: Opportunities Are Available to Apply Managed Care Strategies
(GAO/T-HEHS-95-81, Feb. 10, 1995)
Although the private sector quickly embraced managed care
as an effective way to control the growth of health care costs,
Medicare has moved more slowly. GAO believes that Medicare
could benefit from the experience of the private sector and
should test such managed care strategies as competitive bidding
for HMOs. Using market power to negotiate with HMOs over price
and increasingly over quality and the production of report-
card-type information, large employers are becoming more
prudent and sophisticated purchasers of health care. The
particulars of these efforts may not be directly transferable
to the federal government, but their goals of using incentive-
based solutions to contain costs, guarantee quality, and inform
consumers are worthy of consideration and testing.
Medicare: Private Payer Strategies Suggest Options to Reduce Rapid
Spending Growth (GAO/T-HEHS-96-138, Apr. 30, 1996)
Improvements to Medicare's traditional fee-for-service
program could yield much-needed savings. With better
management, this program, which now serves about 90 percent of
beneficiaries, could run more efficiently while continuing to
provide good service to the nation's elderly. This means
allowing Medicare to use tools similar to those used by private
payers to manage health care costs. Negotiated discounts,
competitive bidding, preferred providers, case management
utilization reviews--these and other tools allow private payers
to use market forces to control health care costs. Most,
however, are not authorized for general use by HCFA, which runs
Medicare. This results in a publicly financed program that pays
higher-than-market rates for some goods and services and
sometimes pays without question for improbably high bills.
Recent HCFA efforts and pending legislation to address these
problems appear promising. In addition, HCFA should test the
feasibility of applying management strategies in high-cost,
high-utilization areas. Finally, the Congress needs to give HHS
the flexibility to make prompt price adjustments.
Medicare: Private Sector and Federal Efforts to Assess Health Care
Quality (GAO/T-HEHS-96-215, Sept. 19, 1996)
HCFA now estimates that 4.3 million Medicare beneficiaries
are enrolled in HMOs. Enrollment is believed to be growing at a
rate of 100,000 new members per month. This testimony discusses
ways to ensure that quality care is provided to the Medicare
beneficiaries joining these HMOs. HCFA, which runs Medicare,
finds the potential cost savings associated with managed care
attractive. Concerns have been raised, however, that the cost
control strategies employed by HMOs could undermine the quality
of care. This testimony discusses (1) quality assessment
methods used by large corporate purchasers of health insurance
from HMOs, (2) quality assessment methods used by HCFA in
administering the Medicare HMO program, (3) quality assessment
methods HCFA plans for the future, and (4) what both corporate
purchasers and HCFA are doing to share information about
quality with employees and Medicare beneficiaries.
Medicare: Rapid Spending Growth Calls for More Prudent Purchasing (GAO/
T-HEHS-95-193, June 28, 1995)
Last year, federal spending for Medicare totaled $162
billion--more than $440 million a day. In March 1995, the
Congressional Budget Office estimated that these outlays would
approach $350 billion by 2002. In 2005, they could exceed $460
billion unless changes are made. This testimony discusses ways
in which the Medicare program could avoid excessive or
unnecessary spending. GAO examines areas of rapid spending
growth and ways to conserve program dollars--mainly by revising
reimbursement policies and better controlling unwarranted use
of services.
Medicare: Reducing Fraud and Abuse Can Save Billions (GAO/T-HEHS-95-
157, May 16, 1995)
Medicare is overwhelmed in its efforts to keep pace with,
much less stay ahead of, those bent on cheating the system.
Various factors converge to create a particularly rich
environment for profiteers. These include the following: (1)
weak fraud and abuse controls to detect questionable billing
practices, (2) few limits on those who may bill--companies
using post office box numbers have qualified to bill the
program for virtually unlimited amounts--and (3) overpayment
for services. This testimony describes how providers exploit
the system, why they are able to do so, and what steps Medicare
has taken and what remains to be done to protect the program
and the taxpayers against fraudulent reimbursement schemes and
abusive billing practices.
Medicare Transaction System: Strengthened Management and Sound
Development Approach Critical to Success (GAO/T-AIMD-96-12,
Nov. 16, 1995)
HCFA is developing a critical new claims-processing system,
the Medicare transaction system (MTS), to replace the nine
systems now used by Medicare. MTS' goal is to better protect
program funds from waste, fraud, and abuse; allow better
oversight of Medicare contractor operations; improve service to
beneficiaries and providers; and cut administrative expenses.
The weaknesses in HCFA's development of MTS stem from a lack of
a disciplined management process; a process in which
information systems and technology should be managed as
investments. Not managing MTS in this way has led to system
design and development proceeding despite (1) difficulties in
defining requirements, (2) a compressed scheduled containing
significant overlap of system-development phases, and (3) a
lack of reliable information on costs and benefits. These risks
in the development of MTS can be substantially reduced if HCFA
adopts some of the best practices that have proven effective in
other organizations: managing systems as investment, changing
information management practices, creating line manager
ownership, better managing resources, and measuring
performance.
Pharmacy Benefit Managers: Early Results on Ventures With Drug
Manufacturing (GAO/T-HEHS-96-85, Feb. 7, 1996)
Recently, some of the largest drug companies have merged or
formed alliances with some of the largest PBMs. PBMs manage the
prescription drug part of health insurance plans covering
millions of Americans. These ventures gained attention not only
because of their size but because of concerns that the PBMs
would automatically give preference to their manufacturer
partners' drugs over those made by competitors. The results of
GAO's analysis of PBM formularies--a list of preferred
prescription drugs by therapeutic class, often with cost
designations--indicate that continued oversight of mergers and
alliances between pharmaceutical manufacturers and PBMs is
warranted to ensure competition in the marketplace. For
example, the changes in Medco's formulary that appear to favor
Merck drugs do not necessarily show that Medco automatically
gave preference to Merck drugs over those of competitors.
However, the formulary changes support the Federal Trade
Commission's decision to continue monitoring the Merck/Medco
merger and other such ventures.
Prescription Drug Pricing: Implications for Retail Pharmacies (GAO/T-
HEHS-96-216, Sept. 19, 1996)
Congressional hearings during the late 1980s highlighted
the fact that the prices that consumers paid for prescription
drugs were increasing more rapidly than the rate of inflation.
In 1990, the Congress tried to control prescription drug
expenditures by significantly changing the way that Medicaid
pays for outpatient drugs. Vertical integration in the
pharmaceutical market later became a concern, particularly
mergers between large drug companies and PBMs. This testimony
responds to the following three questions: How and why has the
process by which drugs get from manufacturers to patients
changed? What have been the consequences for retail pharmacies
of changes in this process? What general strategies are retail
pharmacies undertaking or proposing to respond to an
increasingly competitive environment?
Prescription Drugs and the Elderly: Many Still Receive Potentially
Harmful Drugs Despite Recent Improvements (GAO/T-HEHS-96-114,
Mar. 28, 1996)
GAO's analysis of 1992 data found that 17.5 percent of
nearly 30 million Medicare recipients were still being
prescribed drugs that were generally unsuitable for their age
group. Although this is an improvement over the almost 25
percent reported for 1987 data, the inappropriate use of
prescription drugs remains a major health problem for the
elderly. Insufficient coordination of patient drug therapies
and weaknesses in communication between providers, pharmacists,
and patients have compounded the problem. Inappropriate
prescribing practices and the ensuing drug use have caused many
elderly persons to suffer harmful effects that, according to
FDA, have resulted in hospitalizations costing $20 billion
annually. The costs are partly covered by Medicare and
Medicaid. States, advocacy groups, and physician and pharmacy
organizations have, however, taken steps to reduce
inappropriate drug use. In addition, managed care, pharmacy
benefit management, and other coordinated health care systems
have features designed to reduce inappropriate prescription
drug use among the elderly.
Prescription Drugs: Implications of Drug Labeling and Off-Label Use
(GAO/T-HEHS-96-212, Sept. 12, 1996)
Physicians use a drug ``off-label'' when they prescribe an
FDA-approved drug for treatments other than those specified on
the label. GAO testified that off-label prescribing is
prevalent and presents various problems for policymakers at
different times. As it stands now, the problem is that the drug
industry believes that labels overly constrain its ability to
promote its products. This problem can be solved either by
relying on sources in addition to the label to define
appropriate promotion or by improving the process for updating
the label. These two options are not necessarily mutually
exclusive and both have benefits and drawbacks.
Status of Medicare's Federal Hospital Insurance Trust Fund (GAO/T-HEHS-
96-94, Feb. 29, 1996)
This testimony focuses on GAO's ongoing review of the
status of Medicare's Federal Hospital Insurance (part A) Trust
Fund. GAO discusses (1) when the administration became aware
that the trust fund had an operating deficit--that is, cash
outlays exceeded cash receipts--of $36 million for fiscal year
1995 and how the information was disseminated and (2) what the
status is of current projections regarding the trust fund.
housing issues
Housing and Urban Development: Limited Progress Made on HUD Reforms
(GAO/T-RCED-96-112, Mar. 27, 1996)
Despite the promise of reform, reinvention, and
transformation initiatives aimed at solving problems at the
Department of Housing and Urban Development (HUD), much more
remains to be done. HUD is very much an agency in limbo, and
few of the proposals in its reinvention blueprint have been
adopted. This testimony addresses HUD's difficulties in
addressing (1) its long-standing management shortcomings, (2)
its portfolio of multi- and single-family housing insured by
the Federal Housing Administration, (3) budget and management
problems plaguing the public housing program, (4) the spiraling
cost of assisted housing programs, and (5) the need for
consensus on HUD reforms.
Housing and Urban Development: Public and Assisted Housing Reform (GAO/
T-RCED-96-22, Oct. 13, 1995)
Current federal housing programs are seen as overly
regulated and leading to warehousing of the poor, and the
Congress is asking state and local governments to assume a
larger role in defining how the programs work. The Congress is
now reconsidering the most basic aspects of public housing
policy--whom it will house, the resources devoted to it, the
amount of existing housing stock that will be retained, and the
rules under which it will operate. These statements provide
GAO's views on legislation pending before Congress--S. 1260 and
H.R. 2406--that would overhaul federal housing policy. GAO
testified that the two bills contain provisions that will
likely improve the long-term viability of public housing, such
as allowing mixed incomes in public housing and conversion of
some public housing to housing vouchers or tenant-based
assistance when that makes the most sense. GAO also supports
provisions to significantly beef up HUD's authority to
intervene in the management of troubled housing authorities,
but GAO cautions that questions remain about the reliability of
the oversight system that HUD uses to designate these agencies
as troubled.
Multifamily Housing: Issues and Options to Consider in Revising HUD's
Low-Income Housing Preservation Program (GAO/T-RCED-96-29, Oct.
17, 1995)
HUD's program for preserving low-income housing seeks to
maintain the affordable low-income housing that was created
mainly under two federal housing programs during the 1960s and
1970s. Under these programs, when owners received HUD-insured
mortgages with 40-year repayment periods, they entered into
agreements with HUD that imposed affordability restrictions,
such as limits on the income level of tenants and on the rents
that could be charged at the properties. After 20 years,
however, owners had the right to pay off their mortgages in
full without prior HUD approval and terminate the affordability
restrictions. The preservation program has proven to be complex
and costly, prompting recommendations from HUD and others to
change or repeal the program. This testimony focuses on (1) how
the current preservation program works, (2) the status of
preservation-eligible projects, (3) concerns that have been
raised about the program, and (4) options for revising the
program.
INCOME SECURITY ISSUES
Congressional Retirement Issues (GAO/T-GGD-95-165, May 15, 1995)
The retirement benefits provided by the Civil Service
Retirement System for Members of Congress are generally more
generous than those provided for other federal employees. The
major differences are found in the eligibility requirements for
retirement and the formulas used to calculate benefits. The
Member benefit formula applies to congressional staff, but they
are covered by the general employee retirement eligibility
requirements. Law enforcement officers and firefighters may
retire earlier than general employees and are covered by a more
generous benefit formula than are general employees. Under the
Civil Service Retirement System, the provisions for air traffic
controllers fall between those for law enforcement officers and
firefighters and those for general employees. Many of the
advantages afforded to Members of Congress and congressional
staff under the Civil Service Retirement System were continued
under the Federal Employees Retirement System, which covers
workers hired in 1984 and thereafter. But under the Federal
Employee Retirement System, provisions for law enforcement
officers, firefighters, and air traffic controllers are very
similar to provisions for Members.
Disability Insurance: Broader Management Focus Needed to Better Control
Caseload (GAO/T-HEHS-95-164, May 23, 1995)
Rising numbers of applicants for disability benefits have
increased workloads at SSA and led to growing backlogs of
claims. As a result, applicants are waiting longer to find out
if they have been awarded benefits. Applicants wait almost 90
days to learn whether they have been awarded benefits, while
persons who appeal their claims to SSA's administrative law
judges wait more than a year. These long waits can impose
substantial hardship on applicants, particularly those with
limited incomes and no medical insurance. SSA has undertaken
several short-term initiatives to address the backlog problem.
It has also begun a long-term effort to redesign its disability
determination process. GAO shares congressional concerns that
these changes may sacrifice decisional accuracy for faster
processing. SSA is also addressing its workload increases while
dealing with substantial resource constraints. Nonetheless, SSA
needs to focus more attention on terminating benefits for those
who are no longer eligible and encouraging beneficiaries to
return to work. SSA, now an independent agency, also needs to
provide more data and advice to the Congress on matters
affecting disability insurance policy.
Federal Downsizing: The Administration's Management of Workforce
Reductions (GAO/T-GGD-95-108, Mar. 2, 1995)
The Federal Workforce Restructuring Act of 1994 requires
the federal government to eliminate about 270,000 positions
between 1993 and 1999. To accomplish this downsizing without a
reduction-in-force, the act allows federal agencies to offer
buyouts to employees who agree to resign or retire by March 31,
1995. This testimony discusses (1) the administration's
compliance with the act, including which positions are counted
toward full-time-equivalent reductions and from what baseline,
and whether savings from the reductions are being used to pay
for the Violent Crime Control and Law Enforcement Act of 1994;
(2) the targets of workforce downsizing; and (3) how the
workforce reductions are being managed.
Federal Downsizing: The President's Fiscal Year 1996 Budget and Its
Compliance With the Federal Workforce Restructuring Act of 1994
(GAO/T-GGD-95-105, Mar. 30, 1995)
GAO's analysis of the President's fiscal year 1996 budget
shows that government agencies are well on their way to
achieving the downsizing goals mandated by the Federal
Workforce Restructuring Act. Although payroll savings will no
doubt accrue from these reductions, some of the projected
savings may be offset by costs associated with what agencies do
with the work previously done by separated employees. To the
extent that work is shifted to other employees, contracted out,
or transferred to other agencies, downsizing's true savings to
taxpayers may be reduced.
Federal Downsizing: The Status of Agencies' Workforce Reduction Efforts
(GAO/T-GGD-96-124, May 23, 1996)
The downsizing of the federal workforce is ahead of the
schedule set by the Workforce Restructuring Act. At the same
time, the administration has called on agencies to restructure
their workforces by reducing management positions. These jobs
have yet to be reduced to the extent called for by the National
Performance Review. With regard to future workforce reductions,
GAO found that in terms of absolute numbers--and given
historical quit rates--the remaining employment ceilings called
for by the act probably could be achieved governmentwide
through attrition. Nevertheless, some agencies may be forced to
downsize more than others. In such situations, buyouts or
reductions in force (RIF) may be necessary. GAO found that
buyouts offer greater savings than RIFs, except when employees
affected by a RIF do not bump and retreat and are eligible to
retire.
Federal Retirement Issues (GAO/T-GGD-95-111, Mar. 10, 1995)
This testimony focuses on ongoing GAO work on two issues
involving federal employee retirement programs. First, GAO
compares the retirement provisions for Members of Congress and
congressional staff in the Civil Service Retirement System and
the Federal Employees Retirement System with the provisions
applicable to other employees covered by these systems. Second,
GAO analyzes retirement programs in the private sector and
state government.
Federal Retirement System Financing (GAO/T-GGD-95-197, June 28, 1995)
Federal retirement system financing is a complex issue.
This testimony seeks to bring some perspective to the subject
by describing how the government finances its retirement system
and by describing the budget implications of the financing
methods being used and possible changes to these methods. GAO
concentrates on the Civil Service Retirement System and the
Federal Employees Retirement System because they are the
largest retirement programs for federal workers.
Financial Management: Interior's Efforts to Reconcile Indian Trust Fund
Accounts and Implement Management Improvements (GAO/T-AIMD-96-
104, June 11, 1996)
Although the Department of the Interior has brought to a
close its project to reconcile the Indian trust funds, tribal
accounts were never fully reconciled because of missing records
and the lack of an audit trail in Interior's automated
accounting systems. In addition, the 1996 report package that
Interior provided to each tribe on the reconciliation results
did not explain or describe the many changes in reconciliation
scope and methodologies or the procedures that had been planned
but were not implemented. As a result, the limitations of the
reconciliation were not evident. Also, because of cost
considerations and the potential for missing records,
individual Indian trust fund accounts were not included in the
reconciliation project. Indian tribes have raised concerns
about the scope and the results of the reconciliation process.
The vast majority of tribes have yet to decide whether to
accept or dispute their account balances. If Interior cannot
resolve the tribes' concerns, a legislated settlement process
could be used to settle disputes over account balances.
Interior has taken steps during the past 3 years to correct
these long-standing problems with the accuracy of the Indian
trust fund accounts, but these efforts will take years to
complete. Moreover, the existing trust fund management and
accounting systems cannot ensure accurate trust fund accounting
and asset management. The appointment of a Special Trustee for
American Indians was an important step in establishing high-
level leadership at Interior for Indian trust fund management.
Means-Tested Programs: An Overview, Problems, and Issues (GAO/T-HEHS-
95-76, Feb. 7, 1995)
Nearly 80 means-tested programs have been created over the
years for low-income people. In fiscal year 1992, the federal
government spent about $208 billion on these programs to meet
the needs of poor Americans of all ages. The many means-tested
programs are costly and difficult to administer. On the one
hand, the programs sometimes overlap one another; on the other
hand, they are often so narrowly focused that service gaps
hinder clients. GAO notes that although advanced computer
technology is essential to the programs operating efficiently,
it is not being effectively developed or used. Due to their
size and complexity, many of these programs are vulnerable to
waste, fraud, and abuse. Moreover, the welfare system is often
difficult for clients to use effectively. Finally,
administrators have not articulated clear goals and objectives
for some programs and have not collected data on how well the
programs are working.
Overview of Federal Retirement Programs (GAO/T-GGD-95-172, May 22,
1995)
This testimony describes how the federal retirement systems
work, the benefits they provide, and how they compare with
private sector programs. GAO concentrates on the Civil Service
Retirement System and the Federal Employees Retirement System
because they are the largest retirement systems for federal
civilian personnel. GAO describes the history of the two
retirement systems and discusses four issues that are often
raised in connection with federal retirement: (1) retirement
eligibility provisions, (2) benefit formulas, (3) COLAs, and
(4) system financing.
Social Security Disability: Management Action and Program Redesign
Needed to Address Long-Standing Problems (GAO/T-HEHS-95-233,
Aug. 3, 1995)
SSA has serious problems managing its Disability Insurance
(DI) and Supplemental Security Income (SSI) programs. First,
the lengthy and complicated decisionmaking process results in
untimely decisions, especially for those who appeal, and shows
troubling signs of inconsistency. Second, SSA has a poor record
of reviewing beneficiaries to determine whether they remain
eligible for benefits and an even worse record of providing
rehabilitation to help move people off the disability rolls and
into employment. This reinforces the public perceptions that
SSA pays disability benefits to persons who are not entitled to
them. Third, SSA needs to make better decisions about work
capacity to restore public confidence and to better serve
beneficiaries. Although these problems are serious, solutions
do exist. GAO believes that relatively quick action could be
taken to reduce inconsistent decisionmaking, step up review of
beneficiaries who may be able to return to work, and improve
rehabilitation outcomes. In some cases, SSA has the authority
to take action, in others, decisionmakers may need to rethink
the goals and objectives of the disability programs.
Social Security: Federal Disability Programs Face Major Issues (GAO/T-
HEHS-95-97, Mar. 2, 1995)
This testimony discusses the reasons for the tremendous
growth in federal disability programs during the past 10 years,
including program factors and social changes. GAO also comments
on the impact of fraud and abuse on this growth and its effect
on program integrity. In addition, GAO notes legislative
reforms included in the Social Security Independence Act last
year that tried to improve program integrity. Finally, GAO
discusses weaknesses in SSA's efforts to return DI and SSI
beneficiaries to work.
Social Security: Disability Programs Lag in Promoting Return to Work
(GAO/T-HEHS-96-147, June 5, 1996)
On average, SSA pays over $1 billion in cash payments to DI
and SSI beneficiaries each week. Although these payments
provide a measure of income security, they do little to enhance
the work capacities and promote the economic independence of
recipients. Societal attitudes have shifted, and current law,
such as the Americans With Disabilities Act, promotes economic
self-sufficiency among the disabled. A growing number of
private companies are exploring ways to return people with
disabilities to the workforce. Moreover, medical advances and
new technologies provide greater opportunities for people with
disabilities to work. This testimony discusses how the
structure of the DI and SSI programs impedes recipients' return
to work and how strategies used in other disability systems
could help restructure the programs to encourage recipients to
return to work.
Social Security Administration: Effective Leadership Needed to Meet
Daunting Challenges (GAO/T-OCG-96-7, July 25, 1996)
With a staff of 64,000, SSA runs the largest federal
program--Social Security--as well as the largest cash welfare
program--SSI. The agency's expenditures totaled $363 billion in
fiscal year 1995, almost one-fourth of the $1.5 trillion
federal budget. This testimony discussed the difficult
challenges facing SSA in the coming decades: taking part in the
debate over future financing of Social Security; encouraging
disability recipients to return to work; reducing fraud and
abuse; and managing workforce and technology investments so
that SSA can meet the needs of America's retired, disabled, and
poor.
SSA Benefit Statements: Statements Are Well Received by the Public But
Difficult to Comprehend (GAO/T-HEHS-96-210, Sept. 12, 1996)
The personal earnings and benefit estimate is a six-page
statement produced by SSA that supplies information about a
worker's yearly earnings on record at SSA; eligibility for
social security retirement, survivor, and disability benefits;
and estimates of these benefits. SSA has tried to improve the
statement, and the public has found it to be helpful for
retirement planning. However, the statement falls short in
clearly communicating the complex information that readers need
to understand concerning SSA's programs and benefits. For
example, the document's design and organization make it
difficult for readers to locate important information. Readers
are also confused by several important explanations, such as
who in their family is also eligible for benefits and how much
these family members might receive. SSA is considering
redesigning the statement, but only if this effort reduces
printing costs. This approach overlooks hidden costs, such as
(1) inquiries from people who do not understand the statement
and (2) the possibility that a poorly designed statement can
undermine public confidence.
SSA Disability Reengineering: Project Magnitude and Complexity Impede
Implementation (GAO/T-HEHS-96-211, Sept. 12, 1996)
Given the high cost and lengthy processing times of SSA's
current disability claims process, the agency needs to continue
its redesign efforts. SSA's redesign plan is proving to be
overly ambitious, however. Some initiatives are also becoming
more complex as SSA expands the work required to complete them.
The agency's approach is likely to limit the chances for the
project's success and has delayed implementation: testing
milestones have slipped and support for the redesign effort has
waned. In addition, the increasing length of the overall
project and specific initiatives heighten the risk of
disruption from turnover among key executives. GAO believes
that as SSA proceeds with its redesign project it should focus
on key initiatives, starting first with those that will quickly
and significantly reduce claims processing time and
administrative costs.
Supplemental Security Income: Noncitizens Have Been a Major Source of
Caseload Growth (GAO/T-HEHS-96-88, Feb. 6, 1996)
Noncitizens are among the fastest growing groups receiving
benefits from the SSI program, which provides means-tested
benefits to eligible blind, elderly, or disabled persons.
Noncitizens represent nearly one-third of aged SSI recipients
and 5.5 percent of disabled recipients. About two-thirds of
noncitizen SSI recipients live in three states--California, New
York, and Florida. On the whole, noncitizens are more likely to
receive SSI than citizens, but this may be true primarily for
refugees and asylum seekers. Adult children of aged immigrants
and others who say they are willing to financially support them
sometimes do not. Eventually, many of these aged immigrants
receive SSI. Also, some translators help noncitizens to
fraudulently obtain SSI disability benefits.
Supplemental Security Income: Noncitizen Caseload Continues to Grow
(GAO/T-HEHS-96-149, May 23, 1996)
(This testimony is similar to our February 6, 1996,
testimony summarized above. Since the data used was updated
from that used in the February testimony, the May testimony is
summarized below.)
Noncitizens are one of the fastest growing groups of
recipients of SSI benefits. They represent nearly one-third of
aged SSI recipients and about 6 percent of disabled recipients.
Although the growth rate for noncitizen caseloads has slowed,
it is still higher than that for citizens, and the percentage
of noncitizens relative to other SSI recipients continues to
rise. About two-thirds of noncitizen recipients--roughly
520,000--live in three states: California, New York, and
Florida. On the whole, noncitizens are more likely to receive
SSI than are citizens, but this may be primarily true for
refugees and asylum seekers. Adult children of aged immigrants
and others who say they are willing to financially support them
sometimes do not. Eventually, some of these older immigrants
receive SSI. Also, some translators have helped noncitizens to
fraudulently obtain SSI disability benefits
Supplemental Security Income: Recent Growth in the Rolls Raises
Fundamental Program Concerns (GAO/T-HEHS-95-67, Jan. 27, 1995)
This testimony discusses the growth of SSI rolls and
changes in the characteristics of SSI recipients. Last year,
SSA paid nearly $22 billion in federal benefit payments to
about 6.3 million aged, blind, and disabled SSI recipients.
Since 1986, payments have risen by $13.5 billion, more than
doubling. Benefits for the disabled accounted for nearly 100
percent of this increase. Since 1986, the number of disabled
SSI recipients under age 65 has increased an average of more
than 8 percent annually, adding nearly 2 million younger
recipients to the rolls, while the number of aged and blind
recipients has remained level. The trend toward younger
beneficiaries, coupled with low exit rates from the program,
means that costs will continue to burgeon in the near term.
Without a slowing in the growth of this younger population, SSI
will become even more costly. Since 1991, three groups--
disabled children, legal immigrants, and adults with mental
problems--have accounted for nearly 90 percent of the SSI
caseload growth. Of the 2 million mentally disabled adults,
roughly 100,000 are disabled mainly by drug addiction or
alcoholism. The dramatic increases pose fundamental questions
about eligibility standards, accountability, and program
effectiveness.
Supplemental Security Income: Recipient Population Has Changed As
Caseloads Have Burgeoned (GAO/T-HEHS-95-120, Mar. 27, 1995)
The SSI program provides means-tested income support
payments to eligible aged, blind, or disabled persons. Last
year, more than 6 million SSI recipients received nearly $22
billion in federal benefits and more than $3 billion in state
benefits. SSI is one of the fastest growing programs, with
program costs soaring 20 percent annually during the past 4
years. This testimony focuses on factors contributing to
caseload growth, characteristics of SSI recipients, and ways to
improve SSI.
VETERANS' AND DOD ISSUES
Defense Health Care: TRICARE Progressing, but Some Cost and Performance
Issues Remain (GAO/T-HEHS-96-100, Mar. 7, 1996)
DOD's nationwide managed health care program--TRICARE--
represents a sweeping reform of the $15 billion per year
military health care system. TRICARE seeks to improve access to
care and ensure high-quality, consistent health care benefits
for the 1.7 million active-duty service members and some 6.6
million nonactive-duty beneficiaries. It also seeks to preserve
choice for nonactive-duty beneficiaries by allowing them to
choose whether to enroll in TRICARE Prime, which resembles an
HMO; use a preferred provider organization; or use civilian
health care providers under a fee-for-service arrangement.
Despite initial beneficiary confusion caused by education and
marketing problems, early implementation of the program is
progressing consistent with congressional and DOD goals.
Measures may be necessary, however, such as gathering cost and
access-to-care data, to help the Congress and DOD better assess
the program's future success. In addition, retirees, who make
up half of those eligible for military health care, remain
concerned about TRICARE's effect on their access to medical
services.
VA Health Care: Approaches for Developing Budget-Neutral Eligibility
Reform (GAO/T-HEHS-96-107, Mar. 20, 1996)
Reforming eligibility for health care benefits offered by
VA would pose a major challenge even with unlimited resources.
But with the Congress and VA facing mounting pressure to limit
VA health care spending as part of governmentwide efforts to
reduce the deficit, this challenge has become even greater.
This testimony discusses (1) the problems that VA's current
eligibility and contracting provisions create for veterans and
providers, (2) the relationship between inappropriate
admissions to VA hospitals and VA eligibility provisions, (3)
proposals to reform VA eligibility and contracting rules and
their potential impact on the deficit, and (4) options for
achieving budget-neutral eligibility reform.
VA Health Care: Challenges and Options for the Future (GAO/T-HEHS-95-
147, May 9, 1995)
VA lags far behind the private sector in improving the
efficiency of its hospitals. During the past decade, GAO has
highlighted a series of management problems limiting VA's
ability to (1) improve the efficiency and the effectiveness of
its hospitals and (2) shift more of its inpatient care to less
costly ambulatory settings. Although VA plans a major
reorganization and other initiatives to improve its management
capabilities, GAO remains concerned that some of the actions
may not go far enough. Even if it improves the efficiency of
its hospitals, VA is at a crossroads in the evolution of its
health care system. The average daily workload in its hospitals
dropped about 56 percent during the past 25 years, and further
decreases are likely. At the same time, however, demand for
outpatient care, nursing home care, and some specialized
services is expanding, taxing VA's ability to meet veterans'
needs. GAO concludes that a complete reevaluation of the VA
health care system is needed. Absent such an effort, use of VA
hospitals will likely continue to decline to a point at which
VA's ability to provide quality care and support its secondary
missions will be jeopardized.
VA Health Care: Efforts to Improve Veterans' Access to Primary Care
Services (GAO/T-HEHS-96-134, Apr. 24, 1996)
VA runs one of the nation's largest health care systems,
including 173 hospitals and 220 clinics. Last year, VA spent
about $16 million serving 2.6 million veterans. This testimony
focuses on VA's efforts to increase veterans' access to health
care. GAO discusses legal, financial, and equity-of-access
issues facing VA managers as they try to establish new access
points--a VA clinic or a VA-funded or VA-reimbursed private
clinic, group practice, or individual practitioner that is
geographically separate from the parent facility. Access points
are intended to provide primary care to all veterans and refer
those needing specialized services or inpatient stays to VA
hospitals.
VA Health Care: Issues Affecting Eligibility Reform (GAO/T-HEHS-95-213,
July 19, 1995)
In this testimony GAO summarizes the results of a number of
reviews that have detailed problems in administering VA's
outpatient eligibility provisions; compared VA benefits and
eligibility to those of other public and private health
benefits programs; and assessed VA's role in a changing health
care marketplace. In summary, veterans' eligibility for VA
health care has evolved over time in terms of both the types of
veterans eligible for care and the services they are eligible
to receive. VA has gone from a system primarily covering
hospital care for veterans with war-related injuries to a
system covering a wide array of hospital and other medical
services for both wartime and peacetime veterans and veterans
both with and without service-connected disabilities. VA now
has multiple categories of veterans eligibility based on a
number of factors.
VA Health Care: Opportunities to Increase Efficiency and Reduce
Resource Needs (GAO/T-HEHS-96-99, Mar. 8, 1996)
With a fiscal year 1995 appropriation of $16.2 billion, the
VA health care system faces mounting pressure to contain or
reduce spending as part of governmentwide efforts to reach a
balanced budget. This testimony addresses (1) VA's forecasts of
future resource needs, (2) opportunities to run the VA system
more efficiently, (3) differences between VA and the private
sector in terms of initiatives to become more efficient, and
(4) recent VA efforts to reorganize its health care system and
create incentives to operate more efficiently.
VA Health Care: Opportunities to Reduce Outpatient Pharmacy Costs (GAO/
T-HEHS-96-162, June 11, 1996)
VA allows its doctors to prescribe over-the-counter
products because concerns have been raised that some veterans
may lack the money to buy needed items. VA requires
prescriptions as a way to control veterans' access to over-the-
counter products in VA pharmacies. In fiscal year 1995, for
example, VA pharmacies dispensed analgesics, such as aspirin
and acetaminophen, nearly 3 million times. The benefits package
that most VA facilities offer for over-the-counter products is
more generous than that available from other health plans. VA
also provides other features, such as free over-the-counter
product mail service and deferred credit for copayments owed,
that are not common in other plans. GAO makes several
suggestions for reducing the amount of money VA spends to
dispense over-the-counter products. First, VA staff could more
strictly adhere to statutory eligibility rules. Second, VA
could more efficiently dispense over-the-counter products and
collect copayments. Third, VA facilities could further reduce
the number of over-the-counter products available to veterans
on an outpatient basis. Finally, the Congress could expand
copayment requirements.
Veterans' Benefits Modernization: Management and Technical Weaknesses
Must Be Overcome If Modernization Is to Succeed (GAO/T-AIMD-96-
103, June 19, 1996)
If the Veterans Benefits Administration (VBA) is to reduce
operating costs and improve critical service to nearly 27
million veterans and their dependents, it needs to streamline
its business processes and take more advantage of information
technology. However, VBA is experiencing many of the classic
management and technical problems that have prevented federal
agencies from reaping the benefits of substantial investment in
information technology. This testimony discusses the steps VBA
needs to take in the following three areas to improve its
chances for success: (1) creating a credible business strategy
and supporting an information resources management plan; (2)
developing a better investment strategy for choosing and
managing its portfolio of information technology projects in a
more disciplined, businesslike way; and (3) strengthening its
technical ability to develop software applications that are
critical to its efforts to control costs and improve service to
veterans.
Veterans' Health Care: Challenges for the Future (GAO/T-HEHS-96-172,
June 27, 1996)
With a budget of $16.6 billion and a network of hundreds of
hospitals, outpatient clinics, and nursing homes, VA's health
care system provides medical services to more than 26 million
veterans. VA has sought to fundamentally change the way in
which it runs its health care delivery and financing systems.
It has also sought authority to significantly expand
eligibility for health care benefits and to both buy health
care services from and sell them to the private sector. This
testimony discusses (1) changes in the veterans population and
the demand for VA health care services; (2) how well the
existing VA system, and other public and private health
benefits programs, meet the health care needs of veterans; (3)
steps that could be taken, using existing resources and
legislative authority, to address veterans' unmet health care
needs and increase equity of access; (4) how other countries
have addressed the needs of an aging and declining veteran
population; and (5) approaches for preserving VA's direct
delivery system, alternatives to preserving the direct delivery
system, and combinations of both.
ITEM 22--LEGAL SERVICES CORPORATION
----------
Service to the Aging
The Legal Services Corporation (LSC) was created by
Congress in 1974 to provide access to civil legal aid to low-
income Americans. The Corporation receives an annual
appropriation from Congress. In 1996, LSC funded some 275 local
legal aid programs across the country, serving every county in
the nation.
Legal services clients are as diverse as our nation,
encompassing all races and ethnic groups and ages. The problems
that bring people to local legal services offices arise out of
everyday life. Usually they relate to matters of family law,
housing, employment, government benefits, or consumer
disagreements. Frequently they represent matters of crisis for
clients and their families. The possible consequences may be as
serious as the loss of a family's only source of income,
homelessness, or the breakup of a family.
In 1996, LSC-funded programs served 152,420 Americans over
the age of 60. Older Americans represented 11 percent of the
clients served by legal services programs. Because of their
special health, income, and social needs, older people often
require legal assistance, especially in coping with the
government-administered benefits on which many depend for
income and health care.
Some local legal services programs have special elderly law
units, but every program provides services to the elderly. Most
LSC programs are listed in the blue or yellow pages of the
phone book, usually listed under ``Legal Aid'' or ``Legal
Services.'' You can also get a referral by calling LSC at (202)
336-8800; going to the LSC web site (www.lsc.gov); or writing
to Public Affairs, LSC, 750 First St., NE, Washington, DC
20002.
ITEM 23--NATIONAL ENDOWMENT FOR THE ARTS
----------
Summary of Activities Relating to Older Americans Fiscal Year 1997
introduction
The National Endowment for the Arts holds as its guiding
principle that the authentic experience of the arts should be
available to the broadest public, including people of all ages.
Through its grants programming and technical assistance, the
Arts Endowment works to ensure the continued involvement of
older adults in the arts as artists, teachers, mentors,
volunteers, students, patrons and consumers. The wisdom, energy
and creative potential that older Americans bring to the arts
are part of our cultural heritage.
office of accessability
Located in the Endowment's Partnership, Planning and
Stabilization Division, the AccessAbility Office is the
advocacy and technical assistance arm of the Arts Endowment
that works to make the arts fully accessible to older adults,
individuals with disabilities and people living in
institutions. Through a wide variety of efforts, the
Coordinator of this one-person office develops partnerships
with grantees, private groups and other Federal agencies to
better educate and assist access to the arts for the targeted
populations. The focus is inclusion, opening up existing
programs, and outreach to citizens who would not otherwise have
opportunities to be involved in the arts.
In addition to administering projects featured in this
report, the Coordinator organizes and conducts panels and
workshops for the arts community and organizations representing
older or disabled people to better educate them concerning the
value of making the arts accessible. During this reporting
period, the Coordinator organized seminars for the National
Council on Aging, the American Association of Museums, the
Cleveland Arts Festival, Build Boston Conference, Dance
Umbrella Festival, and the Southeastern Museum Conference.
Further, she traveled to Natchez, Mississippi to assist
Signature Works, the largest employer of people who are blind
in the country, to assist them in developing ceramic and
sculpture programs for its employees with the future
possibility of marketing their art as one of its products.
national database on the arts and older americans
As a result of the Arts Endowment's work with the 1995
White House Conference on Aging, this aging supported the
creation of the first National Database on the Arts and Older
Americans that was undertaken by the National Council on Aging
(NCoA). This unique database should open the way to better
communication between networks of arts organizations and aging
groups to assist quality arts programming for, by and with
older Americans. The database includes 536 agencies and
individuals that are administering a wide variety of arts
programming involving older adults. Of these, 328 are arts
groups and the remainder consist of aging or educational
agencies. The listings include program profiles and contact
information. NCoA is presently working to post the database
through its website.
sense and sensitivity: a regional symposium on the arts and
accessibility
The Arts Endowment worked with Arts Midwest in Minnesota, a
regional arts group that encompasses a nine state area, to
convene a symposium that addressed access to the arts for older
and disabled people. Convened in Milwaukee, Wisconsin on
September 15-17, 1997, approximately 180 artists and arts
administrators participated in the meeting to better educate
themselves on making their own activities more available to
older and disabled individuals; and educating their
constituents about access issues.
Over 35 acknowledged leaders in the arts and accessibility
communities led workshops that focused on: design; performing
and visual arts; outreach to people in institutions including
nursing homes; and technology that is making the arts more
accessible such as audio description and assistive listening
systems.
For example, Julie Bailey from the Iowa Arts Council
presented their highly successful program, I Card, which
involves 85 local arts councils and community agencies that
work together to provide free or discounted admission for low
income individuals and families to attend arts events
throughout the state. Further, Patricia O'Mally from the
Chicago Department of Aging discussed her agency's Renaissance
Court, an arts program in downtown Chicago that includes a
first rate gallery which showcases the work of artists over age
55.
This symposium represents the fourth in a series of
regional access meetings over the past seven years sponsored by
the National Endowment for the Arts.
careers in the arts forum
The Arts Endowment developed a cooperative agreement with
the John F. Kennedy Center for the Performing Arts to convene a
national forum on ``Careers in the Arts'' that will take place
at the Kennedy Center on June 14-16, 1998. This first-ever
forum will bring together 230 artists, art technicians, art
administrators, rehabilitation professionals and
representatives of government agencies to focus on employment
and education issues relating to individuals with disabilities
in a wide variety of arts careers.
A 17-member planning committee, composed of select
leadership from the fields of the arts, rehabilitation and
education, met at the Kennedy Center on September 21-23, 1997
to develop a vision and shape for the forum, as well as,
provide invaluable guidance on its objectives and program.
This effort grew out of a series of interagency agreements
that the Arts Endowment initiated with the U.S. Department of
Education and the U.S. Department of Health and Human Services.
The Federal agencies are joining with the Endowment in
supporting the Forum to address their common concerns: the need
for increased educational and career opportunities in the arts
for people of all ages with disabilities; identifying obstacles
and strategies to overcome them; and developing recommendations
to advance arts careers for people with disabilities.
universal design
The first collection of 37 Universal Design Exemplars, that
represent examples of design excellence in the fields of
architecture, graphic design, industrial design, interior
design and landscape architecture, was supported by the Arts
Endowment as highlighted in last year's report to the Special
Committee. Universal design goes beyond codes and standards to
create excellent design is usable by everyone throughout their
lifespan. The collection is organized in a slide presentation
with descriptive text, and is intended to encourage and assist
the understanding and practice of this important design
concept.
On April 21, 1997, the AccessAbility Office worked with
nine Endowment interns to organize and present the collection
to staff from eight Federal agencies, including the Department
of Justice and the Government Services Administration. Audience
members found it to be comprehensive and said that they gained
increased understanding concerning universal design and its
importance to their respective fields.
The Arts Endowment plans to support a second collection in
1998 that will be disseminated to designers, city planners and
others on CD Rom.
ARTS ENDOWMENT FUNDING
Endowment supported programs are aimed at benefitting
Americans of all ages. In addition, some projects specifically
address older adults. For example:
Dance
The Boston Dance Umbrella of Cambridge, Massachusetts
received funding to support the 1997 International Festival of
Wheelchair Dance, which took place June 2-14, 1997 in Boston.
This unprecedented gathering featured performances, workshops,
lecture/demonstrations, seminars, a conference, and a full
program of education and community outreach activities. The
Festival included both disabled and non-disabled artists who
are developing this relatively new art form. Dance Umbrella
collaborated with Very Special Arts Massachusetts and Axis
Dance Troupe from Oakland, California to plan, implement and
evaluate this highly successful project.
Professional Flair Inc. of Cleveland, Ohio received funds
to support the expansion of its dance troupe, Cleveland Ballet
Dancing Wheels, to accommodate the increased demand for its
lecture demonstrations. This pioneering dance company, that
showcases dancers with disabilities, will add a second
performing troupe of professional dancers with and without
disabilities to present programs geared to a number of
different audiences, such as nursing homes, schools, and
colleges.
Folk arts
Fellowships
Seven National Heritage fellowships were awarded to artists
fifty-five years and older in recognition of their outstanding
contributions to the traditional arts. These artists include an
acadina spinner & weaver, a North American sarod player & raga
composer, two bluegrass musicians, an African American quilt
maker, as well as the following:
Charles Brown is a West coast Blues pianist and singer
originally from Texas City, Texas. His sophisticated approach
blends classical music technique with the blues and jazz. Brown
was one of ``The Three Blazers,'' whose sound epitomized the
relaxed West Coast piano trio style and integrated a blues
quality to the music. He toured with artists such as Fats
Domino, Bill Doggett, Roy Brown, and Amos Milburn, and was
inducted into the Blues Foundation's Blues Hall of Fame in
1977.
Wenyi Hua, a Chinese Kunqu opera singer, was born in
Shanghai, China and lives in Arcadia, CA. Her gesticulation,
diction, and beautiful voice earned her many honors. In 1978,
she joined the Shanghai Kun Opera Company and later became its
director in 1985. In 1986, she received China's highest
artistic honor, the Plum Blossom Award for her performance in
the play ``Yun Zan Ji'' (The Jade Hairpin). Chinese opera
scholar Dr. Pertel Jain describes her artistry, ``Wenyi Hua is
a rare theater performer who transcends the boundaries of the
form, reaching a profound understanding of dramatic character
which is almost spiritual in nature.''
Francis Whitaker is a Blacksmith/Ornamental Ironworker from
Wodurn, Massachusetts. At sixteen, he dropped out of high
school to become an apprentice with a premier ornamental
blacksmith, Samuel Yellin, in Philadelphia. Whitaker said,:
``The first time I shaped a piece of hot iron, I was hooked.
There's magic to it.'' After working for a general contractor
for seven years, he opened his own shop in 1933, during the
depths of the Depression. He spent 20 years teaching across the
United States and founded the Francis Whitaker Blacksmith
School at the Rocky Mountain School. Whitaker received the 1995
Colorado Governor's Award for Excellence in Arts and an
Honorary Doctorate in Humane Letters from the University of
Colorado.
The Los Reyes de Albuquerque of New Mexico received funding
to support a year-long series of performances of traditional
New Mexican Hispanic music for children, older people, homeless
individuals, and institutionalized people. This non-profit
organization is the result of the efforts of the folk group of
Los Reyes de Albuquerque which was founded some thirty-three
years ago. The purpose of the Los Reyes de Albuquerque
Foundation is to preserve, promote and perpetuate the
traditional Hispanic music and songs of northern New Mexico and
southern Colorado.
Media arts
The Film Arts Foundation of San Francisco, California,
received funding to support the production of a documentary
film by Allie Light and Irving Saraf about the work of seven
imaginative people with physical disabilities.
``Dreamwalkers'', the film's working title, explores each
person's concept of motion through thought, fantasy, and
dreams. Combining cinema verite footage of the subjects with
dramatizations and visualizations of their thoughts, which have
been shared through interviews, the film portrays their lives.
Museum
The Wichita Art Museum of Wichita, Kansas, received funding
to support the expanded use of its Art Resource Center, a new
museum facility that serves as a lending library of audio-
visual materials about the visual arts for teachers, parents
and community groups. The Center opened in 1995 and acquired
over 13,000 constituents in less than twelve weeks. This
Resource Center is the only one of its kind in the state that
reaches out to include parents, day care providers, recreation
leaders, senior center participants and other community groups
in its activities.
Theater
The Stagebridge Theater of Oakland, California received
funding to support its intergenerational arts and literacy
project, Storybridge, where low-income older adults interact
with at-risk children through a program of story telling in the
schools and various community venues. Its goal is to develop
literacy skills for young and old, particularly at-risk
elementary age children and low-income, minority elders. All
facets of their programs include curriculum guides and
materials. Storybridge presents three inventive programs: The
first is entitled, ``Grandparents Tales,'' which features a
play performance about grandparents from different cultures and
is performed by a multicultural cast of older actors. The
second program, ``Senior Storytellers in the Schools,''
recruits and trains older adults to be storytellers in Oakland,
Berkeley and San Francisco schools. The third is a storytelling
assembly in which Stagebridge tours its experienced ``band of
elder storytellers'' to local schools where students in small
groups hear multiple pairs of storytellers.
Visual arts
The Clay Studio of Philadelphia, Pennsylvania received
funding to support the circulation of the ``Claymobile,'' a
ceramics class in a van that travels to inner city and low
income Philadelphia communities. The van goes to specific
locations such as cultural centers, programs for older adults,
after-school programs, homeless shelters, summer camps and
schools. The Claymobile contains a complete stash of equipment
and materials necessary to teach a class and transport the
finished pieces back to the Clay Studio for firing. This art
program broadens access to quality arts classes and increases
the participation of many populations who are undeserved in the
arts.
The Little City Foundation of Palatine, Illinois received
funding to support a two-phase exhibition of artwork created by
people with developmental disabilities in the Chicago
metropolitan area. The exhibitions include drawings, paintings,
sculptures, prints, and performance works. The purpose of this
effort its to bring more public attention to the art of
individuals with developmental disabilities. This both
increases the market for their work and attracts additional
people with disabilities to the Foundation's programs. The
project also intends to encourage purposeful discussion about
the disability culture and the use of art as an important means
of cultural self-expression.
The Grass Roots Arts and Community Efforts (GRACE) of West
Glover, Vermont received funding to promote a ``Twenty Years of
GRACE--An Inside View,'' a collection of work and biographies
of self-taught artists in northern rural Vermont, that will be
published in May 1998. This 30-page book will celebrate the
work of GRACE's participants as well as interpret its history,
philosophy and methods of working for a broad audience. GRACE
primarily works with artists who require long-term care. In
nursing homes, town halls, day-care centers, and hospitals,
participants are encouraged to work independently, exploring
their own creative capabilities.
ITEM 24--NATIONAL ENDOWMENT FOR THE HUMANITIES
National Endowment for the Humanities Report on Activities Affecting
Older Americans in Fiscal Years 1995 and 1996
lifelong learning
Grants awarded by the National Endowment for the Humanities
support teaching, scholarship, and programs for the general
public in history, literature, philosophy, and other
disciplines of the humanities. The purpose that NEH exists to
foster--the transmission of knowledge to succeeding
generations, the creation of new knowledge, and the diffusion
of cultural opportunity--are really manifestations of the same
thing; they express our national commitment to, in the words of
the Endowment's authorizing legislation, ``progress and
scholarship in the humanities.'' In the American democratic
context, that commitment has meant, among other things,
ensuring a continuum of possibility for lifelong learning for
everyone, of whatever age.
Guaranteeing the availability of lifelong learning
opportunities for older Americans in particular has never been
a greater national priority than it is now. According to
projections of the U.S. Census Bureau, the percentage of the
population that is 65 or older, currently 12.5 percent, will
rise to 18.5 percent by 2025. Living longer, older Americans
are spending more years in retirement and enjoying better
health as they do. Not only are older Americans more vigorous,
but they are also better educated than ever before; 65 percent
of Americans 65 or older have at least a high school diploma,
14 percent have completed four years of college. Of course, the
approaching retirement of the Baby Boom generation will only
intensify these trends.
Active engagement with learning can make retirement more
productive and fulfilling, stimulating continued intellectual
growth and interaction with others. But, learning is the task
of a lifetime, not just of the retirement years. In a special
paper prepared for the President's Committee on the Arts and
the Humanities, Ronald J. Manheimer, director of the North
Carolina Center for Creative Retirement at the University of
North Carolina, Ashville, comments as follows:
Most of the research findings in the field of
gerontology support the ``continuity theory of aging,''
that people not only remain pretty much the same, in
terms of taste, interests and choice of activities from
earlier in adulthood, they become even more who they
were--preferences, like personality traits,
intensifying.
School children whose earliest experience of literature
will be more memorable because a favorite English teacher has
attended a substantive summer study program; undergraduates
whose understanding of history is grounded in the most current
scholarship because those who teach that subject in America's
colleges and universities have access to research fellowships
and other opportunities for professional growth; and working
adults who can find cultural enrichment in libraries and
museums or on television in the communities where they live--
these are the ultimate beneficiaries of NEH grant programs that
help sustain a continuum of lifelong learning opportunities for
everyone. The benefits that Americans derive from these
experiences will accrue throughout a lifetime, and not least
during the years of retirement.
library programs
During fiscal years 1995 and 1996, more than 40,000 NEH-
supported reading and discussion programs took place in more
than 800 libraries and other community-based institutions
nationwide. These activities are open to the general public,
but the scholars and other specialists who direct them report
especially strong participation by older Americans.
Some reading and discussion programs are designed
specifically for seniors. For example, in FY 1995 a grant of
$70,000 enabled the National Council on the Aging to conduct
reading and discussion programs in senior centers, nursing
homes libraries, and veterans hospitals throughout the country.
The project brought together scholars, veterans, factors and
farm workers, teachers, and high school and college students to
discuss ``Remember World War II.'' An anthology and discussion
guide, developed with grant funds, provided the thematic and
chronological focus for each discussion group, and was
augmented by activities such as listening to tapes of radio
broadcasts during the war. In FY 1996, the National Council on
the Aging received $50,000 to conduct programs that encourage
seniors to read and discuss literary autobiographies by authors
of their own generation. Held at libraries and senior centers
in six states and employing instructional materials developed
under a previous NEH grant, the programs focused on
autobiographical works by Richard Wright, Philip Roth, Maxine
Hong Kingston, and Eudora Welty.
Most NEH-supported reading and discussion programs are
geared to intergenerational audiences, but all are well suited
to the needs of older Americans, based as they are on locally
available resources and activities that are intellectually
stimulating without being physically demanding. Many of these
library-based programs reach urban and rural communities that
have few other sources of cultural enrichment. In FY 1996, the
American Library Association received $400,000 to conduct a
series of library-sponsored, radio call-in programs on
Northwest and Southwest regional writing. Developed in
coordination with radio stations in Albuquerque and Missoula,
the programs were based on regionally significant works by such
writers as Mark Twain, Rudolfo Anaya, Denise Chavez, Frank
Waters, Lislie Silko, and James Welsh. More than 50 libraries
in nine states distributed books and other educational
materials toparticipating readers, who during the regular
program broadcasts conducted live, on-air discussions with studio-based
scholars via an 800 number.
museum exhibitions
Museum attendance is now one of the most popular
recreational activities in the United States. In New York,
museums annually generate considerably larger audience figures
than do all of the city's professional sports teams combined.
That older Americans should be a part of this is not
surprising; today's seniors are more active and better educated
than ever before. According to a survey commissioned by the
National Endowment for the Arts, 16 percent of adults 65 or
older visited an art museum at least once during a 12-month
period (1992), and 20 percent of the immediate post-retirement
cohort aged 65 to 74 did so. Impressive as these figures are,
they do not take account of additional numbers of older
Americans who may have visited historical and other kinds of
museums.
At any time during FY 1995 and FY 1996, between 100 and 150
different, NEH-funded museum exhibitions could be seen at over
400 locations throughout the United States. Exhibitions
supported by the Endowment are ideally suited to the needs of
retirees living on a fixed income; museums agree as a condition
of their NEH grant to set aside at least several admission-free
hours each week.
One of these exhibitions available to seniors free of
charge was Splendors of Imperial China, which attracted 427,000
visitors at its Metropolitan Museum of Art venue in New York,
making it the world's biggest museum attraction in 1996.
Incorporating approximately 350 objects from among the finest
and most famous artworks in the Asian tradition--including
paintings and calligraphy, and works in jade, bronze, and
lacquer, many of them leaving China for the first time--the
show provided a visually stunning and richly interpreted
perspective on Chinese history and culture from the Neolithic
period to the 18th century. After leaving New York, the show
traveled to Washington, DC, Chicago, and San Francisco. In St.
Louis, Meet Me at the Fair: Memory, History, and the 1904
World's Fair Exhibition, supported with a $300,000 grant to the
Missouri Historical Society, employed the family mementos and
taped reminiscences of Fair participants, along with
photographs, artifacts, and documents to examine the impact of
this defining event on St. Louis' civic identity. After Louis
Armstrong: A Cultural Legacy was shown during 1995 at the
Queens Museum of Art in New York, a smaller version of the
exhibition, also developed with NEH support and with a
Smithsonian SITES grant, traveled during 1996 to seven other
cities: Dallas; Chicago; Charleston; New Orleans; Rochester,
New York; Savannah; and Washington, D.C.
Seniors who do not happen to live near a major urban center
can still see an engaging and thought-provoking exhibition.
Barn Again!, examines that familiar agricultural structure as
functional form, monument on the landscape, and symbol of
community and country life. Developed by the Utah Humanities
Council in cooperation with the humanities councils in Alabama,
Georgia, Oregon, Ohio, West Virginia, Illinois, and Missouri,
and with a $115,000 from NEH, the exhibition has been touring
32 small rural museums and historical societies since 1996.
television documentaries
Public television reaches virtually every community and
home in the United States. During 1995 and 1996, millions
nationally watched such NEH-funded documentaries as Ken Burns'
12-hour series, The West; the eight-hour series, The Great War
and the Making of the Twentieth Century; the four-and-a-half-
hour series FDR; and Ken Burns' Baseball, rebroadcast in 1995
after this fall 1994 premier. For seniors who have limited
mobility or who simply prefer to stay home, wholesome, serious
viewing choices such as these are an especially welcome
alternative to the usual fare of sitcoms and tabloid news
offered on commercial television.
cultural tourism
More and more Americans are discovering the special places
in every region of the United States that attest to the history
and cultural uniqueness of the American experience. NEH grants
for site interpretation, and the historical and archival
research that make it possible, continually reinforce this
process of self-discovery, helping Americans make tangible
connections with the past that is our common patrimony. Older
Americans, the generation that has the biggest stake in the
past and the time that the retirement years afford for travel,
are enthusiastically joining the burgeoning ranks of cultural
tourists. In 1992, according to the NEA-commissioned survey
Arts Participation in America, 22 percent of American 65 or
older visited an historical park at least once, and 29 percent
of those between 65 and 74 did so.
A few examples will suffice to show the range of NEH-
supported projects underway, in communities large and small, to
reclaim our historic places. In FY 1996, an NEH grant of
$150,000 enabled the Mississippi River Museum in Dubuque, Iowa,
to begin interpretation of the riverfront site of the Dubuque
Boat and Boiler Works, where Mississippi riverboats were built
and launched for over 100 years. In FY 1995, the Florida
Division of Historical Resources received $250,000 to interpret
the site of the 17th-century Spanish mission at San Luis de
Talimali. Based on more than a decade of work by archaeologists
and historians, much of it supported by the Endowment, the
fifty-acre historical park includes an audiovisual orientation,
living history demonstrations, an interpretive trial through
six excavation sites, and an exhibition explaining the current
archaeological research. In FY 1995, the Lower East
SideTenement Museum in New York opened an NEH-supported exhibition and
tour program that interprets the authentically reconstructed interior
of an actual tenement building and documents the lives of the Gumpertz
and Baldizzi families, who lived there between 1865 and 1935.
senior scholars
NEH grants support a number of long-term research projects
in the humanities that have been directed and sustained over
the years by some of the most eminent scholars in their field.
Not a few of these renowned scholars are quite senior; yet
despite their emeritus status they cheerfully persevere in the
research work they know supremely well. Thus, Endowment support
of senior scholars benefits the public in two ways; it enables
uniquely qualified individuals to continue contributing
authoritatively to the advancement of humane learning, and it
incidentally furnishes the rest of us with inspirational
examples of active engagement well past the traditional age of
retirement. Anne Frior Scott of Duke University, editor of the
Jane Addams papers; independent scholar Frederick Burkhardt,
who is compiling an edition of the correspondence of Charles
Darwin under the auspices of the American Council of Learned
Societies; Dorothy Twohig of the University of Virginia, editor
of the papers of George Washington; and Frederic Cassidy of the
University of Wisconsin, editor of Dictionary of American
Regional English--these are among the senior, but-still-active
scholars whose work NEH research grants supported during fiscal
years 1995 and 1996.
Each year the Endowment chooses an exemplary scholar and
teacher to deliver the Jefferson Lecture in the Humanities, the
highest honor bestowed by the federal government for
intellectual achievement. Not coincidentally, many of the
scholars so honored have been among the most senior members of
their profession. The 1995 Jefferson Lecturer was Vincent
Scully, architectural historian and legendary teacher of
generations of undergraduates at Yale University.
non-discrimination
Older scholars have always been eligible to compete for
Endowment support on the same basis as all other similarly
qualified applicants. Accordingly, no information regarding age
is requested from applicants, and funding application are
evaluated and grants awarded exclusively on the basis of the
merit of the proposed activities. Each year, numerous projects
are funded that involve older persons as primary investigators,
project personnel, or consultants. Each year, older persons
serve on the NEH peer panels that evaluate grant applications
for funding.
NEH publications notify the public that the Endowment does
not discriminate on the basis of age. The Endowment also has a
special telephone number for the deaf and hearing impaired to
use in requesting information. Alternative format publications
concerning Endowment programs (i.e., audio tapes, large print)
are also made available upon request. In addition, the
Endowment maintains a site on the world wide web that provides
information about current projects and grant application
requirements. The Endowment encourages applicants to consider
issues related to program as well as architectural
accessibility in early planning stages of a project. Costs of
exhibition and program accommodations for people with
disabilities are generally eligible project costs.
state humanities councils
In addition to activities benefiting older Americans that
the Endowment supports directly, library programs, exhibitions,
speakers bureaus, and other programs for the general public--
and in many cases, for older audiences in particular--are
provided at the local level by the Endowment's affiliates, the
state humanities councils. The Federal/State Partnership of the
Endowment makes grants to humanities councils in 50 states,
Puerto Rico, the Virgin Islands, the Marianas, and Guam. The
special emphasis of the state humanities councils is to make
focused and coherent education possible in places and by
methods that are appropriate for adults.
ITEM 25--NATIONAL SCIENCE FOUNDATION
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National Science Foundation Report for Developments in Aging
The National Science Foundation, an independent agency of
the Executive Branch, was established in 1950 to promote
scientific progress in the United States. The Foundation
fulfills this responsibility primarily by supporting basic and
applied scientific research in the mathematical, physical,
environmental, biological, social, and engineering sciences,
and by encouraging and supporting improvements in science and
engineering education. The Foundation does not support projects
in clinical medicine, the arts and humanities, business areas,
or social work. The National Science Foundation does not
conduct laboratory research or carry out educational projects
itself; rather, it provides support or assistance to grantees,
typically associated with colleges and universities, who are
the primary performers of the research.
The National Science Foundation is organized generally
along disciplinary lines. None of its programs has a principal
focus on aging-related research; however, a substantial amount
of research bearing a relationship to aging and the concerns of
the elderly is supported across the broad spectrum of the
Foundation's research programs. Virtually all of this work
falls within the purview of the Directorate for Social,
Behavioral, and Economic Sciences and the Directorate for
Engineering.
directorate for social, behavioral, and economic sciences (sbe)
The Directorate for Social, Behavioral, and Economic
Sciences supports research in a broad range of disciplines and
interdisciplinary areas through its Division of Social,
Behavioral, and Economic Research. For example, sociological
research is being supported which examines how the labor force
participation and earnings of older Americans have been
affected by recent economic trends; how Americans in their 50's
cope with the dual pressures of supporting aging parents and
grown children; how income distribution differs between the
``young old'' and the ``old old,'' and how the degree of
political activism of older Americans has changed over time in
the twentieth century. Projects within anthropology are being
supported to examine how economic development affects patterns
of caring for dependent elderly, and with cognitive psychology
to examine the extent to which knowledge acquired in youth is
retained in later life.
The SBE Directorate also supports several large-scale data
gathering efforts which can be and have been used to study
issues related to aging, although that is not their sole or
even primary purpose. For example the Panel Study of Income
Dynamics, which has been tracking a sample of more than 7,000
American families since 1968, provides information on changing
household composition, labor force participation, income,
assets, and consumption patterns as individual respondents grow
older. The General Social Survey, which has carried out sample
surveys of the U.S. adult population more or less annually
since 1972, contains several attitudinal items dealing with the
status of, and care for, the elderly. These surveys enable
researchers to examine how attitudes toward the elderly have
changed over time and how age groups differ across a wide range
of opinion areas. The National Election Survey, which has
studied American elections since 1952, provides information on
how attitudes regarding candidates and issues vary across age
groups. The SBE Directorate is also supporting a project that
will make available to researchers in a consistent and readily
usable form public use microdata from the U.S. censuses from
1850 through 1990. When completed, this project will make it
possible to examine how the status and family relationships of
older Americans have changed over the course of a century and a
half.
directorate for engineering (eng)
The National Science Foundation's Directorate for
Engineering seeks to enhance long-term economic strength,
security, and quality of life for the Nation by fostering
innovation, creativity, and excellence in engineering education
and research. This is done by supporting projects across the
entire range of engineering disciplines and by identifying and
supporting special areas where results are expected to have
timely and topical applications, such as biotechnology and
materials processing.
Aging-related research is primarily supported within the
Directorate for Engineering through the Biomedical Engineering
and Research to Aid Persons with Disabilities programs.
Research funded in this program relates to issues of aging and
the elderly due to the propensity for the elderly to develop
physical disabilities. Projects recently supported by this
program include the following studies:
Biophysical mechanisms of cartilage repair and
generation;
Mechanisms of drug delivery in the treatment of
various diseases, including those associate with aging,
such as diabetes;
Simple, noninvasive, quantitative methods to assess
postural instability associated with aging;
Investigation of biodegradable polymer matrices to
support the growth of bone and the generation of bone-
like tissues for application in osteoporosis;
A variety of activities involving joint replacement,
including computer assisted design of orthopedic
surgery, cementing techniques, failure detection
techniques, and the pathophysiology of implant device-
related infection;
An image processing system for low vision people such
as those with age-related maculopathies;
A visual speech articulation training aid for the
hearing impaired; and
Undergraduate projects by student engineers to design
and fabricate custom designed devices and software for
disabled individuals.
While these projects are not specifically directed toward
problems of aging, all of these studies have potential for
dealing with conditions prevalent among the elderly.
ITEM 26--PENSION BENEFIT GUARANTY CORPORATION
ITEM 27--POSTAL SERVICE
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Programs Affecting Older Americans
vote by mail
Many states have arranged for voting through the mail. This
allows voters who are unable to visit a polling place, such as
the elderly and physically impaired, to enjoy the convenience
and security of voting through the mail.
carrier alert program
Carrier Alert is a voluntary community service provided by
city and rural delivery letter carriers who watch participants'
mailboxes for mail accumulations that might signal illness or
injury. Accumulations of mail are reported by carriers to their
supervisors, who then notify a sponsoring agency, through
locally developed procedures, for follow-up action. The program
completed its 15th year of operation in 1997 and continues to
provide a lifeline to thousands of elderly citizens who live
alone.
delivery service policy
The Postal Service has a long-standing policy of granting
case-by-case exceptions to delivery regulations based on
hardship or special needs. This policy accommodates the special
needs of the elderly, handicapped, or infirm customers who are
unable to obtain mail from a receptacle located some distance
from their home. Information on hardship exceptions to delivery
receptacles can be obtained from local postmasters.
services available from your rural carrier
Rural carriers continue to provide their customers with the
retail services they have come to expect from the rural ``post
office on wheels.'' Some of the retail services provided by
rural carriers are registered and certified mail, accepting
parcels for mailing, taking applications for money orders, and
providing their customers with receipts for these services.
Retail services are available to all customers served by
rural carriers but are most beneficial to those individuals who
are elderly or have a physical handicap which limits their
ability to go to the post office for these important services.
Rural carriers provide their customers with almost all retail
services available from the post office 302 days per year.
parcel delivery policies
For customers who are unavailable to receive parcels, but
who normally are at home, we automatically redeliver the
article on the following day. Additionally, if the mailer
requests, uninsured parcels are left at customers' homes or
businesses provided there is reasonable protection from the
weather and theft. Both of these policies make it easier for
customers to receive mail, and minimize the need for trips to
the post office.
accessibility
The Postal Service is subject to the Architectural Barriers
Act of 1968. The resulting standards for the design,
construction, and alteration of leased and owned facilities,
are published in the Postal Service Handbook RE-4, Standards
for Facility Accessibility by the Physically Handicapped.
Significant progress continues to be made to increase the
accessibility of the 36,000 Postal Service facilities. In
Fiscal Year 1997, approximately $16 million were invested in
accessibility projects, with most of it spent on retrofitting
historic facilities. Also, 823 new facilities meeting the
highest access standards were opened. Our commitment to
barrier-free facilities is apparent as over $300 million has
been spent in the last 10 years on accessibility projects. The
Postal Service values its elderly customers and feel they will
benefit from our efforts to make facilities more accessible.
consumer education and fraud prevention
The Postal Inspection Service endeavors to alert consumers
and businesses to current crimes by attracting media attention
to postal crime trends, publicizing positive law enforcement
accomplishments, circulating media releases and hosting crime
prevention presentations.
In February 1997, the Inspection Service joined with the
American Association of Retired Persons (AARP) and the Attorney
General's Office of the State of New Mexico in a continuing
public education initiative aimed at preventing telemarketing
fraud. Volunteers from the Albuquerque area AARP, state and
local consumer protection agencies, the New Mexico Attorney
General's Office, and the Postal Inspection Service worked
together to turn the tables on crooked boiler room operators.
Using lists of previous victims of telemarketing fraud and
names of seniors gleaned from commercial phone lists,
volunteers telephoned 1,500 New Mexico residents to warn them
of the dangers of telemarketing fraud.
This same tactic, on a somewhat larger scale, was attempted
with great media interest in Los Angeles in February 1998.
Postal Inspectors teamed with FBI Special Agents and AARP
members in a ``reverse boiler room'' operation underwritten by
CellularOne of Los Angeles. Approximately 5,000 previous
victims were contacted by phone and warned of possible renewed
attempts by con artists to contact them by phone or mail.
In New Jersey and Massachusetts, inspectors and local AARP
volunteers formed partnerships to educate senior citizens about
some of the fraudulent promotions which target the elderly
through direct mail and telemarketing schemes. Senior
volunteers were recruited to participate by collecting all
questionable or suspicious unsolicited promotional mailings
received during a specific period of time. Volunteers also kept
a log of all unsolicited telemarketing calls received.
Everything collected by the volunteers was turned over to
inspectors for examination and follow-up attention. The results
of the seniors' collection effort and the inspectors'
preliminary investigations were publicized with media
cooperation. This served to highlight drmatically the quantity
of fraudulent solicitations which target senior citizens.
At a joint press conference in September 1997, the Chief
Postal Inspector, and members of the AARP, FTC and the
Attorneys General Offices of Massachusetts and Arizona, via
satellite, announced Operation Mailbox. This cooperative effort
focused attention on unsolicited mailings received by seniors,
including suspicious prize offerings, sweepstakes promotions
and requests for charitable contributions. Senior volunteers
collected hundreds of unsolicited mailings which were displayed
dramatically at the press conference. Inspectors have been
working with the other agencies to review the mail collected
through Operation Mailbox and identify offers or solicitations
which may require follow-up investigation.
Senior victimization also was the topic of a Dateline NBC
story which featured the Inspection Service's efforts to stop
the flood of illegal foreign lottery mailings entering the
United States. The story focused on the success inspectors have
achieved in identifying illegal mailings at border entry
points, with the assistance of the U.S. Customs Service, which
has led to the seizure and destruction of over 4.5 million
pieces of foreign lottery mail. The story also explored the sad
tales of financial ruin suffered by many elderly victims of
these schemes who seem easy prey to the allure of promised
multi-million dollar jackpots.
injunctions and other civil powers
In addition to the investigation of individuals or
corporations for possible criminal violations, the Inspection
Service can protect consumers from material misrepresentations
through the use of several statutes. In less severe cases,
operators of questionable promotions agree to a Voluntary
Discontinuance. This is an informal promise to discontinue the
operation of the promotion. Should the agreement be violated,
formal action against the promoter could be initiated. In
certain cases where a more formal action is better suited, a
Consent Agreement is obtained. Generally, a promoter signs a
Consent Agreement to discontinue the false representations or
lottery charged in a complaint. If this agreement is violated,
the Postal Service may withhold the promoter's mail pending
additional administrative proceedings.
The Postal Service (Judicial Officer) is empowered under 39
U.S.C. (b)(2) to issue a Cease and Desist (C&D) Order which
requires any person conducting a scheme in violation of Section
3005 to immediately discontinue. C&D orders are issued as part
of a False Representation order and, as a matter of course, are
agreed to as a part of a Consent Agreement. Violators of C&D
orders may be subject to civil penalties under 39 U.S.C. 3012.
When more immediate relief to protect the consumer is
warranted, the Postal Service has a number of effective
enforcement options available. Title 39 U.S.C. 3003 and 3004
enables the Postal Service, upon determining that an individual
is using a fictitious, false, or assumed name, title, or
address in conducting or assisting activity in violation of 18
U.S.C. Sections 1302 (Lottery), 1341 or 1342 (Mail Fraud), to
withhold mail until proper identification is provided and the
person's right to receive mail is established.
In those instances where a more permanent action is
necessary, 39 U.S.C. 3007 allows the Postal Service to seek a
Temporary Restraining Order detaining mail. By withholding
service to the suspected violator, the extent of victimization
is limited while an impartial judge reviews the facts and makes
a final determination. If the judge decides that all mail
pertaining to the promotion should be returned, then a False
Representation Order, authorized under 39 U.S.C. 3005 is
issued. In addition, U.S. District Judges may hold a hearing on
alleged fraudulent activity, and issue a permanent injunction
regarding the operation pursuant to 18 U.S.C. 1345.
By requesting the court to withhold mail while a case is
argued, Postal Inspectors have been successful in many cases in
limiting the extent of victimization. Action under these
statutes does not preclude criminal charges against the same
target.
customer advisory councils
In October 1988, the Postal Service introduced the concept
of Customer Advisory Councils (CACs). The council concept was
developed to encourage community interaction with local postal
officials. CACs provide one more way for the Postal Service to
listen to its customers. In 1995 the number of active councils
grew to 1,778 nationwide, and almost 2,000 in Fiscal Year 1996.
CAC membership usually includes up to 10 individuals who
are representative of their community; small business owners,
local government officials, university/college students,
homemakers, and retired persons. Retired persons play an
integral role in many of the council efforts, including
``mystery shopping'' where members ``shop'' the various post
offices, stations and branches to rate the cleanliness of the
facility, clerk knowledge, courtesy, and other related aspects
of our retail services. The valuable feedback received from
councils is often used by local postal officials to improve
service.
national consumers week
The Postal Service has sponsored an annual Consumer
Protection Week since 1977. Since 1980, the Postal Service has
scheduled its observance to coincide with the National
Consumers Week sponsored by the U.S. Office of Consumer
Affairs. Postmasters and facility managers are urged to sponsor
special activities to educate customers about postal products
and services as well as Postal Inspection Service efforts to
protect consumers from perpetrators of fraudulent schemes and
other postal crimes. In conjunction with open houses and
special gatherings scheduled during National Consumers Week,
brochures are distributed to warn consumers about mail fraud
and misrepresentations of products and services sold by mail.
Helpful information about proper addressing of mail, packaging
parcels correctly, temporary address changes, sending valuables
through the mail, and how to report service problems are made
widely available through planned events. As medical fraud and
work-at-home schemes have traditionally ranked at the top of
fraudulent promotions, the focus of material distributed is
frequently directed toward alerting senior citizens of these
other schemes.
Stamps by Automated Teller Machine (atm)
Stamps by ATM is one of the Stamps to Go Services and a
convenient way to purchase stamps at a bank's automated teller
machine. A specially designed sheetlet of 18 First-Class stamps
is dispensed at the touch of a button. The cost is debited from
your checking or savings account, treated like a cash
withdrawal. Because many ATMs are accessible 24 hours a day,
our customers are able to do banking and buy postage stamps at
their convenience.
stamps by mail
Stamps by Mail is another one of the Stamps to Go Services
that allows postal customers to purchase postal products such
as booklets, sheets, coils, postal cards, and stamped
envelopes, by ordering through the mail.
The Stamps by Mail program benefits a wide variety of
people and is particularly beneficial to elderly or shut-in
customers who cannot travel to the post office. Stamps by Mail
provides order forms incorporated in self-addressed postage-
paid envelopes to customers for their convenience in obtaining
products and services without having to visit a Postal Service
retail unit. The form is available in lobbies or from the
customer's letter carrier. The customer fills out the order
form and returns it to the carrier or drops it in a collection
box. Orders are normally returned to the customer within 2 or 3
business days.
stamps by phone
Stamps by Phone is a convenient program that is intended to
target business, professional, and household customers who are
willing to pay a service charge for the convenience of ordering
by phone and paying by credit card (VISA or Master Card) to
avoid trips to the post office. The customer calls the (1-800-
STAMPS-24) toll-free number, 24 hours a day, 7 days a week, and
orders from a menu of postal products. There is no minimum
amount and customers will receive their order within 3 to 5
business days.
window automation at retail facilities
The Postal Service is installing automated retail systems
called Point of Service One at the service windows in retail
facilities in all medium to large cities. These terminals use
video screens to display information about each transaction for
the customer. The screens show mailing options, value added
services, required mailing forms, total amount due, and change
from the amount tendered. The display of this type of
information is useful to many customers with hearing
impairments, including some older Americans.
alternate postal retail sites
Alternate postal retail sites include contract Postal
Units, and stamp consignment outlets (grocery stores, etc.). By
providing retail services at alternate sites, the Postal
Service allows customers to combine postal errands with other
errands ``one-stop'' shopping. This is particularly
advantageous to the elderly.
Contract postal units provide more convenient locations
available for our customers to purchase stamps, which generally
means less wait time for them to obtain these retail services.
Purchasing stamps and postal money orders, registering a
letter, and other postal errands, can be combined with a trip
to the neighborhood shopping center. This is particularly
advantageous to the elderly.
stamps on consignment
The Postal Service consigns stamps to supermarkets, drug
stores, and other large retail chains for resale to customers
at no more than face value. This provides our customers who
need stamps an alternative to window service. This is
especially convenient for our elderly customers who may have
limited access to transportation and can purchase stamps while
at the grocery or drug store.
ITEM 28--U.S. RAILROAD RETIREMENT BOARD
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Annual Report on Program Activities for the Elderly--FYS 1995 and 1996
The U.S. Railroad Retirement Board is an independent agency
in the executive branch of the Federal Government,
administering comprehensive retirement-survivor and
unemployment-sickness benefit programs for the Nation's
railroad workers and their families under the Railroad
Retirement and Railroad Unemployment Insurance Acts. The Board
also has administrative responsibilities under the Social
Security Act for certain benefit payments and railroad workers'
Medicare coverage.
Under the Railroad Retirement Act, the Board pays
retirement and disability annuities to railroad workers with at
least 10 years of service. Annuities based on age are payable
at age 62, or at age 60 for employees with 30 years of service.
Disability annuities are payable before retirement age on the
basis of total or occupational disability. Annuities are also
payable to spouses and divorced spouses of retired workers and
to widow(er)s, divorced, or remarried widower(er)s, children,
and parents of deceased railroad workers. Qualified railroad
retirement beneficiaries are covered by Medicare in the same
way as social security beneficiaries.
Under the Railroad Unemployment Insurance Act, the Board
pays unemployment benefits to railroad workers who are
unemployed but ready, willing and able to work and pays
sickness benefits to railroad workers who are unable to work
because of illness or injury.
benefits and beneficiaries
During fiscal year 1996, retirement and survivor benefit
payments under the Railroad Retirement Act amounted to almost
$8.1 billion, $54 million more than the prior year. The number
of beneficiaries on the retirement-survivor rolls on September
30, 1996, totaled 765,000. The majority (86 percent) were age
65 or older.
At the end of the fiscal year, 344,000 retired employees
were being paid regular annuities averaging $1,187 a month. Of
these retirees, 162,000 were also being paid supplemental
railroad retirement annuities averaging $43 a month. In
addition, approximately 188,000 spouses and divorced spouses of
retired employees were receiving monthly spouse benefits
averaging $471 and, of the 243,000 survivors on the rolls,
205,000 were aged widow(er)s receiving monthly survivor
benefits averaging $708. Some 9,000 retired employees were also
receiving spouse or survivor benefits based on their spouse's
railroad service.
About 699,000 individuals who were receiving or were
eligible to receive monthly benefits under the Railroad
Retirement Act were covered by hospital insurance under the
Medicare program at the end of fiscal year 1996. Of these,
684,000 (98 percent) were also enrolled for supplementary
medical insurance.
Gross unemployment and sickness benefits paid under the
Railroad Unemployment Insurance totaled $97.7 million during
fiscal year 1996, while net benefits totaled $65.6 million
after adjustments for recoveries of benefit payments, some of
which were made in prior years. Total gross and net payments
increased by approximately $4.8 million and $4.1 million,
respectively, from fiscal year 1995. Unemployment and sickness
benefits were paid to 36,000 railroad employees during the
fiscal year. However, only about $0.02 million (less than 1
percent) of the benefits went to individuals age 65 or older.
financing
At the end of fiscal year 1996, the net position of all of
the Railroad Retirement Board trust funds was $14.8 billion,
with revenues for the year exceeding expenditures by $564.4
million. Investment earnings of $1.1 billion during the year,
including a capital gain of $148.9 million on the sale of
investments, were a major portion of the increase in the net
position of the trust funds.
The Board's 1996 railroad retirement financial report to
Congress, which addressed railroad retirement financing during
the next 25 years, was generally favorable and reflected a
continuing improvement over the previous 2 years. It concluded
that, barring a sudden, unanticipated, large decrease in
railroad employment, no cash-flow problems arise over the
entire 25-year projection period. However, like previous
reports over the last decade, the 1996 report also indicated
that the long-term stability of the system, under its current
financing structure, is still dependent on future railroad
employment levels.
The Board's 1996 railroad unemployment insurance financial
report was also favorable, indicating that experience-based
contribution rates will keep the unemployment insurance system
solvent, even under the most pessimistic employment assumption.
The Board's reports consequently did not recommend
financing changes for the railroad retirement or unemployment
insurance systems.
legislation
Legislation enacted on March 29, 1996, provided an increase
in the social security earnings limits. As a result, railroad
retirement annuitants ages 65-69 who work after retirement can
earn more without a reduction in their benefits.
Legislation enacted on October 9, 1996, increased the
railroad unemployment and sickness insurance daily benefit rate
and revised the formula for indexing future benefit rates. It
also reduced the waiting period for initial benefit payments
and eliminated duplicate waiting periods in continuing periods
of unemployment and sickness. In addition, the legislation
applied an earnings tests to claims for unemployment and
reduced the duration of extended benefit periods for long-
service employees. The provisions of the legislation were based
on joint recommendations to Congress negotiated by rail labor
and management in order to update the railroad unemployment
insurance system so that its provisions are more comparable to
those of most State programs.
service and administrative improvements
The Railroad Retirement Board has continued to improve
agency operations and better serve its customers. An agency-
wide reorganization effected in fiscal year 1995 was developed
further in 1996 to achieve greater flexibility and economies of
scale by combining like functions, eliminating organizational
barriers, reducing layers of management, improving supervisory
ratios, and developing more consistent policy and procedures.
During 1996, the Board also closed a number of its field
offices as part of a continuing restructuring of its field
operations. The Board, nonetheless, through greater utilization
of telephone and itinerant service, continued to maintain its
high level of beneficiary service.
The Board's fiscal year 1996 performance in terms of its
Customer Service Plan standards for responding to
correspondence and paying lump-sum death benefits and
unemployment and sickness claims improved over the previous
year while performance in other areas declined. These dips in
performance are not believed to be indicative of a trend.
During 1996, the Board completed its 5-year management
improvement plan, at less cost than anticipated after
successfully meeting or exceeding every goal, many ahead of
schedule. The plan, based on an agreement with the White House
Office of Management and Budget, required the Board to reduce
claims processing backlogs, enhance debt collection activities,
expand fraud controls, improve tax accounting operations,
enhance automated claims processing systems, and make other
improvement in its administrative management operations.
Consistent with its desire to provide easier access to
internal policies, the Railroad Retirement Board completely
revised its 10 Consolidated Board Orders which served as the
basic management policies of the agency. The 10 orders of 334
pages were reduced to 5 orders of 69 pages. The revision of
these orders was also in accord with Executive Order 12861,
which required each agency to reduce by at least 50 percent its
internal management regulations.
Initiatives designed to improve operations included the
development of an information technology capital plan as well
as a plan to renovate mainframe systems to incorporate new date
standards which will function properly beyond the year 2000. An
interagency agreement with the Social Security Administration
allows direct system-to-system access to that agency's benefit
and wage databases, and allows Social Security Administration
systems direct access to Board databases in future phases of
this initiative. Cost containment initiatives included plans to
covert ground floor space at the agency's Chicago headquarters
facility into retail developments and the move of the Chicago
office of the National Railroad Adjustment Board to the
Railroad Retirement Board's headquarters.
office of inspector general
During fiscal year 1996, the Office of Inspector General
continued its efforts to assist management in increasing the
efficiency of agency programs. Twenty-three audits and
evaluations issued during the year contained findings for
improvement in both administrative and program operations.
Investigative activities resulted in 135 criminal convictions,
66 indictments/informations, 50 civil judgments and $4.1
million in court ordered restitutions, fines, recoveries and
prevention of overpayments. From these activities, about
$701,000 was returned to the agency trust funds and $64,000 to
the Medicare trust funds in fiscal year 1996.
public information activities
The Board maintains direct contact with railroad retirement
beneficiaries through its 53 field offices located across the
country. Field personnel explain benefit rights and
responsibilities on an individual basis, assist railroad
employees in applying for benefits and answer any questions
related to the benefit programs. The Board also relies on
railroad labor groups and employers for assistance in keeping
railroad personnel informed about its benefit programs.
At informational conferences held for railroad labor union
officials, Board representatives describe and discuss the
benefits available under the railroad retirement-survivor,
unemployment-sickness and Medicare programs, and the attendees
are provided with comprehensive informational materials. During
1996, 2,000 railroad labor union officials attended 42
informational conferences held in cities throughout the United
States. In addition, railroad labor unions frequently request
that a Board representative speak before their meetings,
seminars and conventions. In 1996, the Labor Member's Office of
the Railroad Retirement Board was represented at 34 union
gatherings attended by 4,421 railroad labor officials. Field
personnel addressed 84 local union meetings with 4,794 members
in attendance.
At seminars for railroad executives and managers, Board
representatives review programs, financing, and administration,
with special emphasis on those areas which require cooperation
between railroads and Board offices. The Board also conducts
informational seminars on benefit programs for employees at the
request of railroad management. During 1996, the Management
Member's Office of the Railroad Retirement Board conducted 17
seminars for railroad officials. It also conducted 13 pre-
retirement counseling seminars attended by railroad employees
and their spouses, and 16 benefit update presentations.
The Board's headquarters is located at 844 North Rush
Street, Chicago, Illinois 60611-2092, phone (312) 751-4500. In
addition, the Board maintains an Office of Legislative Affairs
in Washington, DC as a liaison for dealing with Members of
Congress on matters involving the Railroad Retirement and
Unemployment Insurance Acts and legislative issues that affect
the Board. The Office of Legislative Affairs is located at 1310
G Street, NW, Suite 500, Washington, DC 20005-3004, phone (202)
272-7742.
ITEM 29--SMALL BUSINESS ADMINISTRATION
The SBA continues to create, implement and deliver
technical and financial assistance programs for the benefit of
the Nation's small business community. We currently do not have
a program that gives specific focus to older Americans.
However, the SBA is the sponsoring Federal agency for the
Service Corps of Retired Executives (SCORE) program. SCORE is
an organization of nearly 12,000 business men and women who
volunteer their time and expertise to provide management
counseling and training to small business owners and people
just starting a new business. They have extensive business
experience, either as entrepreneurs and business owners or as
former corporate executives. SCORE counseling is confidential
and free of charge and is provided at more than 700 locations
in the United States and its territories.
ITEM 30--SOCIAL SECURITY ADMINISTRATION
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Programs Administered by the Social Security Administration--Calendar
Years 1995 and 1996
The Social Security Administration (SSA) administers the
Federal old-age, survivors, and disability insurance (OASDI)
program (title II of the Social Security Act). OASDI is the
basic program in the United States that provides income to
individuals and families when workers retire, become disabled,
or die. The basic idea of the cash benefits program is that,
while they are working, employees and their employers pay
Social Security taxes; the self-employed also are taxed on
their net earnings. Then, when earnings stop or are reduced
because of retirement in old-age, death, or disability, cash
benefits are paid to partially replace the earnings that were
lost. Social Security taxes are deposited to the Social
Security trust funds and are used only to pay Social Security
benefits and administrative expenses of the program. Amounts
not currently needed for these purposes are invested in
interest bearing obligations of the United States. Thus,
current workers help to pay current benefits and, at the same
time, establish rights to future benefits.
SSA also administers the Supplemental Security Income (SSI)
program for needy aged, blind, and disabled people (title XVI
of the Social Security Act). SSI provides a federally financed
floor of income for eligible individuals with limited income
and resources. SSI benefits are financed from general revenues.
In about 54 percent of the cases, SSI is reduced due to
individuals' having countable income from other sources,
including Social Security benefits.
SSA shares responsibility for the black lung program with
the Department of Labor. SSA is responsible, under the Federal
Coal Mine Health and Safety Act, for payment of black lung
benefits to coal miners and their families who applied for
those benefits prior to July 1973 and for payment of black lung
benefits to certain survivors of miners.
Local Social Security offices process applications for
entitlement to the Medicare program and assist individuals with
questions concerning Medicare benefits. Overall Federal
administrative responsibility for the Medicare program rests
with the Health Care Financing Administration, HHS.
Following is a summary of beneficiary data and selected
administrative activities for calendar year 1996.
i. old-age, survivors, and disability insurance benefits and
beneficiaries
At the beginning of 1996, about 96 percent of all jobs were
covered under the Social Security program. It is expected that,
under the present law, this percentage of jobs will increase
slightly through the end of the century. The major groups of
workers not covered under Social Security are Federal workers
hired before January 1, 1984 and State and local government
employees covered under a retirement system for whom the State
has not elected Social Security coverage.
At the end of December 1996, 43.7 million people were
receiving monthly Social Security cash benefits. Of these
beneficiaries, 26.9 million were retired workers, 3.4 million
were dependents of retired workers, 6.1 million were disabled
workers and their dependents, 7.4 million were survivors of
deceased workers and 653 were persons receiving special
benefits for uninsured individuals who reached age 72 some
years ago.
The monthly amount of benefits being paid at the end of
December 1996 was $29.4 billion. Of this amount, $21.3 billion
was payable to retired workers and their dependents, $3.4
billion was payable to disabled workers and their dependents,
$4.7 billion was payable to survivors, and $0.1 million was
payable to uninsured persons who reached age 72 in the past.
(The cost of these special benefits for aged uninsured persons
is financed from general revenues, not from the Social Security
trust funds.)
Retired workers were receiving an average benefit at the
end of December 1996 of $745, and disabled workers received an
average benefit of $704.
During the 12 months ending December 1996, $347 billion in
Social Security cash benefits were paid. Of that total, retired
workers and their dependents received $232.9 billion, disabled
workers and the dependents received $44.2 billion, survivors
received $69.8 billion, and uninsured beneficiaries over age 72
received $1.4 million.
Monthly Social Security benefits were increased by 2.6
percent for December 1995 (payable beginning January 1996) to
reflect a corresponding increase in the Consumer Price Index
(CPI).
ii. supplemental security income benefits and beneficiaries
In January 1996, SSI payment levels (like Social Security
benefit amounts) were automatically adjusted to reflect a 2.6
percent increase in the CPI. From January through December
1996, the maximum monthly Federal SSI payment level for an
individual was $470. The maximum monthly benefit for a married
couple both of whom were eligible for SSI, was $705.
As of December 1996, 6.6 million aged, blind, or disabled
people received Federal SSI or federally administered State
supplementary payments. Of the 6.6 million recipients on the
rolls during December 1996, about 2.1 million were aged 65 or
older. Of the recipients aged 65 or older, about 678,000 were
eligible to receive benefits based on blindness or disability.
About 4.5 million recipients were blind or disabled and under
age 65. During December 1996, Federal SSI benefits and
federally administered State supplementary payments totaling
slightly over $2.4 billion were paid.
For calendar year 1996, $28.3 billion in benefits
(consisting of $25.3 billion in Federal funds and $3.0 billion
in federally administered State supplementary payments) were
paid.
iii. black lung benefits and beneficiaries
Although responsibility for new black lung miner claims
shifted to the Department of Labor (DOL) in July 1973, SSA
continues to pay black lung benefits to a significant, but
gradually declining, number of miners and survivors. (While DOL
administers new claims taken by SSA under part C of the Federal
Coal Mine Health and Safety Act, SSA is still responsible for
administering part B of the Act.)
As of December 1996, about 131,000 individuals (102,000 age
65 or older) were receiving $53 million in black lung benefits
which were administered by the Social Security Administration.
These benefits are financed from general revenues. Of these
individuals, 21,000 miners were receiving $9 million, 86,000
widows were receiving $37 million, and 24,000 dependents and
survivors other than widows were receiving $6 million. During
calendar year 1996 SSA paid out black lung payments in the
amount of $655 million. About 21,000 miners and 86,000 widows
and wives were age 65 or older.
Black lung benefits increased by 1.8 percent effective
January 1996. The monthly payment to a coal miner disabled by
black lung disease increased from $427.40 to $435.10. The
monthly benefit for a miner or widow with one dependent
increased from $641.10 to $652.70 and with two dependents from
$748.00 to $761.50. The maximum monthly benefit payable when
there are three or more dependents increased from $854.40 to
$870.20.
iv. communication and services
SSA's public information initiatives are aimed at more than
44 million Social Security beneficiaries, more than six million
SSI recipients and about 148 million workers currently paying
into the system. SSA seeks to ensure that current and future
beneficiaries are aware of programs, services, and their rights
and responsibilities.
In 1995 and 1996, SSA planned public information outreach
activities to help educate the public about Social Security. A
public service campaign was conducted in conjunction with SSA's
60th anniversary in 1995. The campaign was promoted through
print media, as well as radio and television, and informed the
public about Social Security's disability and survivors
benefits programs. The media donated more than $4 million in
advertising space.
Subjects covered through public information messages
included changes in the law affecting drug addicts and
alcoholics, welfare recipients and disabled children. Messages
were placed in the form of news releases, radio and television
public service announcements and publications such as Social
Security Today, a newsletter distributed to national
organizations.
SSA produces a wide range of publications on all Social
Security programs. More than 100 consumer booklets and fact
sheets keep the public informed about the programs and policies
affecting them. Many publications also are available in
Spanish. All are available through the agency's FAX Catalog, as
well as on the Internet at SSA's web site, http://www.ssa.gov.
Also, SSA's Public Information Distribution Center provides
materials directly to external groups and organizations.
The agency released several new videos designed to inform
the public about Social Security. One, ``The Evolution of
Social Security,'' highlights the history of the program.
Another video was produced to accompany the SSA Teacher's Kit,
which was marketed directly to more than 17,000 secondary
schools. In addition to these video products, SSA spends a
package of radio public service announcements on Social
Security themes to 5,000 radio stations once a year.
SSA also conducted a series of focus groups around the
country to assess the public's knowledge of the Social Security
program and to obtain their opinions on ways to increase public
understanding and confidence.
v. summary of legislation that affects ssa, 1995-96
P.L. 104-103 (H.R. 2924), An Act to Guarantee the Timely Payment of
Social Security Benefits in March 1996, signed on February 8,
1996
Provides the Secretary of the Treasury authority to issue
obligations of the United States equal to the aggregate monthly
Social Security benefits payable in March 1996. Because such
obligations would not be subject to the debt ceiling, the
Secretary could issue new Federal debt obligations in order to
obtain the cash necessary to cover Social Security benefits
payments in March. The exemption terminated on March 15, 1996.
P.L. 104-115 (H.R. 3021), An Act to Guarantee the Continuing Full
Investment of Social Security and Other Federal Funds in
Obligations of the United States, signed on March 12, 1996
Extended, from March 15, 1996, through March 30, 1996, the
authority (enacted in P.O. 104-103) to issue obligations of the
United States equal to the aggregate monthly Social Security
benefits payable in March 1996.
P.L. 104-121 (H.R. 3136), the Contract With America Advancement Act of
1996 (Includes the Senior Citizens' Right to Work Act of 1996),
signed on March 29, 1996
Denial of disability benefits to drug addicts and
alcoholics
Prohiits disability insurance (DI) and Supplemental
Security Income (SSI) eligibility to individuals whose drug
addiction and/or alcoholism (DAA) is a contributing factor
material to the finding of disability. This provision applies
to individuals who file for benefits on or after the date if
enactment. For beneficiaries who, as of March 29, 1996, were
already receiving DI and/or SSI benefits based on DAA
materiality, this provisionbecame effective on January 1, 1997,
SSA was required to: 1) notify DAA beneficiaries of new provisions by
June 27, 1996; and 2) complete new medical determinations by January 1,
1997, for affected beneficiaries who requested such a determination
within 120 days after the date of enactment.
Applies special representative payee requirements to DI or
SSI beneficiaries who have a DAA condition, as determined by
the Commissioner, and who are incapable of managing benefits.
SSA is to refer these individuals to the appropriate State
agency for treatment. In addition, allows certain
organizational payees to collect a $50 monthly fee from
beneficiaries who have a DAA condition.
Provided an additional appropriation of $50 million for
each of fiscal years 1997 and 1998 to carry out on a priority
basis activities relating to the treatment of drug and alcohol
abuse under section 1933 of the Public Health Service Act.
Continuing Disability Reviews
Authorizes additional funds to SSA for fiscal years 1996
through 2002 for the purpose of conducting Social Security
disability insurance continuing disability reviews (CDRs) and
SSI CDRs and disability redeterminations. This would be
accomplished by increasing the amount of funds available for
appropriations under the discretionary spending cap in the
Budget Enforcement Act.
Directs the Commissioner of Social Security to ensure that
the funds made available pursuant to this provision are used,
to the greatest extent practicable, to maximize the combined
savings to the old-age, survivors, and disability insurance
(OASDI), SSI, Medicare, and Medicaid programs.
Requires the Commissioner to report annually, for fiscal
years 1996 through 2002, to Congress on the amount of money
spent on CDRs, the number of reviews conducted (by category),
the disposition of such reviews (by program), and the estimated
savings over the short-, medium-, and long-term for OASDI, SSI,
Medicare, and Medicaid programs from CDRs which result in
cessations, and the estimated present value of such savings.
Chief actuary
Establishes by statute in the Social Security
Administration the position of Chief Actuary, to be appointed
by, and report directly to, the Commissioner, and be subject to
removal only for cause.
Dependency test for stepchildren
Provides that a stepchild has to be receiving at least one-
half support from the stepparent when the child's claim is
filed to get benefits. (The option for finding dependency based
on the child's living-with the stepparent was eliminated.) This
provision is effective for benefits of individuals who become
entitled for months after June 1996.
If the natural parent and the stepparent of an entitled
stepchild divorce, benefits to the stepchild based on the work
record of the stepparent would terminate the month after the
month in which such divorce becomes final. This provision is
effective for final divorces occurring after June 1996.
Increase in the earnings test annual exempt amount
Gradually raises, beginning in 1996, the earnings limit for
the retirement earnings test (RET) for beneficiaries who have
attained normal retirement age to $30,000 by 2002 (compared
with $14,640 for 2002 under prior law, based on the assumptions
in the President's FY 1998 Budget). The applicable 1996 exempt
amount under prior law was $11,520. Exempt amounts under P.L.
104-121 (exempt amounts under prior law are also shown) are:
------------------------------------------------------------------------
Estimated
Exempt amount exempt amount
Year under Public under prior
Law 104-121 law
------------------------------------------------------------------------
1996.................................... $12,500 $11,520
1997.................................... 13,500 12,000
1998.................................... 14,500 12,600
1999.................................... 15,500 12,960
2000.................................... 17,000 13,560
2001.................................... 25,000 14,040
2002.................................... 30,000 14,640
------------------------------------------------------------------------
After 2002, the annual exempt amount will be indexed to
growth in average wages.
The substantial gainful activity (SGA) amount applicable to
individuals who are statutorily blind is no longer linked to
the RET exempt amount for individuals ages 65 to 69. Instead,
the SGA amount for blind people will continue to be adjusted
annually as under present law, i.e., based on the national
average wage index.
Benefit and tax statements
Requires SSA to conduct a pilot study of the efficacy of
providing title II beneficiaries with information about their
Social Security benfits and taxes. The study will involve a
sample of retirement beneficiaries whose entitlement began in
or after 1984 and continued for a period of at least 5 years.
SSA will send each beneficiary one statement with estimates of
the aggregate covered earnings of the insured person, the
aggregate Social Security taxes (including the employer share
paid on those earings), and the total amount of benefits paid
on the insured person's record.
Requires the study to be conducted within a 2-year period
beginning as soon as practicable in 1996 and a report on its
results be provided to Congress within 60 days of its
completion.
Investment of Social Security and Medicare trust funds
Prohibits the Secretary of the Treasury from refraining
from investing Social Security and Medicare trust fund monies
in Federal securities, and from redeeming securities held by
the trust funds, to avoid increasing or reducing outstanding
public debt obligations. Effective March 29, 1996.
Professional staff for the Social Security Advisory Board
Authorizes the Social Security Advisory Board to appoint
three professional staff employees, one of whom is to be
appointed from among individuals approved by Advisory Board
members who do not belong to the political party represented by
the majority of the Board.
Review of Federal regulations
Requires that when Federal agencies promulgate certain
regulations, including some of those issued by SSA, the agency
must prepare a final regulatory flexibility analysis. The
agencies must also provide the Chief Counsel for Advocacy of
the Small Business Administration information on the potential
impacts of the proposed rule on small entities and the type of
small entities that might be affected. This provision does not
apply to any proposed or final rule if the head of the agency
cerifies that the rule will not, if promulgated, have a
significant economic impact on a substantial number of small
entities. The statute also provides for judicial review of
agency compliance with this provision.
P.L. 104-134 (H.R. 3019), the Omnibus Consolidated Rescissions and
Appropriations Act of 1996, signed on April 26, 1996
Debt collection
Provides SSA with permanent debt collection authorities,
including administratively offsetting other Federal benefit
payments, offsetting Federal salaries, administrative
garnishment of employees' pay, reporting delinquent debt to
credit bureaus, using private collection agencies, and
assessing late charges. The first $9000 per year of an
individual's Federal benefit payments are exempt from
administrative offset.
Authorizes the collection of debts owed to the Federal
Government by administrative offset against black lung benefits
and benefits under title II of the Social Security Act.
Electronic funds transfer (EFT)
Requires recurring Federal payments, including Social
Security and SSI benefits, to persons who begin to receive them
after July 1996 to be paid by EFT. However, the head of each
agency can waive the requirement for recipients who certify
that they do not have a bank account or payment agent.
All recurring Federal payments made after January 1, 1999,
will be made by EFT, except that the Secretary of the Treasury
may waive the requirement in certain circumstances.
P.L. 104-188 (H.R. 3448), the Small Business Job Protection Act of 1996
and the Minimum Wage Increase Act of 1996, signed on August 20,
1996
Crews of fishing boats
Treats crew members as self-employed (rather than
employees) if (1) the crew of a vessel was normally composed of
no more than 10 members, determined on the basis of the average
size of the crew during the preceding four calendar quarters,
and (2) under limited circumstances, the crew members received
cash pay of not more than $100 per trip. The provision was
effective January 1, 1994. It also applies to the period 1985-
1994, unless the remuneration had been treated as wages when
paid.
Employer-provided educational assistance
Resinstates a provision that expired January 1, 1995, under
which certain employer-provided educational assistance was
excluded for Social Security and income tax purposes. The
extension is extended, but only for courses that began before
January 1, 1997. However, with respect to graduate level
education, the exclusion does not apply to expenses relating to
courses beginning after June 30, 1996.
Retired members of the clergy
Excludes from Social Security tax the rental value of a
parsonage (or the parsonage allowance) and benefits from a
church plan (as defined in the Internal Revenue Code) received
by a retired member of the clergy. Applies to years beginning
before, on, or after December 31, 1994.
Newspaper deliverers
Defines persons engaged in the business of distributing
newspapers or shopping news as direct sellers for Social
Security and income tax purposes--i.e., independent contractors
(self-employed). Applies to services performed beginning
January 1, 1996.
Work opportunity tax credit
Replaces the targeted jobs tax credit with the work
opportunity tax credit for employers hiring individuals from
one or more targeted groups. This includes disabled individuals
referred to an employer upon completion of (or while receiving)
rehabilitation services pursuant to an individualized written
plan under a State plan for vocational rehabilitation services
approved under the Rehabilitation Act of 1973.
The provision applies to individuals who begin work for the
employer after September 30, 1996.
P.L. 104-193 (H.R. 3734), the Personal Responsibility and Work
Opportunity Reconciliation Act of 1996, signed on August 22,
1996
Limited Eligibility of Noncitizens
Social Security benefits
Prohibits the payment of Social Security benefits to any
noncitizen in the U.S. who is not lawfully present in the U.S.
(as determined by the Attorney General), unless the payment is
made pursuant to a totalization agreement or treaty obligation.
Applied for benefits based on applications filed on or
after December 1, 1996.
SSI benefits
Prohibits SSI eligibility for all qualified noncitizens
except: \1\ Refugees (eligibility limited to the 5-year period
after their arrival in the United States); asylees (eligibility
limited to the 5-year period after the date they are granted
asylum); noncitizens who have had deportation withheld under
INA section 243(h) (eligibility limited to the 5-year period
after the date their deportations are withheld; certain active
duty Armed Forces personnel, honorably discharged veterans, and
their spouses and dependent children; and lawful permanent
residents who have earned 40 quarters of coverage for Social
Security purposes. An individual under the age of 18 would be
credited with all quarters of coverage earned by his or her
parent, and a married individual (including widow(er))
generally would be credited with all quarters of coverage
earned by his or her spouse during the marriage. However, for
quarters earned after December 31, 1996, a quarter would not
count as one of the required 40 if the noncitizen or person
whose quarters are being credited to the noncitizen received
federally funded public assistance during the quarter the work
was done.
---------------------------------------------------------------------------
\1\ This definition was amended by P.L. 104-208 (see description in
section titled ``Provisions Related to Noncitizens''). Further
significant changes were made by P.L. 105-33.
---------------------------------------------------------------------------
In addition, with certain exceptions, noncitizens who enter
the U.S. as lawful permanent residents after August 22, 1996,
are ineligible for any Federal means-tested benefits (including
SSI) for 5 years.
Effective upon enactment. However, with regard to
individuals on the SSI rolls at the time of enactment, requires
the Commissioner to redetermine the eligibility of all
noncitizens who may not meet the new eligibility categories
within 1 year after enactment. If a qualified noncitizen is not
in one of the new categories, his or her eligibility would end
as the date of the redetermination.
Required the Commissioner to notify all potentially
affected beneficiaries on the SSI rolls of the provision by
March 31, 1997.
Deeming of sponsors' incomes and resources
For purposes of eligibility under SSI, deems the sponsors'
(and sponsors' spouses') incomes and resources to the
noncitizen until citizenship with the following exception:
Deeming ends before citizenship in the case of lawful
permanent residents who earn 40 quarters of coverage.
Deeming for children and spouses of workers also could
end before citizenship if they are credited with 40
quarters, i.e., an individual under the age of 18 is
credited with all quarters of coverage earned by his or
her parent, and a married individual (including
widow(er)) generally is credited with all quarters of
coverage earned by his or her spouse during the
marriage. However, for quarters earned after December
31, 1996, a quarter will not count as one of the
required 40 if the noncitizen or person whose quarters
are being credited to the noncitizen received federally
funded public assistance during the quarter the work
was done.
Effective for sponsored noncitizens who are admitted into
the country under new, legally enforceable affidavits of
support.
Requirements for affidavits of support for sponsorship
Makes affidavits of support legally enforceable against the
sponsor until the noncitizen becomes a U.S. citizen. The
affidavit is enforceable for a period of 10 years after the
noncitizen last received public assistance benefits, including
SSI.
Requires the agency that provides assistance to a
noncitizen to request reimbursement from the sponsor for the
assistance it provided. If the sponsor does not respond or is
unwilling to make reimbursement within 45 days after the
agency's request, the agency may take legal action against the
sponsor. Allows the agency to hire individuals to collect
reimbursement.
Requires the Attorney General, in consultation with the
Secretary of State and the Secretary of Health and Human
Services, to develop a standard affidavit of support within 90
days after the date of enactment. Also requires--effective with
a date specified by the Attorney General which would be no
earlier than 60 and no later than 90 days after development of
the standard affidavit--that all newly signed affidavits be
legally enforceable.
Reports to INS
Requires the Commissioner to furnish to INS the name,
address, and other identifying information of any individual
that SSA knows is unlawfully in the United States. Such reports
are required at least four times a year and upon request of
INS. Also requires the Commissioner to ensure that State
supplementary program agreements with States include provisions
for the State also to furnish such information to INS at such
times on persons whom the State knows are unlawfully in the
United States.
Effective upon enactment.
Childhood Disability
SSI eligibility based on childhood disability
Eliminates the comparable severity standard and provides
instead that a child under age 18 be considered under a
disability if he/she has a medically determinable physical or
mental impairment which results in marked and severed
functional limitations and which can be expected to result in
death or which has lasted or can be expected to last for a
continuous period of not less than 12 months.
Directs SSA to eliminate references to maladaptive behavior
in the domain of personal/behavioral function in specified
sections of the Listing of Impairments for children and to
discontinue the use of an individualized functional assessment
in evaluating a child's claim for benefits.
These provisions are applicable to any individual who
applies for SSI benefits based on disability, or whose claim is
finally adjudicated, on or after the date of enactment, without
regard to whether implementing regulations have been issued.
Current recipients
Required SSA to notify recipients eligible for SSI benefits
based on disability on enactment date and whose ligibility may
be affected by the new childhood disability eligibility
criteria, no later than January 1, 1997.
Required SSA to redetermine the eligibility of such
recipients, using the new childhood disability eligibility
criteria, no later than 1 year after the date of enactment.
Benefits for those recipients who did not meet the new
childhood disability eligibility criteria terminated for the
month beginning on or after the later of July 1, 1997, or the
date of the redetermination.
Eligibility redeterminations and continuing disability reviews (CDRs)
Requires CDRs: once every 3 years for recipients under age
18 with impairments that are considered likely to improve; and
not later than 12 months after birth for children for whom low
birth weight is a contributing factor material to the
determination of disability.
Requires the representative payee of a recipient whose
continuing eligibility is being reviewed to present evidence
that the recipient is receiving treatment which is considered
medically necessary and available, unless SSA determines that
providing evidence of such treatment would be inappropriate or
unnecessary. If the representative payee refuses, without good
cause, to cooperate, SSA may change the payee if it is in the
best interests of the child.
Requires an eligibility redetermination, using the adult
initial eligibility criteria, during the 1-year period
beginning on a recipient's 18th birthday.
Applies to benefits for months beginning on or after the
date of enactment, without regard to whether implementing
regulations have been issued.
Repeals the requirement in the Social Security Independence
and Program Improvements Act of 1994 (Public Law 103-296) that
SSA (1) redetermine, using the adult eligibility criteria, the
eligibility of one-third of the recipients who attain age 18 in
or after May 1995 in each of fiscal years 1996 through 1998 and
(2) submit a report regarding these reviews to the House
Committee on Ways and Means and the Senate Committee on Finance
not later than October 1, 1998.
Medical improvement review standard
Makes conforming changes in the medical improvement review
standard to reflect the new definition of disability for
children who file for SSI benefits.
Applicable with respect to benefits for months beginning on
or after the date of enactment, without regard to whether
implementing regulations have been issued.
Funding
Authorized the appropriation of an additional $150 million
in fiscal year 1997 and $100 million in fiscal year 1998 for
the costs of processing CDRs and redeterminations.
Regulations
Required SSA to issue regulations implementing the changes
relating to benefits for disabled children within 3 months
after enactment date.
Directs SSA to submit final regulations pertaining to a
child's eligibility for SSI disability benefits to the Congress
at least 45 days before such regulations become effective.
Reports
Required SSA to report to the Congress, not later than 180
days following the date of enactment, on its progress in
implementing the changes in the SSI disabled children's
provisions.
Requires GAO, not later than January 1, 1999, to study and
report on the impact of the changes made by this Act on the SSI
program and the extra expenses incurred by families of children
receiving SSI benefits that are not covered by other Federal,
State, or local programs.
other ssi changes
Prisoner reporting
Provides for incentive payments from SSI program funds to
State and local penal institutions and mental hospitals for
furnishing information (date of confinement and certain
identifying information) to SSA which results in suspension of
SSI benefits ($400 for information received within 30 days of
confinement or $200 for information received from 31 to 90 days
after confinement).
Applies to individuals whose period of confinement
commences on or after the first day of the seventh month
beginning after the month of enactment.
Exempts SSI reporting agreements under which incentive
payments are made from the computer matching provisions of the
Privacy Act of 1974, as amended.
Required the Commissioner to study and report to Congress
(within 1 year of enactment) on the feasibility of prisoner
reporting by courts and mandatory electronic reporting by
correctional facilities and other institutions having incentive
payment agreements with SSA for purposes of carrying out the
suspension of benefits under the SSI program.
Requires SSA to provide Congress (not later than October 1,
1998) with a list of the institutions that are, and are not,
providing information on inmates to SSA under the incentive
payment provision.
Authorizes SSA to provide, on a reimbursable basis,
information obtained pursuant to SSI reporting agreements under
which incentive payments are made to any Federal or Federally-
assisted cash, food, or medical assistance program for
eligibility purposes.
Modify the effective date of applications
Provides that an individual's application for SSI benefits
is effective on the first day of the month following the date
on which the application is filed, or following the date on
which the individual first becomes eligible, whichever is
later. The amendment, in effect, eliminates prorated payments
for the month of application by providing that the first month
for which benefits can be paid is the month after the month in
which the application is filed.
Permits the issuance of an emergency advance payment in the
month the application is filed to an individual who is
presumptively eligible and has a financial emergency.
Requires that the emergency advance payment be repaid
through proportional reductions in the individual's SSI
benefits over a period of not more than 6 months.
Effective for applications filed on or after the date of
enactment.
Reduction in cash benefits payable to institutionalized individuals
whose medical costs are covered by private insurance
Limits to not more than $30 a month SSI cash benefits
payable to children under age 18 who are in medical
institutions receiving payments (with respect to that
individual) under any health insurance policy issued by a
private provider of such insurance.
Effective with respect to benefits for months beginning 90
or more days after the date of enactment.
Installment payments of large past-due SSI payments
Requires SSA to pay in installments retroactive SSI benefit
amounts that equal or exceed 12 times the monthly Federal
benefit rate (FBR) plus the monthly State supplemental level.
Payments are to be made in no more than three installments at
6-month intervals. The first and second installment generally
cannot exceed 12 times the FBR ($5,640 based on 1996 rates)
plus any Federally administered State supplement. Any remaining
retroactive benefits will be paid in the third installment.
Provides that where an individual has incurred debts for
food, clothing, shelter, or medical expenses or has current or
anticipated expenses for medical needs or the purchase of a
home, the maximum amount of an installment payment may be
increased by the total amount of these debts and expenses.
Provides that the installment payment requirements do not
apply to an individual who is terminally ill or who is
currently ineligible for benefits and likely to remain so for
the next 12 months.
Effective with respect to past-due benefits payable after
the third month following the month of enactment.
Dedicated savings accounts
Requires the representative payee of a disabled or blind
child to establish a bank account to maintain retroactive SSI
benefits that exceed 6 times the FBR (smaller retroactive
benefit amounts may also be placed in such accounts once
established).
Allows funds in the account to be used only for the
following expenses: medical treatment, education or job skill
training; or, if related to child's impairment, personal needs
assistance, special equipment or housing modifications, therapy
or rehabilitation, other items or services related to the
child's impairment which SSA determines appropriate.
Provides that unauthorized expenditures constitute
misapplication of benefits and are recoverable by SSA from the
child's representative payee.
Requires SSA to establish an accountability system to
monitor these accounts under which payees are required to
report on the use of these funds.
Provides that these accounts are excluded from resource
counting and that interest earned is excluded from income.
Effective with respect to payments made after the date of
enactment.
Denial of benefits for fugitive felons and probation and parole
violators/exchange of information with law enforcement officers
Denies eligibility for SSI with respect to any month during
which an individual is fleeing to avoid prosecution for a
felony, fleeing to avoid custody or confinement after
conviction of a felony, or violating a condition of probation
or parole imposed under State or Federal law.
Requires SSA to provide upon written request of any
appropriate agency, the current address, SSN, and photograph
(if applicable) of any SSI recipient, provided that the
requesting law enforcement officer furnishes the name of the
recipient and other identifying information and notifies SSA
that the recipient: is fleeing to avoid prosecution for a
felony, or custody or confinement after a felony conviction; or
is violating a condition of probation or parole; and has
information that is necessary for the officer of the agency to
conduct the officer's official duties and the location or
apprehension of the recipient is within the officer's official
duties.
Effective upon enactment.
Denial of SSI benefits for 10 years to individuals who have
misrepresented residence in order to obtain benefits in two or
more states
Denies SSI benefits for a period of 10 years to an
individual convicted in Federal or State court of having made a
fraudulent statement or representation with respect to his or
her place of residence in order to receive benefits
simultaneously in two or more States.
Effective upon enactment.
Annual report on the SSI program
Requires the Commissioner to report to the President and
Congress regarding the SSI program, not later than May 30 of
each year, including: a comprehensive description of the
program; historical and current data on allowances and denials,
including number of applications and allowance rates for
initial determinations, reconsideration determinations,
administrative law judge hearings, appeals council reviews, and
Federal court decisions; historical and current data on
characteristics of recipients and program costs, by recipient
group (aged, blind, disabled adults, and disabled children);
historical and current data on prior enrollment by recipients
in public benefit programs, including State programs funded
over Part A of title IV of the Social Security Act and State
general assistance programs; projections of future numbers of
recipients and program costs, through at least 25 years;
information on the number and outcomes of redeterminations and
continuing disability reviews, utilization of work incentives,
administrative and other program costs, State supplementation
program operations; summaries of relevant research; and a
historical summary of statutory changes to the SSI law.
Provides that each member of the Social Security Advisory
Board be permitted to include their views on the SSI program in
the annual report.
Effective upon enactment.
use of social security numbers
Social Security card
Required the Commissioner of Social Security to develop a
prototype of a counterfeit-resistant Social Security card that:
is made of durable, tamper-resistant material (e.g., plastic);
employs technologies that provide security features (e.g.,
magnetic stripe); and provides individuals with reliable proof
of citizenship or legal resident alien status.
Required the Commissioner of Social Security to study and
report on different methods of improving the Social Security
card application process, including: evaluation of the cost and
workload implications of issuing a counterfeit-resistant Social
Security card for all individuals over a 3-, 5-, and 10-year
period; evaluation of the feasibility and cost implications of
imposing a user fee for replacement cards and cards issued to
individuals who apply for such a card prior to the scheduled 3-
, 5-, and 10-year phase-in options.
Required the Commissioner to submit the report and a
facsimile of the prototype card to the Congress within 1 year
of the date of enactment.
Expansion of the Federal Parent Locator Service
Requires HHS to transmit to SSA, for verification purposes,
certain information about individuals and employers maintained
under the Federal Parent Locator Service in an automated
directory to be known as the National Directory of New Hires.
SSA is required to verify the accuracy of, correct, or supply
to the extent possible, and report to HHS the name, SSN, and
birth date of each individual regarding whom HHS maintains
information for purposes of the Federal Parent Locator Service
and the employer identification number of each such employer.
SSA will be reimbursed by HHS for the cost of this verification
service.
Effective upon enactment.
Collection and use of SSNs for use in child-support enforcement
Provides that State child support enforcement procedures
require that the SSN of any applicant for a professional
license, commercial driver's license, occupational license, or
marriage license be recorded on the application. The SSN of any
person subject to a divorce decree, support order, or paternity
determination or acknowledgement will be placed in the
pertinent records. SSN's also must be placed in the records
relating to the death and recorded on death certificates.
Effective upon enactment.
Earned Income Tax Credit (EITC)
Provides that, in order to be eligible for the EITC, an
individual must include on his or her tax return a Social
Security number assigned to the individual which was not
assigned solely for nonwork purposes as well as, where
applicable, a Social Security number meeting the aforementioned
requirement for his or her spouse.
Effective for taxable years beginning after 1995.
P.L. 104-208 (H.R. 3610), An Act Making Omnibus Consolidated
Appropriations for FY 1997, signed on September 30, 1996
This omnibus budget bill includes six FY 1997
appropriations measures and contains SSA's FY 1997
appropriation. The bill also includes the Illegal Immigration
Reform and Immigrant Responsibility Act of 1996. Included in
the immigration reform section of H.R. 3610 were the following
provisions of interest to SSA:
provisions related to noncitizens
Definition of ``qualified alien''
Amends section 431 of P.L. 104-193 to add to the list of
six specific immigration categories that comprise the
definition of ``qualified alien,'' the following new category:
Aliens and their children who have been battered or
subjected to extreme cruelty by a spouse or parent or a
member of the spouse's or parent's family living in the
same household as the alien if the alien has a petition
for adjustment of immigration status approved or
pending and the Attorney General determines that there
is a substantial connection between such battery or
cruelty and the need for benefits. A noncitizen would
not be considered to be a qualified alien for any month
in which the noncitizen lives in the same household as
the individual responsible for the battery or extreme
cruelty.
Note.--In order to be eligible for SSI, a ``qualified
alien'' would also have to meet the noncitizen SSI eligibility
criteria under P.L. 104-193.
Sponsorship deeming
Amends section 421 of P.L. 104-193 to add the following two
exceptions to sponsor-to-immigrant deeming:
Requires that if a noncitizen is indigent and the
agency makes a determination for a 12-month period that
without SSI benefits the noncitizen is unable to obtain
food and shelter taking into account the noncitizen's
income and cash, food, housing, and other assistance
provided by any individual including the sponsor, then
only the amount of income and resources actually
provided the noncitizen by the sponsor is counted for
deeming purposes. In all cases in which such
determinations are made, the agency is required to
report the names of the noncitizens and their sponsors
to the Attorney General.
Provides that deeming would not apply for a 12-month
period if noncitizens or their children have been
battered or subjected to extreme cruelty by family
members. The deeming exemption period (with regards to
the sponsor batterers income and resources only) is
extended if the battering or cruelty has led to an
order from a judge, an Administrative Law Judge (ALJ),
or the Immigration and Naturalization Service (INS),
and the benefit-paying agency determines that the need
for benefits has a substantial connection to the
battery or cruelty. The deeming exemption does not
apply for any month in which the noncitizen lives in
the same household as the person responsible for the
battery or extreme cruelty.
These provisions are effective for noncitizens whose
sponsors execute legally enforceable affidavits of support (see
below).
Affidavits of support
Replaces the affidavit of support provisions in P.L. 104-
193 with the following:
Requires that affidavits of support be made contracts
under which the sponsor agrees to provide support at an
annual income that is not less than 125 percent of the
poverty line. Affidavits of support are made legally
enforceable against the sponsor by the sponsored
immigrant, and the Federal, State, local governments,
or other entity which provide the sponsored noncitizen
any means-tested public benefit. These affidavits are
required to include the sponsors' agreement to support
the noncitizens until they become U.S. citizens or
until they (or, under certain conditions, their spouses
or individuals who claimed them as dependents on their
income tax return) have worked 40 quarters in the
United States, whichever is earlier.
Requires the agency to request reimbursement from the
sponsor for assistance provided the noncitizen. If 45
days after the reimbursement request, the sponsor is
unresponsive or unwilling to make reimbursement, the
agency has 10 years to take legal action against the
sponsor. Allows the agency to hire individuals to
collect reimbursement.
The Attorney General, in consultation with the Secretary of
Health and Human Services (HHS), was required to develop a
standard affidavit of support within 90 days after enactment
and the provision was effective no earlier than 60, and no
later than 90, days after enactment.
Study of noncitizens who are not ``qualified aliens'' receiving SSI on
another's behalf
Required that the General Accounting Office within 180 days
of enactment submit a report to Congress and the Department of
Justice on the extent to which means-tested benefits are being
paid to noncitizens acting as representative payees who are not
``qualified aliens''.
Reports of earnings of noncitizens not authorized to work
Effective beginning with FY 1996, requires the Commissioner
to report to Congress, no later than 3 months after the end of
each fiscal year, the aggregate number of Social Security
numbers (SSNs) issued to noncitizens not authorized to work,
but under which earnings were reported.
Required the Commissioner to transmit to the Attorney
General, within 1 year of enactment, a report on the extent to
which SSNs and Social Security cards are used by noncitizens
for fraudulent purposes.
Maintaining information on noncitizens
Authorizes the Attorney General to require any noncitizen
to provide his/her SSN for purposes of inclusion in any record
maintained by the Attorney General or INS. Effective on the
date of enactment.
Ineligibility of noncitizens not lawfully present for social security
benefits
Prohibits payment of Social Security benefits to any
noncitizen in the U.S. for any month during which the
noncitizen is not lawfully present in the U.S. (as determined
by the Attorney General).
Effective for benefits based on applications filed on or
after the first day of the first month that begins at least 60
days after the date of enactment.
Improvements in identification-related documents
Birth certificate requirements
Prohibits Federal agencies from accepting copies of
domestic birth certificates that do not conform to standards
set forth in Federal regulations. The President was to select
one or more Federal agencies to develop appropriate standards
for birth certificates and include them in a final regulation
to be promulgated no later than 1 year after the date of
enactment. The regulation shall: provide for certification by
the issuing agency; provide for use of safety paper, the seal
of the issuing agency, and other features designed to resist
tampering, counterfeiting, and duplicating for fraudulent
purposes; not require a single design to be used by all States;
and accommodate the differences between States in the manner
and form in which birth records are stored and birth
certificates are produced.
The restriction on the acceptance of birth certificates by
Federal agencies applies to birth certificates issued after the
day that is 3 years after promulgation of the regulation.
Requires the Department of Health and Human Services (HHS)
to provide grants: to encourage States to develop the
capability to match birth and death records, within each State
and among the States, and to note the fact of death on the
birth certificates of deceased persons (fosucing first on
individuals born after 1950); and for projects in 5 States to
demonstrate the feasibility of a system by which State vital
statistics records will reflect in-State deaths within 24 hours
of that office's acquiring death information from persons
required to report such information.
Required HHS to submit a report to Congress within 1 year
of enactment on ways to reduce birth certificate fraud,
including any use of a birth certificate to obtain an SSN or
State or Federal identification or immigration document.
Effective upon enactment.
Driver's license requirements
Prohibits Federal agencies from accepting for any
identification-related purpose a driver's license, or
comparable identification document, issued by a State, unless
the license: has an application process that requires the
presentation of such evidence of identity as is required by
regulations published by the Secretary of Transportation within
1 year of enactment; is consistent with regulations that
require security features designed to limit tampering,
counterfeiting, photocopying, and use of the license or
document by imposters; and contains the SSN which can be read
visually or by electronic means. (This requirement does not
apply if the State does not require the SSN to appear on the
license; requires every applicant for a license to submit his/
her SSN; and requires State verification with SSA that the SSN
is valid.)
The restriction on acceptance of drivers licenses by
Federal agencies would be effective beginning October 1, 2000.
Development of prototype of counterfeit-resistant social security card
Required the Commissioner of Social Security, within 1 year
of enactment, to develop a prototype of a counterfeit-resistant
Social Security card that: is made of durable, tamper-resistant
material (e.g., plastic); employs technologies that provide
security features (e.g., magnetic stripe); and provides
individuals with reliable proof of citizenship or legal
resident noncitizen status.
Requires the Commissioner of Social Security and the
Comptroller General each to study and report to Congress on
different methods of improving the Social Security card
application process, including: evaluation of the cost and
workload implications of issuing a counterfeit-resistant Social
Security card for all individuals over a 3-, 5-, and 10-year
period; and evaluation of the feasibility and cost implications
of imposing a user fee for replacement cards and cards issued
to individuals who apply for such a card prior to the scheduled
3-, 5-, and 10-year phase-in options.
other provisions
Employment verification
Requires three specific pilot programs to begin no later
than 1 year after enactment and end no later than 4 year after
the pilot begins.
Provides for employers to participate voluntarily in any
one of the pilots.
Basic Pilot--employers in five of the seven States
with the highest estimated population of noncitizens
not lawfully present are to confirm, through a toll-
free telephone line or other electronic media system
established by the Attorney General, the identify and
employment eligibility of the individual based on SSN
and immigration document (if applicable).
Citizen Attestation Pilot--an employer would not
confirm identify or work authorization for individuals
attesting that they are citizens. This pilot would
operate only in States with a driver's license that
contains a photograph and has been determined by the
Attorney General to have security features/reliable
means of identification.
Machine-readable Document Pilot--an employer would
confirm an individual's identify and work authorization
by means of a machine-readable SSN on a driver's
license. This pilot would apply to individuals who do
not attest citizenship and would operate only in States
with a driver's license that contains a photograph and
has been determined by the Attorney General to have
security features/reliable means of identification.
Requires SSA to advise whether the name and SSN match SSA
records and whether the SSN is valid for employment. In cases
of tentative non-confirmation, the Attorney General in
consultation with SSA and the INS must provide a secondary
verification process to confirm (or not) the validity of the
information provided.
Verification of alien student eligibility for post-secondary federal
student financial assistance
Required the Secretary of Education and the Commissioner of
Social Security jointly to submit to Congress within 1 year of
enactment of the legislation a report on the Department of
Education computer matching program for student loan, grant, or
work assistance purposes. The report was to include: an
assessment of the effectiveness of the computer matching
program, and a justification for such assessment; the ratio of
successful matches under the program to inaccurate matches; and
such other information as the Secretary and the Commissioner
jointly consider appropriate.
ITEM 31--DEPARTMENT OF VETERANS AFFAIRS
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ACTIVITIES ON BEHALF OF OLDER VETERANS FOR FISCAL YEAR 1995
I. Introduction
The Department of Veterans Affairs has the potential
responsibility for a beneficiary population of more than 26
million veterans whose median age is approximately 57 years.
Over thirty-three percent of the veteran population is age 65
and older. By the year 2005, over four and a half millions
veterans will be 75 years or older.
This demographic trend will require VA to redistribute its
resources to meet the different needs of this older population.
Historically, older persons are greater users of health care
services. The number of physician visits, short-term hospital
stays, and number of days in the hospital all increase as the
patient moves from the fifth to seventh decade of life.
VA has developed a wide range of services to provide care
in a variety of institutional, non-institutional, and community
settings to ensure that the physical, psychiatric and
socioeconomic needs of the patient are met. Special projects, a
variety of innovative, medically-proven programs and individual
VA medical center (VAMC) initiatives have been developed and
tested that can be used for veteran patients and adapted for
use by the general population.
VA operates the largest health care system in the Nation,
encompassing 173 hospitals, 131 nursing home care units, 39
domiciliaries, and 391 outpatient clinics. Veterans are
alsoprovided contract care in non-VA hospitals and in community nursing
homes, fee-for-service visits by non-VA physicians and dentists for
outpatient treatment, and support for care in 77 State Veterans Homes
in 39 States. As part of a broader VA and non-VA network, affiliation
agreements exist between virtually all VA health care facilities and
nearly 1,000 medical, dental, and associated health schools. This
affiliation program with academic health centers results in almost
109,000 health profession students receiving education and training in
VAMCs each year.
In addition to VA hospital, nursing home and domiciliary
programs, VA is increasing the number and diversity of non-
institutional extended care programs. The dual purpose is to
facilitate independent living and keep the patient in a
community setting by making available the appropriate
supportive medical services. These programs include Hospital-
Based Home Care, Community Residential Care, Adult Day Health
Care, Psychiatric Day Treatment and Mental Hygiene Clinics, and
Homemaker/Home Health Aide Services.
The need for both acute and chronic hospitalization will
continue to rise as older patients experience a greater
frequency and severity of illness, as well as a different mix
of diseases, than younger patients. Cardiovascular diseases,
chronic lung diseases, cancers, psychiatric, and mental
disorders, bone and joint diseases, hearing and vision
disorders, and a variety of other illnesses and disabilities
are all more prevalent in those persons age 65 and older.
II. Geriatrics and Extended Care Programs
va nursing home care
Nursing Home Care Units (NHCU), which are based at VA
medical centers, provide skilled nursing care and related
medical services. An inter-disciplinary approach to care is
employed, which encourages diverse professional staff, working
together, to meet the multiple physical, social, psychological,
and spiritual needs of the patients. Nursing home patients
typically require a prolonged period of care and/or
rehabilitation services to attain and/or maintain optimal
functioning.
In fiscal year 1995, more than 33,000 veterans were treated
in 131 VA nursing homes, generating a total average daily
census (ADC) of almost 13,600.
VHA is continuing to offer NHCU staff educational programs
to enhance the care of the mentally ill nursing home patient.
Interest in the use of the Patient Assessment Instrument
(Minimum Data Set) remains high. While the use of this
instrument is not mandated, many facilities have reported plans
to adopt it.
community nursing home care
This is a community-based, contract program for veterans
who require skilled or intermediate nursing care when making a
transition from a hospital setting to the community. Veterans
who have been hospitalized in a VA facility for treatment,
primarily for a service-connected condition, may be placed at
VA expense in community facilities for as long as they need
nursing care. Other veterans may be eligible for community
placement at VA expense for a period not to exceed 6 months.
Selection of nursing homes for a VA contract requires the prior
assessment of participating facilities to ensure they meet our
standards of care. Follow-up visits are made to veterans by
teams from VA medical centers to monitor patient programs and
quality of care.
In September, 1995, VA issued a request for proposals (RFP)
to corporate level, multi-state nursing home providers for bids
to provide nursing home care to veterans with a minimum level
of guaranteed expenditures. Responses to the RFP were received
in January, 1996. Up to six multi-state contracts are expected
to be established by mid-1996. This initiative is expected to
result in reduced administrative costs (and potentially per
diem costs), improvement of VA's access to nursing home beds,
and more consistent quality of care.
In fiscal year 1995, 27,000 veterans were treated in the
program. The number of nursing homes under contract was 3,500
and the average daily census of these homes was 8,300.
va domiciliary care
Domiciliary care in VA facilities provides necessary
medical and other professional care for eligible ambulatory
veterans who are disabled by disease, injury, or age and are in
need of care but do not require hospitalization or the skilled
nursing services of a nursing home.
The domiciliary offers specialized interdisciplinary
treatment programs that are designed to facilitate the
rehabilitation of patients who suffer from head trauma, stroke,
mental illness, chronic alcoholism, heart disease and a wide
range of other disabling conditions. With increasing frequency,
the domiciliary is viewed as the treatment setting of choice
for many older veterans.
Implementation of rehabilitation-oriented programs has
provided a better quality of care and life for veterans who
require prolonged domiciliary care and has prepared increasing
numbers of veterans for return to independent or semi-
independent community living.
Special attention is being given to older veterans in
domiciliaries with a goal of keeping them active and productive
as well as integrated into the community. The older veterans
are encouraged to utilize senior citizens and other resources
in the community where the domiciliary is located. Patients at
several domiciliaries are involved in senior center activities
in the community as part of VA's community integration program.
Other specialized programs in which older veterans are involved
include Foster Grandparents, Handyman Assistance to senior
citizens in the community, and Adopt-A-Vet.
In fiscal year 1995, 18,100 veterans were treated in 40 VA
domiciliaries resulting in an average daily census of 5,713. Of
these numbers, approximately 3,410 veterans and an average
daily census of more than 1,300 were admitted to the
domiciliaries for specialized care for homelessness. This
latter group had an average age of 43 years, while the overall
average age of domiciliary patients was 59 years.
state homes
The State Home Program has grown from 10 homes in 10 states
in 1888 to 77 state homes in 39 States. Currently, a total of
22,510 beds is authorized by VA to provide hospital, nursing
home, and domiciliary care. VA's relationship to state veterans
homes is based upon two grant programs. The per diem grant
program enables VA to assist the states in providing care to
eligible veterans who require domiciliary facilities. The other
VA grant program provides up to 65 percent federal funding to
states to assist in the cost of construction or acquisition of
new domiciliary and nursing home care facilities, or the
expansion, remodeling, or alteration of existing facilities.
hospice care
VA has developed programs that provide pain management,
symptom control, and other medical services to terminally ill
veterans, as well as bereavement counseling and respite care to
their families. The hospice concept of care is incorporated
into VA medical center approaches to the care of the terminally
ill. All VA medical centers have appointed a hospice
consultation team, which is responsible for planning,
developing, and implementing the hospice program.
hospital-based home care
This program provides in-home primary medical care to
veterans with chronic illnesses. The family provides the
necessary personal care under the coordinated supervision of a
hospital-based interdisciplinary treatment team. The team
prescribes the needed medical, nursing, social, rehabilitation,
and dietetic regimens, and provides the training of family
members and the patient in supportive care.
Seventy-five VA medical centers are providing hospital-
based home care (HBHC) services. In fiscal year 1995, home
visits were made by health professionals to an average daily
census of 5,000 patients.
adult day health care
Adult Day Health Care (ADHC) is a therapeutically-oriented
ambulatory program that provides health maintenance and
rehabilitation services to veterans in a congregate setting
during the daytime hours. ADHC in VA is a medical model of
services, which in some circumstances may be a substitute for
nursing home care. VA operated 13 ADHC centers in fiscal year
1995, with an average attendance of 450 patients. VA also
continued a program of contracting for ADHC services at 83
medical centers. The average daily attendance in contract
programs was 419 in fiscal year 1995.
community residential care
The Community Residential Care home program provides
residential care, including room, board, personal care, and
general health care supervision to veterans who do not require
hospital or nursing home care but who, because of health
conditions, are not able to resume independent living and have
no suitable support system (e.g., family, friends) to provide
the needed care. All homes are inspected by a multidisciplinary
team prior to incorporation of the home into the VA program and
annually thereafter. Care is provided in private homes that
have been selected by VA, at the veteran's own expense.
Veterans receive monthly follow-up visits from VA health care
professionals. In fiscal year 1995, an average daily census of
9,200 veterans was maintained in this program, utilizing
approximately 2,100 homes.
homemaker/home health aide services (H/HHA)
In fiscal year 1995, VA initiated a pilot program of
health-related services for veterans needing nursing home care,
implementing provisions of Public Law 101-366. These services
are provided in the community by public and private agencies
under a system of case management provided directly by VA
staff. For the purpose of the initiative, health-related
services are defined as homemaker/home health aide services
only.
One hundred eighteen VAMCs were purchasing H/HHA services
in fiscal year 1995 for approximately 4,200 veterans.
Geriatric Evaluation and Management Program (GEM)
The Geriatric Evaluation and Management (GEM) Program
includes inpatient units, outpatient clinics, and consultation
services. A GEM Unit is usually a functionally different group
of beds (ranging typically in number from 10 to 25 beds) on a
medical service or an intermediate care unit of the hospital
where an interdisciplinary health care team performs
comprehensive geriatric assessments. The GEM unit serves to
improve the diagnosis, treatment, rehabilitation, and discharge
planning of older patients who have functional impairments,
multiple acute and chronic diseases, and/or psychosocial
problems. GEM clinics provide similar comprehensive care for
geriatric patients not in need of hospitalization as well as
provide follow-up care for older patients to prevent their
unnecessary institutionalization. A GEM program also provides
geriatric training and research opportunities for physicians
and other health care professionals in VA medical centers.
Currently, there are 130 GEM Programs.
Results from a controlled, randomized study of GEM efficacy
that was conducted at the VA Medical Center Sepulveda, CA, and
published in the New England Journal of Medicine in 1984,
showed significant benefits such as improved survival,
decreased rehospitalization rates, improved functional status,
and decreased nursing home placement following admission to GEM
units.
Care of the Acute and Critically ILL Elderly
In 1995, VA Headquarters completed its third printing of a
supplemental guide for medical center staff who care for the
acutely-ill veteran (Geriatric Pocket Pal). This guide is used
by residents, nurses, and allied health personnel in all VA
medical centers. Many requests have been received from non-VA
clinical staff for this popular VHA publication, developed by
VA Headquarters and field staff. The Geriatric Pocket Pal was
revised in November, 1994, to include updated reference
materials and incorporate additional information.
Respite Care
Respite Care provides planned, periodic, short-term care
for a disabled person in order to temporarily relieve the
caregiver from the physical and emotional burden of providing
the needed care and supervision. VA provides respite care by
admitting a veteran to a hospital or nursing home bed for up to
thirty days a year. This institutionally-based program not only
supports this caregiver's role in caring for the veteran at
home, but also provides an opportunity for VA staff to evaluate
and treat the veteran's health care needs and offer guidance to
the caregiver in the home treatment plan.
Alzheimer's Disease and Other Dementias
VA's program for veterans with Alzheimer's disease and
other dementias is decentralized throughout the medical care
system, with coordination and direction provided by the Office
of Geriatrics and Extended Care. Veterans with these diagnoses
participate in all aspects of the health care system including
outpatient programs, acute care programs and extended care
programs. Approximately 56 medical centers have established
specialized programs for the treatment of veterans with
dementing illnesses. Policy guidance concerning a continuum of
dementia services to be provided in VA's health care networks
is currently under development.
In order to advance knowledge about the care for veterans
with dementia, VA investigators conduct basic biomedical,
applied clinical and health services research, much of which
occurs at VA's Geriatric Research, Education and Clinical
Centers (GRECCs), and which is supported through the Office of
Research and Development. Rehabilitation Research and
Development Service develops and evaluates new technologies and
techniques designed to minimize disability associated with
dementia. Continuing education for staff is provided through
training classes sponsored by GRECCs and VA's continuing
education field units.
VA Headquarters has disseminated a variety of dementia
patient care educational materials in the form of publications
and videos to all VA medical centers. In fiscal year 1990, all
VA libraries received a revised edition of guidelines for
diagnosis and treatment of dementia, a series of 21 dementia
caregiver education pamphlets developed by the Minneapolis
GRECC, and 3 videotapes on Alzheimer's disease developed by the
Bedford Division of the Boston GRECC. In fiscal year 1993, VA
libraries received a series of 3 geriatric health care
videotapes that are relevant to dementia patient care. In
addition, a comprehensive instructional program, ``Keys to
Better Care,'' was made available to all VA medical centers
through regional audiovisual delivery sites. This 14-part
training package for health care providers caring for patients
with Alzheimer's Disease and other dementias addresses a wide
range of issues related to quality care and it is being used
extensively by VA staff. Also, an audiovisual videotape on
rehabilitation of the cognitively-impaired patient, produced by
the Northeast VA Learning Resources Service, was made available
at all VA libraries.
During 1990 and 1991, VA Headquarters surveyed a sample of
VA medical centers with established inpatient units for
patients with dementia. A summary report of these dementia unit
site visits was published by VA in September, 1993, and has
been disseminated widely throughout the VA system and to the
non-VA community. The report details the organization and
delivery of inpatient services to dementia patients from
admission to discharge. Results of these site visits will aid
in planning future dementia programs and services, with
information addressing such issues as dementia unit staffing
patterns, programming, and overall organization.
In fiscal years 1994 and 1995, VA conducted teleconferences
that featured national experts on Alzheimer's disease.
Presented were state-of-the-art strategies for diagnosis and
treatment of this devastating disease from a primary care
perspective. Staff at both VA and non-VA sites, including State
Veterans Homes, participated in these educational
teleconferences.
As a further development, a joint VA/University Health
System Consortium (UHC) technical advisory group has been
working since July, 1995, on an updated clinical guideline for
the identification and assessment of dementia. The guideline,
which will emphasize the role of primary care clinicians in the
diagnostic process, will be distributed throughout the VA and
UHC systems.
Also, in fiscal year 1995, a comprehensive Center for
Alzheimer's Disease and Other Neurodegenerative Disorders was
begun at the Oklahoma City VA Medical Center. The goal of the
Center is to develop and evaluate a rural health model for the
coordinated care of patients with Alzheimer's disease or other
degenerative neurological disorders in the state of Oklahoma.
Using an interdisciplinary, case-management approach, the
Center provides patient services, including outpatient
diagnosis, treatment and follow-up care, as well as support for
family and other caregivers of veterans with these disorders.
The use of telemedicine technology is being explored to enhance
communication among providers in distant settings.
Collaborative relationships between VA, state and local
community organizations will be coordinated to meet the
community service needs of these patients and their families.
Relevant staff education, training, and research activities
will also be developed.
Geriatric Research, Education, and Clinical Centers (GRECCs)
The Geriatric Research, Education, and Clinical Centers
(GRECCs) assume an important role in further developing the
capability of the VA health care system to provide cost-
effective and appropriate care to older veterans. First
implemented in 1975, GRECCs are designed to enhance the
system's capability to develop state-of-the-art care in
geriatrics through research, education, and clinical care. The
goals of the GRECCs are to develop new knowledge regarding
aging and geriatrics, to disseminate that knowledge through
education and training to health care professionals and
students, and to develop and evaluate alternative models of
geriatric care.
GRECCs have developed many innovative approaches to educate
and train VA clinical staff who care for elderly veterans.
GRECC staff have continued to expand their outreach education
and training to provide expertise to VA staff, particularly in
the area of geriatric evaluation and management. Also, GRECCs
have developed individual topic-specific education programs for
the networks they serve and have collaborated with other GRECCs
to present this information to clinical staff in other networks
as well. This provides a significant number of clinical staff
with the state-of-the-art information on specific issues
concerning care of the elderly.
Each GRECC has developed an integrated program of basic and
applied research, education, training, and clinical care in
selected areas of geriatrics. Current focal areas include
cardiology and prevention of cardiovascular disease; cognitive
and motor dysfunction andneurobiology; endocrinology,
swallowing disorders, metabolism and nutrition; geropharmacology;
immunology, cancer and infectious diseases; osteoporosis and arthritis;
falls; exercise physiology; geriatric rehabilitation; sensory
impairment; depression; bio-ethical aspects of medical decision-making
in the elderly; and cost-effective and quality of geriatric care. Using
an integrated approach, the GRECCs are developing practitioners,
educators, and researchers to help meet the need for training health
care professionals in the field of geriatrics; providing information
for, as well as establishing models on, cost-effective approaches to
care of the elderly; and researching better methods to diagnose and
treat health care problems of the older person, as well as finding
answers to fundamental questions on the processes and consequences of
aging.
At present there are 16 GRECCs. They are located at the
following VA medical centers: Ann Arbor, MI; Baltimore, MD;
Bedford and Brockton/West Roxbury, MA (2 divisions); Durham,
NC; Gainesville, FL; Little Rock, AR; Madison, WI; Miami, FL;
Minneapolis, MN; Palo Alto, CA; San Antonio, TX; St. Louis, MO;
Salt Lake City, UT; Seattle/American Lake, WA (2 divisions);
Sepulveda, CA; and West Los Angeles, CA. Public Law 99-166,
``Veterans Administration Health Care Amendments of 1985,''
increased from 15 to 25 the maximum number of facilities that
the VA Secretary may designate for GRECCs.
III. Office of Clinical Programs
Primary Care
As VHA transitions from an acute, inpatient-based system of
care to an outpatient, primary case-based system of care,
opportunities for collaboration between geriatrics and primary
care are being maximized. Most physicians in geriatrics come
from an internal medicine background with a strong emphasis on
primary care and an interdisciplinary team approach to patient
care. As medical centers implement primary care, one of the
primary care teams is in the area of geriatrics. Development of
geriatric primary care is one of the goals now being
highlighted and encouraged as special training teams are
assisting medical centers in implementing primary care.
Two VHA publications, Sharing Innovations Among VA
Clinicians and VA Innovations in Ambulatory Care, have been
distributed to VHA providers. They highlight new ways of
improving patient care and satisfaction. These books contain
specific information about geriatric-aged patients and new
techniques to meet their needs.
Medical Service
Medical Service in VAMCs serves as the primary source of
physicians for the care of all veterans, including elderly
patients. Due to the aging of the population, Medical Service
is increasingly involved in all aspects of the delivery of
health care to the aged. Acute and intermediate medical wards,
coronary and intensive care units, nursing homes and outpatient
clinics are all seeing an increased proportion of elderly
patients with acute and chronic illnesses. While some care is
provided specifically by geriatricians, as the population ages,
all internists are seeing an older veteran population.
Some subspeciality areas are particularly impacted, such as
cardiology, endocrinology (diabetes), rheumatology and
oncology. Medical Service provides necessary subspecialty care
in inpatient and outpatient settings in addition to
participating in Geriatric Fellowship Training, GRECCs,
Geriatric Evaluation and Management (GEM) Programs, Hospice,
Respite, Nursing Home, and Hospital-Based Home Care. The
specialized care that is required by the elderly has been
recognized by Medical Service at a number of medical centers,
by their establishment of a Geriatric Medicine Section, which
emphasizes clinical care, as well as coordinating research and
education efforts related to geriatrics.
Age alone is less frequently used as a determinant of an
individual patient's care. Geriatric patients undergo invasive
diagnostic procedures as well. For example, the Sunbelt is
experiencing an increasingly heavy cardiac catheterization
workload. The average age of patients treated in coronary and
intensive care units is increasing, producing a concomitant
demand for cardiac rehabilitation and physical fitness programs
that are targeted to the frail elderly and the physically
handicapped of all ages. The special interest and involvement
of Medical Service in geriatrics has also resulted in
participation by internists in such programs as Adult Day
Health Care, as well as in research problems in nutrition and
treatment by hypertension.
Smoking cessation has been shown to benefit even elderly
patients. Thus, the role of Preventive Medicine for this
patient population has expanded. The Medical Service has been
active in implementing preventive strategies in smoking
cessation, immunization (influenza and pneumococcal vaccines),
and colorectal screening (for cancer). Lipid control is an
emerging area that may benefit this population.
Participation in evaluation and treatment of elderly
patients by interdisciplinary teams during intermediate-length
hospital stays will be an increasingly important role for the
physicians of the Medical Service.
Social Work Service
Meeting the biopsychosocial health care needs of an aging
population of veterans and caregivers continues to be a major
priority of Social Work Service and the Veterans Health
Administration. The need to be competitive in a challenging and
changing health care environment, as well as cost-effective and
efficient in addressing the social components of health care,
has led to a re-examination of social work priorities and their
relevance to the VA health care mission, with special reference
to the needs of chronically ill, older veterans. Without a
support network of family, friends, and community health and
social services health care gains would be lost and VHA acute
care resources would be over-burdened. It is frequently not the
degree of illness that determines the need for hospital care,
but rather the presence or absence of family and community
resources.
The expansion of homemaker/home health aide services is
evidence of the importance of non-institutionalized support
networks in maintaining the veteran in the community. Social
workers continue to coordinate discharge planning and to serve
as the focal point of contact between the VA medical center,
the veteran patient, family members, and the larger community
health and social services network. The veteran and family
members have, in many respects, become the ``unit of care'' for
social work intervention. It is this ``customer'' focus which
will undergird social work programming for vulnerable
populations, including older veterans who are demanding that
VHA be more responsive and sensitive to their psychosocial
needs and those of their caregivers.
The role of the caregiver as a member of the VA health care
team and as a key player in the provision of health care
services continues to be a major area of social work practice
and will continue to be in the immediate future. This is
consistent with the recognition that 80 percent of nursing care
is provided in the home by family, neighbors, etc., and that
the family, ordinarily the veteran's spouse, is the key
decision-maker concerning health insurance issues, and, most
probably, access to health and community support services.
As VHA transitions from an acute care to a primary care/
community interactive health care delivery system, Social Work
Service has placed increased emphasis on its pivotal role in
community services coordination, development, and integration.
The development of a ``seamless garment of care,'' with case
management services as its centerpiece, is being given
increased emphasis by Social Work Service and its National
Committee. The National Committee functions in an advisory
capacity concerning social work and systems issues, priorities,
and practice concerns. While case management services have been
a central component of social work practice in VHA, this
service modality is being ``re-discovered'' by the VA health
care system as an essential component of services provided to
``at-risk'' veterans and their caregivers. Case management,
also known as ``care coordination,'' was identified in
veterans' discussion groups as a very important ingredient in
meeting the veterans' health care needs and those of their
caregivers. During 1995 and beyond, VHA, and particularly
Social Work Service, will be challenged to expand case
management services in concert with other community providers
and to provide a perspective that addresses this critical
ingredient of care in terms of its absolute relevance to
successful health care outcomes. In a revitalized and
reconfigured VA health care system, issues of coordination,
access, cost, and appropriateness of VA and community services
will be determined not only by the needs of the customers, but
also by the experience and expertise of the providers.
Older veterans, including those from some minority groups
such as Native Americans, are at significant risk for the
development of health care problems related to geographic
isolation, economic deprivation, and cultural barriers. The
Interagency Task Force on Older Indians continues to address
issues of concern related to the provision of services to a
population that has been underserved by the Federal sector. The
Department of Veterans Affairs, represented by Social Work
Service, has been an active member of this consortium.
Rehabilitation Research and Development
The mission of the Rehabilitation Research and Development
(Rehab R&D) Service is to investigate and develop concepts,
products and processes that promote greater functional
independence and improve the quality of life for impaired and
disabled veterans. Aging, particularly the aging of persons
with disabilities, is a high priority of the service. Efforts
in this area include:
A national VA program of merit-reviewed,
investigator-initiated research, development and
evaluation projects targeted to meet the needs of aging
veterans with disabilities;
Support of a Rehabilitation Research and Development
Center on Aging at Decatur, Georgia, VA Medical Center;
and
Transfer into the VA health care delivery system of
developed rehabilitation technology and dissemination
of information to assist the population of aging
veterans and those who care for them.
In addition to specific projects on aging, may of the
investigations supported through the Service's nationwide
network of research at VAMCs and at four Rehabilitation
Research and Development Centers have relevance for impairments
commonly associated with aging.
Some samples of investigator-initiated studies currently
being carried out are:
A Low-Vision Enhancement System (LVES);
Liquid Crystal Dark-Adapting Eyeglasses;
Electronic Travel Aid for the Blind;
Non-Auditory Factors Affecting Hearing Aid Use in
Elderly Veterans;
The Influence of Strength Training on Balance and
Function in the Aged; and an
Epidemiologic Study of Aging in Spinal Cork Injured
Veterans.
The Rehab R&D Center on Aging is structured around five
interdisciplinary research sections to address the multi-
dimensional nature inherent in problems of aging and
disability: Environmental Research; Vision Rehabilitation;
Neuro-Physiology; Engineering and Computer Science; and Social,
Behavioral, and Health Research. Areas of study include:
Design-related problems that affect the quality of
life of older people, including least restrictive
environments, falls, independence and safety;
Orientation and mobility for the blind, low vision,
and rehabilitation outcomes measurement for older
persons with visual impairment;
The neurologic and physiologic changes that accompany
aging and behavioral coping problems; and
Development and application of new technologies to a
variety of prototypes for the design of assistive
devices and assistive software.
Physical Medicine and Rehabilitation Medicine
Physical Medicine and Rehabilitation Service (PM&RS)
strives to provide all referred older veterans with
comprehensive assessment, treatment and follow-up care for
psychosocial and/or physical disability affecting functional
independence and quality of life. The older veterans's
abilities in the areas of self-care, mobility, endurance,
cognition and safety are evaluated. Therapists utilize physical
agents, therapeutic modalities, exercise and the prescription
of adaptive equipment, to facilitate the veterans' ability to
remain in the most independent life setting. Rehabilitation
personnel provide education to the veterans and their families
around adjustment to their disability or physical limitations
and instruct them in techniques to maintain independence
despite disability.
Over 6,000 veterans per year receive treatment and are
discharged from inpatient rehabilitation programs at
approximately 65 medical centers. There is a growing number of
subacute rehabilitation programs being established at medical
centers across the nation. The subacute setting affords us the
ability to provide less intense rehabilitative services for the
older veteran, aimed at promoting an individuals' integration
back into the community. On both acute and subacute
rehabilitation units, physicians, usually board certified
physiatrists, lead interdisciplinary teams of professionals to
focus on outcomes of functional restoration, clinical
stabilization, or avoidance of acute hospitalization and
medical complications.
A uniform assessment tool, the Functional Independence
Measure (FIM), is being implemented throughout the VA
rehabilitation system. Patients are evaluated on 18 elements of
function at the time of admission, regularly during treatment
and at discharge. Application of FIM results to quality
management activity will assist local and national
rehabilitation clinicians and managers to maximize effective
and efficient rehabilitation care delivery. An administrative
data base called the Uniform Data System for Medical
Rehabilitation (UDS/mr) will monitor outcomes of care and
increase accuracy of developing predictors and ideal methods of
treatment for the older veteran with various diagnoses. As part
of a national contract with UDS/mr, 65 facilities with
rehabilitation bed units provide data and receive outcome
reports as part of the national and international UDS/mr data
bank.
Rehabilitation therapists are leading and participating in
innovative treatment, clinical education, staff development and
research. Rehabilitation professionals work within homebound
health care; independent living centers; Geriatric Evaluation
and Management Units; Adult Day Health Care; Day Treatment
Centers; Domiciliaries; Interdisciplinary Team Training
Programs; Geriatric Research, Education, and Clinical Centers
(GRECCs); and hospice care programs.
Driver training centers are staffed at 40 VA medical
centers to meet the needs of aging and disabled veterans. With
the growing numbers of older drivers, the Department of
Veterans Affairs has put emphasis on the training of the mature
driver. Classroom education, updates in laws and defensive
driving techniques are supported with behind-the-wheel
evaluation by trained specialists.
Nursing Service
Care of the elderly veteran continues to be one of the
highest priorities for Nursing Service. Nurses at every level
of the organization are committed to providing leadership in
the clinical, administrative, research, and educational
components of gerontological nursing.
Professional nurses function as part of interdisciplinary
teams to coordinate and provide care in settings beginning with
Geriatric Evaluation and Management Programs (GEMs) and
progressing along many care settings including ambulatory care,
acute care, long-term care, and community agencies.
Gerontological nurse practitioners and clinical nurse
specialists provide primary care and continuity of care as
clinical care managers and coordinators of care.
Preventive care and health promotion incentives continue to
preserve independence, foster self-care, improve productivity,
and enhance the quality of life by improving the health status
of aging veterans. Proper screening, education, and referral of
elderly veterans are vital activities to meet their health care
needs in the least restrictive environment. Nurses in wellness
clinics and other ambulatory care settings provide supervision,
screening, and health education programs to assist veterans in
maintaining healthy lifestyles.
Nurses play a key role in restoring the functional
abilities of aging veterans with chronic illnesses and
disabilities. Programs for the physically disabled and
cognitively impaired have been established and are administered
by nurses and nurse practioners in home care, ambulatory care
settings, and inpatient units. Treatment programs are goal-
directed toward physical and psychosocial reconditioning or
retraining of patients with biological and
psychosocialdisturbances. Patient and family teaching is a major part
of each program. Family and significant others have a key role in
providing support to aging veterans and are assisted in learning and in
maintaining appropriate caregiver responsibilities. VA nurses
contribute to planning and implementing health care services for the
elderly in the community-at-large. They serve on task forces and
participate in self-help and support groups related to specific
diseases such as Alzheimer's. Nurses are also advisors to local health
planning councils, and they share VA educational activities and
research seminars with other health care professionals.
Nursing leaders continue to collaborate with schools of
nursing to offer positive learning experiences in both
undergraduate and graduate nursing education. Nursing schools
are encouraged to focus more attention on programs in
geriatrics, rehabilitation, and chronic care. Graduate nursing
students receive clinical experience in Geriatric Evaluation
and Management Programs, Nursing Home Care Units, and Hospital
Based Home Care Programs. Nursing Service is committed to
leadership that will ensure the patient care needs of aging
veterans are addressed. The preceptorship training program for
the position of Associate Chief or Supervisor Nursing Home Care
Unit is on hold until the need for nurses in these positions
has been determined. The interdisciplinary approach to reduce
poly-pharmacy continues, with several nursing home care units
reporting successful programs.
Nursing Service continues to support restraint-free
environments throughout the VA health care system. Several
VAMCs report a variety of successful strategies to reduce the
use of restraints, including a successful interdisciplinary
approach to understanding, evaluating, and developing
alternatives to physical restraints. Disciplines involved
include Nursing, Medicine, Pharmacy, Dietetics, Recreation,
Rehabilitation, and Social Work. Strategies that contribute to
restraint reduction include an electronic wandering alert
system, a gait training program, education of family members,
greater use of volunteers and use of hospital beds with egress
alarms.
Many medical centers across the VA system have developed
new initiatives to improve the quality of care for aging
veterans. Many such interventions have improved the quality of
life of patients as well as the quality of care. Some of these
include the following:
An interdisciplinary autonomy committee to create an
environment in which resident autonomy is enhanced and promoted
while meeting the therapeutic needs.
A variety of unique approaches to meet nutrition needs of
aging patients in long-term care settings. Successful
interventions included interdisciplinary total quality
improvement teams for nutrition support and care, an
interdisciplinary progressive self-feeding program and a dining
together program.
The use of Tai-Chi to promote health and improve the
quality of life for the institutionalized aging patient.
Preliminary data suggest improvement in physical functioning
and improved scores on mental status tests for dementia
patients.
An enhanced Geriatric care project developed to provide a
safe user friendly therapeutic environment while promoting an
environment conducive to wellness. Outcomes of the project
include the following:
A safe and protective area for wandering patients;
Greater patient participation, communication, and
socialization through the use of outdoor activities;
Enhanced customer and staff satisfaction.
The use of primary care to reduce admissions and length of
stays for nursing home patients in acute care settings. The use
of multidisciplinary teams to provide Geriatric Primary Care
for the frail elderly and those over the age of 75.
An innovative program designed to prevent and/or minimize
the effects of bed rest utilizing a mobility program called
VIPS (Volunteer in Professional Service). The program was
designed to increase routine ambulating of patients utilizing
trained volunteers. Outcomes of the program include enhanced
mobility, return of patient to a less restrictive environment,
and increased companionship and socialization for patients with
limited mobility.
Research is needed to advance health care for older persons
and to improve gerontological nursing practice. Nursing
research is urgently needed to improve the quality of care in
the following areas:
Urinary incontinence;
Common eating patterns, programs, and nutrition;
Falls;
Enhancing socialization skills;
Care of Alzheimer's patients;
Wandering behavior;
Dementia;
Exercise and mobility;
Medications, including effectiveness of psychotropic
medications, and types and incidence of medication
abuse among the elderly;
Health promotion;
Frail elderly in the home setting;
Alternatives to institutional care; and
Coping mechanisms of patients, families, and
caregivers.
Studies are needed to enhance the quality of life for aging
female veterans in a health care system largely focused on a
male model of care. Osteoporosis is a serious metabolic bone
disease which affects post-menopausal women to a greater degree
than men. Women veterans who served during and prior to the
Korean and Vietnam Wars are a prime risk group for this
disease. Timely application of research findings to clinical
care in all practice settings will improve the quality of care
and quality of life to aging veterans.
nutrition and food service
Medical nutrition care saves money, improves patient
outcomes and enhances the quality of life for our older
veterans. To better serve the veteran and identify nutritional
needs, many VA health care professionals are now using
Determine Your Nutritional Health Checklist and Level I and II
Nutrition Screen developed by the American Dietetic
Association, American Academy of Family Physicians and National
Council on Aging National Screening Initiative. The Checklist
or Level I Screen identifies those at high risk for poor
nutritional status, while Level II Screen provides specific
diagnostic nutritional information. The National Screening
Initiative emphasizes educating the physician in nutritional
care. The booklet, Incorporating Nutrition Screening and
Interventions into Medical Practice, has been nationally
disseminated to doctors. This information complements the
handbook, Geriatric Pocket Pal, developed in collaboration with
the Office of Geriatrics and Extended Care.
Many medical centers have Geriatric Nutrition Specialist
positions. Dietitians in these positions have developed easy-
to-read educational materials for their audience and shared
this information with other medical centers. Several medical
centers are providing outreach services for the elderly in
their community. For example, the Bronx VAMC provides outreach
to local senior centers, and the Dallas VAMC has bi-monthly
visits by their health screening team to facilities in their
area. A variety of nutrition education programs have been
offered for health care providers and patients.
Nutrition and Food Service continues to provide guidance on
quality care. Several practice guidelines have been distributed
to all the medical centers to ensure quality care for our
elderly. In addition, Tomah VAMC has developed
interdisciplinary guidelines for the care of dysphagia. The
clinical indicator to ensure that the patient not only receives
food, but also is fed, was distributed to all medical centers.
Northampton VAMC developed an indicator for high-risk geriatric
patients who are overweight.
Office of Dentistry
Dental care for the geriatric patient involves restoration
of function through rehabilitation of the dentition, and
elimination of pain and suffering attributable to oral disease.
It is important that older adults are able to effectively
masticate a variety of foods so that convalescence after
surgery, chemotherapy, or other significant medical
interventions is expedited.
Interpersonal skills, which are highly dependent upon
physical appearance, as well as effective communication, can be
enhanced by improving the teeth's appearance and by properly
aligning and restoring the anterior teeth to maintain clarity
of speech. The goals of dental care are consistent with those
of all disciplines involved in geriatrics--to maximize function
and foster independence in living. Dentistry should be an
integral part of any comprehensive health care program for the
elderly.
The nature of dental disease in late life--chronic and
often asymptomatic even in advanced stages, aggravated by
coexistent medical problems, and perceived as a low priority by
health funding agencies--requires an increased emphasis on
preventive services. Innovative, individualized, preventive
dental programs are often necessary for each patient.
Preventive modalities include the use of home-applied fluoride
solutions, anti-microbial mouth rinses, specially fabricated
tooth brushes, instruction to family or care givers on oral
hygiene techniques, and more frequent dental examinations.
These are low-cost yet effective measures that can obviate the
need for future expensive or invasive dental care. VA has been
a world leader in developing preventive dental therapies and
field testing them for clinical efficacy.
Oral cancer is a disabling and disfiguring disease that
primarily affects middle-aged and older adults. Ninety-five
percent of cases occur in those over 40. Alcohol, tobacco, and
advanced age are important risk factors in the development of
this disease. Early detection of frequently asymptomatic
lesions can significantly reduce the disease's morbidity.
Through a long-standing program of oral screening examinations,
VA dentists have been able to expeditiously detect incipient
oral cancers. Such interventions minimize the need for ablative
surgery, which often results in swallowing and eating
difficulties. Early detection can also significantly reduce
mortality rates.
Most VA Medical Centers have established Geriatric
Evaluation and Management (GEM) programs. Dental Services
contribute to the GEM's interdisciplinary team effort by
conducting admission oral assessments, collaborating on
treatment planning, providing specialty consultations and
needed care, and preparing summaries of oral care protocols to
be maintained after discharge. Oral examinations conducted
during GEM admissions commonly identify problems previously
undetected that can impede chewing efficiency, safe swallowing,
and clearly articulated speech. Interdisciplinary treatment
planning takes advantage of the synergy associated with group
efforts. Patients are rehabilitated more rapidly with properly
staged and coordinated care. New problems and unexpected
outcomes are better addressed by geriatric interdisciplinary
teams. For matters involving the oral-dental complex, dentistry
has responded with timely assessment, definitive diagnosis, and
recommended treatment. At discharge a review of the patient's
response to treatment, plan for maintenance, and guidance for
future care are prepared. The GEM Program has been an ideal
environment for dentistry to demonstrate its relative merit and
range of contributions to the interdisciplinary team.
The VA Program Guide: Oral Health Guidelines for Long Term
Care Patients developed by the Offices of Dentistry, Clinical
Affairs, and Geriatrics and Extended Care, continues to serve
as the primary handbook for management of the multidisciplinary
oral health efforts. It describes the goals, implementation,
and monitoring of oral care provision for patients in VA long
term care programs.
The impact of VA programs in geriatric dentistry is not
limited to its own health care system, but extends to a broader
level. VA dentistry is represented on both National Institute
of Dental Research (NIDR) reviews and a U.S. Surgeon General's
workshop on oral health promotion and disease prevention. The
American Association of Dental Schools (AADS) has an ongoing
Geriatric Education Project that has developed curricular
guidelines for teaching concepts in gerontology and geriatrics
to dental and dental hygiene students. VA dentists have been
noteworthy contributors to these efforts to define geriatric
educational objectives and identify resource materials for
dental faculty members.
I response to the 1993 research agenda setting conference
``Oral Health for Aging Veterans--Making a Difference:
Priorities for Quality Care,'' emphasis is not being directed
to improving outcomes for geriatric dental interventions. VA
researchers and clinicians in a variety of settings are
assessing the risk/benefit ratio of specific treatment
modalities to determine which are the most effective. These
efforts represent a fundamental shift from research involving
process to that which measures actual outcomes, and as such
will be more useful to clinicians.
In summary, the Office of Dentistry continues to support
efforts that will benefit older veterans in three general
areas. First, optimizing the quality of dental care received by
elderly patients as VA facilities is a priority. Second,
education in geriatric oral health will continue to be made
available to patients, dental staff, and non-dental care
providers such as nurses, physicians, and family members.
Third, research with promise to broaden our understanding of
oral disease and its treatment in older adults will be
encouraged.
Office of Research and Development
In fiscal year 1995 the total Research and Development
Program (which includes the medical, health services and
rehabilitation research programs) expenditure on aging-related
research was $13.2 million, or 8.6 percent of the total
research appropriation. These funds supported 123 research
projects. VA investigators were supported by an additional
$14.6 million from extra VA sources to conduct aging-related
research (these funds supported 192 projects).
va medical research service
As the health care needs of the veteran population change,
so must the areas of research and development funded by the VA
Medical Research Service (VAMRS). Currently, half the veteran
population (approximately 13.2 million) is over age 56. An
estimated 37 percent of veterans (approximately 9 million) will
be 65 or older by the end of the decade. In response, VAMRS has
devoted substantial resources to medical problems common in
this population, including dementia, prostate cancer, other
cancers and heart disease. VA investigators have advanced the
study of neurobiology in Alzheimer's disease, hormone
regulation in prostate cancer, larynx preservation in advanced
laryngeal cancer, and drug therapy or vitamin supplementation
for prevention of heart disease and stroke.
Age-related dementia is a major health concern of the
elderly, affecting 10 percent of people over 65. VHA predicts
that 600,000 veterans will suffer from dementia by the year
2000. VAMRS spent over $4 million on studies of Alzheimer's
disease and other dementias in fiscal year 1995, and an
additional $17.7 million in research grants were obtained from
non-VA sources. Among the nearly 300 investigator-initiated VA
research projects in this area are the following:
Dr. George Bartzokis is the West Los Angeles VA Medical
Center is using magnetic resonance imaging (MRI) to test
hypothesis that patients with Alzheimer's disease have
increased iron in several brain regions. Post-mortem studies
have found elevated iron levels in the brains of these
patients, so iron may play an important role in the development
of the disease. Dr. Bartzokis' ongoing research suggests that
MRI may be useful in diagnosing and treating Alzheimer's
disease.
Dr. Douglas Galasko of the San Diego VA Medical Center is
investigating proteins in cerebrospinal fluid as possible
biological markers for Alzheimer's disease. If such markers are
confirmed, they could lead to earlier diagnosis and treatment
of the illness.
Dr. Maurice Dysken of the Minneapolis VA Medical Center is
conducting a special research initiative under which
neuropsychological tests are administered to subjects 80 and
older. Although cognitive impairment and other problems
experienced by the younger elderly have received increasing
attention, data on those 80 and older are sparse.
Osteoporosis is a crippling disease that affects millions
of postmenopausal women. The long hospitalizations and extended
nursing home care for patients suffering bone fractures is
estimated at $10 billion per year in the United States. VAMRS
devoted more than $1.4 million to research on osteoporosis last
year. Total grants to VA investigators for osteoporosis
research exceeded $4 million and funded more than 70 projects.
Among those studying osteoporosis are Dr. Stavros Manolagas
and Dr. Robert Jilka of the Little Rock VA Medical Center. They
have discovered that the lack of estrogen that occurs with the
completion of menopause causes an overproduction of bone
scavenger cells called osteoclasts. Their work, begun at the
Indianapolis VA Medical Center, opens the door to new therapies
for female veterans.
Other world-recognized investigators studying osteoporosis
include Dr. Norman Bell of the Charleston VA Medical Center,
Dr. Gregory Mundy of the South Texas Veterans Health Care
System, and Dr. David Baylink and Dr. John Farley of the Loma
Linda VA Medical Center. Dr. Baylink's group is conducting
multiple projects aimed at improving understanding of the
unequal changes in the rates of bone formation and bone
resorption in postmenopausal women. Dr. Bell studies the
relationship between vitamin D and bone and is currently
participating in clinical studies of drugs for treating
osteoporosis.
Health Services Research and Development
Health Services Research and Development (HSR&D) is an area
of research designed to enhance veterans' health by improving
the quality and cost effectiveness of the care provided by the
Department of Veterans Affairs (VA). The focus of VA HSR&D is
on (1) advancing the state of knowledge about health services
in VA and the nation and (2) disseminating that knowledge for
practical use. The large number of aging veterans and their
increasing health care needs make this population particularly
important for HSR&D to study. The Service's four major program
areas emphasized aging during Fiscal Year 1995 and are:
(1) The Investigator Initiated Research (IIR) program
encourages and supports projects proposed and conducted by VA
researchers, clinicians, and administrators from throughout the
Nation. In this intramural program of HSR&D, VA staff conduct
merit reviewed and approved projects in VA Medical Centers with
oversight and advice from Headquarters. The IIR program also
includes career development, which encourages interested
clinicians and researchers to pursue careers in VA by
guaranteeing salary support.
Forty-four percent of the 52 HRS&D investigator-initiated
projects addressed questions important to aging veterans. Six
new projects were initiated in Fiscal Year 1995 that impact
aging veterans. Projects included studies of cardiac
procedures: appropriateness and necessity of cardiac procedure
use after acute coronary artery bypass graft (CABG) surgery;
and tow studies addressing utilization of cardiac procedures
(carotid endarterectomy and CABG) in black veterans. One study
is assessing risk factors for patients who may suffer the
adverse affects of drug treatment for tuberculosis and another
study is developing a reliable and valid health status measure
for skin disease to improve outcomes of care.
Ongoing geriatric related investigations included studies
of social factors in the occurrence of cardiac events; home
measurement of peak expiratory flow rate in Chronic Obstructive
Pulmonary Disease; the effects of exercise training on frail,
elderly veterans; Simulated Presence Therapy, a new non-
pharmacologic technique, to reduce problem behaviors in
patients with Alzheimer's disease; the potential demand for
bone marrow transplantation, resource use, and effectiveness;
and malnutrition among elderly patients.
Eight IIR projects related to aging were completed in
Fiscal Year 1995. These projects included studies of the
benefits of arthritic knee joint rehabilitation; risk
assessment for cardiac complication after non-cardiac surgery;
and evaluation of home oxygen programs as compared to
outpatient facility programs; factors that influence mortality
and impatient health care utilization one year following
admission to a medical intensive care unit (ICU); the impact of
polypharmacy use on health related quality of life; the
effectiveness of managed care for improving the health status
and quality of care of aging veterans; rehospitalization
following surgery; pressure ulcer development in long-term
care; and institutional long-term care and hospital
utilization.
(2) The HSR&D Cooperative Studies in Health Services (CSHS)
projects are multi-site health services research studies based
on the model of VA's Cooperative Studies Program. Because of
VA's health care system size, complexity, and data
availability, it offers unique opportunities to conduct large-
scale research projects, such as the CSHSs. These studies are
expected to yield more definitive findings than may be
available in other health care research environments. Three
Centers for Cooperative Studies in Health Services provide
scientific, technical, and management support to the CSHS
investigators. One new CSHS project is determining the cost and
outcome of telephone care. Five ongoing CSHS projects relevant
to the concerns of the aging population are continuing. As a
result of funding constraints, only one of two new CSHS
Geriatric Evaluation and Management (GEM) trials that began
preparations in Fiscal Year 1994 was allowed to continue in
Fiscal Year 1995.
(3) The HSR&D Field Program is a cadre of core VA staff
assigned to a network of selected medical centers. In 1995, the
Service provided funding for nine ongoing HSR&D Field Programs.
In support of program objectives, Fields Program staff conduct
independent research projects and collaborate with community
institutions.
Field Programs serve as Centers of Excellence in selected
areas of expertise in health services research. Four of these
programs have aging as one of their primary research foci. The
Northwest Center for Outcomes Research in Older Adults, the
HSR&D Field Program at Seattle VAMC, continues to examine
issues related to aging, including the magnitude and costs of
prevention strategies for diabetic foot problems; and the
impact of rehabilitation services on inpatients newly diagnosed
with a disabling disorder. The Midwest Center for Health
Services and Policy Research at Hines VAMC in Illinois
emphasized gerontology and rehabilitation issues. The HSR&D
Field Program in Bedford, Massachusetts, is a Center for Health
Quality, Outcome and Economic Research and has a strong
interest in advance directives and health related quality of
life issues. Another HSR&D Field Program, the Center for the
Study of Healthcare Provider Behavior at the Sepulveda VAMC,
has a strong interest in health care quality and outcomes
within both VA and non-VA health systems.
In addition to these Field Program investigations during
Fiscal Year 1995, HSR&D Service provided core support funding
for the Normative Aging Study (NAS), a multidisciplinary and
longitudinal investigation of human aging, and the Dental
Longitudinal Study, a companion study addressing oral health
and risk factors for oral disease in an aging population.
(4) The Special Projects Program encompasses the HSR&D
Service Directed Research (SDR) Program, the Management
Decision Research Center (MDRC), and special activities such as
conferences and seminars. Special projects may include
evaluation research, information syntheses, feasibility studies
and other research projects responsive to specific needs
identified by Congress, other federal agencies, or Department
of Veterans Affairs executive and management staff. This is a
centrally directed program of health services research
conducted by VA field staff, VA Headquarters staff, and/or
contractors engaged to analyze specific problems.
Five ongoing HSR&D Service Directed Research projects focus
on issues relevant to the aging veteran population. These
projects include an evaluation of the diagnosis, treatment, and
outcomes of veterans hospitalized for acute ischemic stroke;
and a study of health related quality of life. Additionally,
three SDR projects are focusing on prostate cancer to include
an assessment of the impact of an educational intervention on
patient preferences of prostate cancer treatment; an
investigation of familial patterns in prostate cancer; and
preference in patients suffering from advancing metastatic
prostate cancer.
As a result of the HSR&D Service initiative on women's
health, six new SDR projects were funded in 1995 that also are
expected to benefit aging female veterans. These projects
address issues of access to VA care; cancers of the
reproductive system as it relates to military experience and
Post Traumatic Stress Disorder; quality of life; long-term
care; workforce participation, health insurance and health care
use; and development of a Registry of Women Veterans.
Six SDR projects were completed in Fiscal Year 1995. They
include an examination of the nursing home minimum data set for
use in VA extended care facilities; an interactive videodisc
project to increase physician discussion of advance directives
with patients; an assessment of the impact of patient education
on prostate cancer screening decisions; a study of breast
cancer among women veterans; a study of the care of acute
myocardial infarction patients; and a special project examining
racial differences in cardiac care.
In addition to these special research initiatives, primers
are being developed by the HSR&D Service Management Decision
and Research Center (MDRC) to explain the fundamentals of a
specific health services research or health care related issue
relevant to VA's efforts to deliver high quality care. The
first primer on primary care was released in September, 1995.
The second primer on Technology Assessment in VA is expected to
be released in mid-1996. Two additional primers are in the
planning stage, one on Outcomes and the other on Program
Evaluation for Managers.
Management briefs are a new effort from MDRC. The purpose
of the management brief is to provide managers with a concise
overview of HSR&D study findings in a particular area as well
as describe the potential impact and possible implementation
strategies and resources for managers. Examples include
``Primary Care: Accessible, Continuous, Comprehensive and
Coordinated,'' and ``Caring for the Elderly Veteran` Commitment
to Quality.''
In Fiscal Year 1995, the MDRC, through its management
consultation program, conducted five studies at the request of
the Office of Geriatrics and Extended Care. Three were
completed in Fiscal Year 1995 and two have continued into
Fiscal Year 1996. Two studies, one a policy analysis and the
other an evaluation of the nursing home enhanced prospective
payment system, provided information about alternative rate
structures for contracting with community nursing homes to
maximize veteran access to high-quality long-term care while
containing costs for the Department. A third study is analyzing
the differences in costs between VA nursing home care units and
rates charged by community nursing homes to understand the
reasons for the differences. A fourth study assessed the extent
of subacute care being provided in VA facilities, and in
community nursing homes. A sixth study evaluated the
effectiveness of the homemaker/home health aide program across
the system.
Office Academic Affiliations
All short- and long-range plans for VHA that address health
care needs of the Nation's growing population of elderly
veterans include training activities supported by the Office of
Academic Affiliations (OAA). The training of health care
professionals in the area of geriatrics/gerontology is an
important component for a variety of programs conducted at VA
medical centers in collaboration with affiliated academic
institutions. Clinical experiences with geriatric patients is
an integral part of health care education for the almost
109,000 health trainees, including 34,000 resident physicians
and fellows, 22,000 medical students, and 53,000 nursing and
associated health students. These residents and students train
in VA medical centers annually as part of affiliation
agreements between VA and nearly 1,000 health professional
schools, colleges, and university health science centers.
Recognizing the challenges presented by the ever-increasing
size of the aging veteran population, the OAA has made great
strides in promoting and coordinating interdisciplinary
geriatric and gerontologic programs in VA medical centers and
in their affiliated academic institutions.
The Office of Academic Affiliations, in VHA, supports
selected geriatric education and training activities through
the VA fellowship and residency programs for physicians and
dentists.
Geriatric medicine
The issue of whether or not geriatrics should be a separate
medical specialty or a subspecialty was resolved in September
1987, when the Accreditation Council for Graduate Medical
Education (ACGME) approved Geriatric Medicine as an area of
special competence. Effective January 1988, the American Board
of Internal Medicine and the American Board of Family Practice
specified procedures for the certification of added
qualifications in geriatric medicine. VA played a critical role
in the development and recognition of geriatric medicine in the
United States, and since 1989, any VA medical center may
conduct training in geriatrics providing an ACGME-accredited
program is in place.
The demand for physicians with special training in
geriatrics and gerontology continues unabated because of the
rapidly advancing numbers of elderly veterans and aging
Americans. The VA health care system offers clinical,
rehabilitation, and follow-up patient care services as well as
education, research, and interdisciplinary programs that
constitute the support elements that are required for the
training of physicians in geriatrics. This special training was
accomplished through the VA Fellowship Program in Geriatrics
from Fiscal Year 1978-89 and through specialty residency
training since Fiscal Year 1990. In Fiscal Year 1995, VA
supported 92 physicians receiving advanced education in
geriatrics.
These educational programs are designed to develop a cadre
of physicians committed to clinical excellence and to becoming
leaders of local and national geriatric medical programs. Their
dedication to innovative and thorough geriatric patient care is
expected to produce role models for medical students and for
residents. The curriculum incorporates clinical,
pharmacological, psychosocial, education, and research
components that are related to the full continuum of treatment
and health care of the elderly.
During its 17-year history, the program has attracted
physicians with high quality academic and professional
backgrounds in internal medicine, psychiatry, neurology, and
family practice. Their genuine interest in the well-being of
elderly veterans is apparent from the high VA retention rate
after completing the fellowship training. Many of the fellows
have published articles on geriatric topics in nationally
recognized professional journals, and several fellows have
authored or edited books on geriatric medicine and medical
ethics. The number of recipients of important awards and
research grants (AGS/Pfizer, AGS/Merck, Kaiser, National
Institutes on Aging, and VA) increases each year.
The VA fellowship alumni continue to represent the largest
single agency contribution to the pool of trained geriatricians
in the United States.
Geriatric dentistry
The VA Dentist Geriatric Fellowship Program ended in June
1994. It proved to be an excellent recruitment source for
dentists uniquely trained in the care of the elderly.
Approximately thirty of these graduated fellows currently serve
as staff dentists throughout the VA system. Others have assumed
leadership positions in geriatric dentistry at academic
institutions. They have enhanced patient care and other
geriatric initiatives at their own as well as regional medical
centers, and have also contributed to the geriatric efforts at
affiliated health centers and in the community. Nationally,
former fellows have made significant contributions to the
professional literature and are actively involved in geriatric
dental research.
In July 1982, a two-year Dentist Geriatric Fellowship
Program commenced at five medical centers affiliated with
Schools of Dentistry. The goals of this program are similar to
those described for the Physician Fellowship Program in
Geriatrics. In Fiscal Year 1988, the number of training sites
increased to six for a final 3-year cycle. As of June 1994, 52
Geriatric Dentistry Fellows had completed their special
training.
The format of these fellowships, however, has changed from
predesignated sites in geriatric dentistry to individual awards
in dental research. Candidates from any VA medical center with
the appropriate resources may now compete for postdoctoral
fellowships for dental research. In Fiscal Year 1995, nine
fellows participated.
Geriatric psychiatry and geriatric neurology
In Fiscal Years 1990 and 1991, the Department of Veterans
Affairs established the 2-year Fellowship Programs in Geriatric
Psychiatry and Geriatric Neurology to develop a cadre of
physicians with expertise in two areas; (1) specialized
knowledge in the diagnosis and treatment of elderly patients
with dementia and other psychiatric/neurological problems; and
(2) innovative teaching and research skills for academic
potential. In Fiscal Year 1995, VA supported 30 Geriatric
Psychiatry Fellows and eight Geriatric Neurology Fellows.
The American Board of Psychiatry developed criteria for
ACGME-accredited training in geriatric psychiatry; and the
approval of Geriatric Psychiatry became official in September,
1993. VA expects to continue funding for fellow-level training
at the current fellowship sites during the transition to
accredited program status. This is another example of VA's
initiative in establishing programs in areas of need. In Fiscal
Year 1996, any accredited VA training site could request
positions in Geriatric Psychiatry as part of the residency
allocation.
nursing and associated health professions
Interdisciplinary team training program
The Interdisciplinary Team Training Program (ITTP) is a
nationwide systematic educational program that is designed to
include didactic and clinical instruction for VA faculty
practitioners and affiliated students from three or more health
professions such as physicians, nurses, psychologists, social
workers, pharmacists, and occupational and physical therapists.
The ITTP provides a structured approach to the delivery of
health services by emphasizing the knowledge and skills needed
to work in an interactive group. In addition, the program
promotes an understanding of the roles and functions of other
members of the team and how their collaborative contributions
influence both the delivery and outcomes of patient care.
The ITTP has been activated at 12 VA medical centers. Two
sites located at VA Medical Centers (VAMCs) Portland, Oregon;
and Sepulveda, California, were designated in 1979. Three
additional VA sites at Little Rock, Arkansas; Palo Alto,
California; and Salt Lake City, Utah, were selected in 1980;
and VAMCs Buffalo, New York; Madison, Wisconsin; Coatesville,
Pennsylvania; and Birmingham, Alabama, were approved in 1982.
In the spring of 1983, three sites were selected at VAMCs
Tucson, Arizona; Memphis, Tennessee; and Tampa, Florida.
The purposes of the ITTP are to develop a cadre of health
practitioners with the knowledge and competencies required to
provide interdisciplinary team care to meet the wide spectrum
of health care and service needs for veterans, to provide
leadership in interdisciplinary team delivery and training to
other VA medical centers, and to provide role models for
affiliated students in medical and associated health
disciplines. Training includes the teaching of staff and
students in selected priority areas of VA health care needs,
e.g., geriatrics, ambulatory care, management, nutrition, etc.;
instruction in team teaching and group process skills for
clinical core staff; and clinical experiences in team care for
affiliated education students with the core team serving as
role models. During Fiscal Year 1995, more than 185 students
from a variety of health care disciplines were provided
monetary support at the 12 model ITTP sites.
Advanced practice nursing
Advanced Practice Nursing, i.e., master's level clinical
nurse specialist and nurse practitioner training, is another
facet of VA education programming in geriatrics. The need for
specialty trained graduate nurses is evidenced by the
sophisticated level of care needed by VA patient populations,
specifically in the area of geriatrics. Advanced nurse training
is a high priority within VA because of the shortage of such
nursing specialists who are capable of assuming positions in
specialized care and leadership.
The master's level Advanced Practice Nursing Program was
established in 1981 to attract specialized graduate nursing
students to VA and to help meet needs in the VA priority areas
of geriatrics, rehabilitation, psychiatric/mental health, adult
health and critical care, all of which impact on the care of
the elderly veteran. Direct funding support is provided to
master's level nurse specialist students for their clinical
practicum at the VA medical centers that are affiliated with
the academic institutions in which they are enrolled. During
Fiscal Year 1995, 146 master's level advanced practice nursing
student positions were supported: 34 in geriatrics, 4 in
rehabilitation, 32 in psychiatric/mental/health, 32 in critical
care, and 44 in adult health/medsurgery.
VA gerontological nurse fellowship program
Gerontological nursing has been a nursing specialty since
the mid-1960's. As society changes, particularly in terms of
the demographic trends in aging, more attention is being
focused on both the area of gerontological nursing and the
education of nurses in this specialty. Doctoral level nurse
gerontologists are prepared for advanced clinical practice,
teaching, research, administration, and policy formulation in
adult development and aging.
In Fiscal Year 1985, a two-year nurse fellowship program
was initiated for registered nurses who were doctoral
candidates with dissertations focused on clinical research in
geriatrics/gerontology. The first competitive review was
conducted in 1986. One nurse fellow was selected for the Fiscal
Year 1986 funding cycle. Since that time, two nurse fellowship
positions have been available for selection at approved VA
medical center sites each fiscal year.
Initial appointments for nurse fellows are for one year.
Reappointments of one additional year are subject to
satisfactory first year's performance evaluation.
Expansion for associated health training in geriatrics
A special priority for geriatric education and training is
recognized in the allocation of associated health training
positions and funding support to VA medical centers hosting
GRECCs and to VA medical centers (non-ITTP/GRECC sites)
offering specific educational and clinical programs for the
care of older veterans. In Fiscal Year 1995, a total of 20
associated health students received funding support in the
following disciplines: Social Work, Psychology, Audiology/
Speech Pathology, Clinical Pharmacy, Advanced Practice Nursing,
Dietetics, and Occupational Therapy.
Health professional scholarship program
The Scholarship Program was established in 1980 and funded
from 1982 through 1985 to assist in providing an adequate
supply of nurses for the VA and the Nation. Beginning in 1988,
the Scholarship Program was reactivated to provide scholarships
to students in full-time nursing and physical therapy
baccalaureate and master degree programs in certain specialties
specified by VA.
By Fiscal Year 1990, additional scholarships were available
to students enrolled in baccalaureate and master's degree
occupational therapy programs, and students enrolled in their
final year of associate degree nursing programs. In Fiscal Year
1992, scholarships were available for students enrolled in
master's degree nurse anesthetist programs. Beginning in 1994,
Respiratory Therapy scholarships became available through this
program.
Since the beginning of the program, 530 awards have been
given to students studying for advanced master's degrees,
including 481 in nursing, 40 in nurse anesthesia, and 9 in
occupational therapy and physical therapy. Of this number, 301
students have completed degrees and fulfilled their obligations
by working as professionals in VA medical centers. Of these 301
professionals, 206 are still employed by VA. The remaining
students are in the process of completing their degrees,
completing their service obligations, or beginning their
service obligation in the near future.
Learning resources
The widespread education and training activities in
geriatrics have generated a broad spectrum of requirements for
learning resources throughout the VA system. Local medical
media services continue to provide thousands of audiovisual
products that meet educational and clinical needs in the areas
of geriatrics and gerontology. Local library services continue
to perform hundreds of on-line searches on data bases such as
MEDLINE and AGELINE (availablethrough Bibliography Retrieval
Services), and continue to add books, journals, and audiovisuals on
topics related to geriatrics and aging. Employee education staff have
produced and/or sponsored a number of satellite programs on Alzheimer's
disease and other dementias. Taped copies of three of these satellite
programs (``Diagnosis and Treatment of Alzheimer's Disease,'' ``Dental
Care of Cognitively Impaired Older Adults: Prioritizing Service
Needs,'' and ``Progressive Aphasia: Overview and Case in Point'') can
be obtained from the local Library Service at every VA medical center.
Employee education
In support of VA's mission to provide health care to the
aging veteran population, education and training continues to
be offered to enhance VA medical center staff skills in the
area of geriatrics. These educational activities are designed
to respond to the needs of VA health care personnel throughout
the entire Veterans Health Administration. Annually, funding is
provided for employee education and distributed to two levels
of the organization for support of continuing education
activities in priority areas.
First Level.--Funds are provided directly to each of the VA
medical centers to meet the continuing education needs of its
employees. VA Headquarters also allocates funds for VAMC-
initiated programs to allow health care facilities, with
assistance from the Employee Education Network, to conduct
education programs within the facility to meet locally-
identified training needs. VAMC-initiated funds were used to
support 23 separate activities specifically having geriatrics
as the primary content.
Second Level.--The Office of Employee Education, through
the Employee Education Network, meets education needs by
conducting programs at the regional and local medical enter
level. Examples of recent programs are:
Dementia, Depression, and Addiction;
JCAHO-Long Term Care Standards;
Alzheimer's and Dementia;
Nursing Role in Caring for the Older Adult;
Geriatric Treatment Update;
Suicide and Depression in the Elderly;
Identification and Treatment of Depression in the
Elderly;
Issues Facing Older Women;
Elder Abuse;
Myths of Aging;
Geropharmacology; and
Geriatric Care--Unresolved Problems.
Employee education programs are also conducted in
cooperation with the GRECCs, which received $276,835 in
training funds in Fiscal Year 1995 to support their identified
needs. This collaborative effort ensures the efficient use of
existing resources to meet the increasing demands for training
in geriatrics/gerontology.
In response to systemwide training needs, a National
Training Program on ``Long Term Care in Psychiatric Hospitals''
was held.
In addition, funds were provided to support continuing
education experiences for the Geriatric Fellows and the
Interdisciplinary Team Training Program staff members.
The Office of Employee Education continues to work
cooperatively with the Office of Geriatrics and Extended Care.
A collaborative initiative was the printing and distribution of
the updated ``Geriatric Pocket Pal,'' a supplemental reference
guide for clinicians.
VII. Veterans Benefits Administration
Compensation and Pension Programs
Disability and survivor benefits such as pension,
compensation and dependency and indemnity compensation
administered by the Veterans Benefits Administration (VBA)
provide all, or part, of the income for 1,700,469 persons age
65 or older. This total includes 1,238,957 veterans, 443,666
surviving spouses, 15,845 mothers and 2,001 fathers.
The Veterans' and Survivors' Pension Improvement Act of
1978, effective January 1, 1979, provided for a restructured
pension program. Under this program, eligible veterans receive
a level of support meeting a national standard of need.
Pensioners generally receive benefits equal to the difference
between their annual income from other sources and the
appropriate income standard. Yearly cost of living adjustments
(COLAs) have kept the program current with economic needs.
This Act providers for a higher income standard for
veterans of World War I or the Mexican border period. This
provision was in acknowledgement of the special needs of the
Nation's oldest veterans. The current amount added to the basic
pension rate is $1,867 as of December 1, 1995.
Veterans Services program Staff
VBA Regional Office personnel maintain an active liaison
with local nursing homes, senior citizen homes, and senior
citizen centers in an effort to ensure that older veterans and
their dependents understand and have access to VA benefits and
services.
Generally, regional office staff visit these facilities as
needed or when requested by the service providers. VA pamphlets
and application forms are provided to the facility management
and social work staff during visits and through frequent use of
regular mailings. State and area agencies on the aging have
been identified and are provided information about VA benefits
and services through visits, workshops and pre-arranged
training session. Senior citizen seminars are conducted for
nursing home operations staff and other service providers that
assist and provide service to elderly patients. Regional office
staff regularly participate in senior citizens fairs and
information events, thereby visiting and partipating in events
where the audience is primarily elderly citizens. VBA staff
also visit places where senior citizens congregate such as
malls, churches, and special luncheons or breakfasts to advise
veterans of their benefit entitlements. Regional office
outreach coordinators continue to serve on local and state task
forces and represent VA as members of special groups that deal
extensively with the problems of the elderly.
ACTIVITIES ON BEHALF OF OLDER VETERANS FOR FISCAL YEAR 1996
I. Introduction
The Department of Veterans Affairs has the potential
responsibility for a beneficiary population of more than 26
million veterans whose median age is approximately 57 years.
Over thirty-three percent of the veteran population is age 65
and older. By the year 2005, over four and a half million
veterans will be 75 years or older.
The demographic trend will require VA to redistribute its
resources to meet the different needs of this older population.
Historically, older persons are greater users of health care
services. The number of physician visits, short-term hospital
stays, and number of days in the hospital all increase as the
patient moves from the fifth to seventh decade of life.
VA has developed a wide range of services to provide care
in a variety of institutional, noninstitutional, and community
settings to ensure that the physical, psychiatric and
socioeconomic needs of the patient are met. Special projects, a
variety of innovative, medically-proven programs and individual
VA medical center (VAMC) initiatives have been developed and
tested that can be used for veteran patients and adapted for
use by the general population.
VA operates the largest health care system in the Nation,
encompassing 173 hospitals, 133 nursing home care units, 40
domiciliaries, and 398 outpatient clinics. Veterans are also
provided care in non-VA hospitals and in community nursing
homes, fee-for-service visits by non-VA physicians and dentists
for outpatient treatment, and support for care in 89 State
Veterans Homes in 42 States. As part of a broader VA and non-VA
network, affiliation agreements exist between virtually all VA
health care facilities and nearly 1,000 medical, dental, and
associated health schools. This affiliation program with
academic health centers results in almost 107,000 health
profession students receiving education and training in VAMCs
each year.
In addition to VA hospital, nursing home and domiciliary
care programs, VA is increasing the number of diversity of non-
institutional extended care programs. The dual purpose is to
facilitate independent living and to keep the patient in a
community setting by making available the appropriate
supportive medical services. These programs include Home-Based
Primary Care, Community Residential Care, Adult Day Health
Care, Psychiatric Day Treatment and Mental Hygiene Clinics, and
Homemaker/Home Health Aide Services.
The need for both acute and chronic hospitalization will
continue to rise as older patients experience a greater
frequency and severity of illness, as well as a different mix
of diseases, than younger patients. Cardiovascular diseases,
chronic lung diseases, cancers, psychiatric and mental
disorders, bone and joint disease, hearing and vision
disorders, and a variety of other illnesses and disabilities
are all more prevalent in those age 65 and older. VA continues
efforts to improve the outcomes of care for elderly patients
with complex problems by supporting Geriatric Research,
Education and Clinical Centers and specialized clinical
services such as Geriatric Evaluation and Management Programs.
II. Veterans Health Administration
office of patient care services
During this fiscal year, the Office of Patient Care
Services reorganized to form ten strategic healthcare groups.
Each of these functional groups has contributed significantly
to VA's efforts on behalf of older veterans.
Primary and Ambulatory Care Strategic Healthcare Group (SHG)
The Office of Primary and Ambulatory Care and the Office of
Geriatrics and Extended Care continue to maximize collaboration
in transforming the veterans health care system from a bed-
based, hospital inpatient system to one rooted in ambulatory
care. Physicians who specialize in geriatrics often come from
an internal medicine background that includes a strong emphasis
on primary care and an interdisciplinary team approach to
patient care. Assistance in continuing development of geriatric
primary care programs is one of the options offered by Primary
Care Education and Consultation Teams.
VHA's National Primary Care Strategic Education Committee
has charged a work group with developing a field facility
educational module specifically designed for integrating
geriatrics and primary care. Other completed modules available
to geriatricians for further developing their geriatric primary
care programs include: Managing Change; Strategic Planning;
Team Development; Customer Service; Patient and Family
Education; Information Management; Performance Measures; Ethics
and Legal Issues; and Medical Faculty Development.
Dentistry
Oral/Dental care for the geriatric patient involves
restoring function of the dentition, and elimination of pain
and suffering attributes to oral disease. It is important that
older adults are able to effectively masticate a variety of
foods so that convalescence after surgery, chemotherapy, or
other significant medical interventions is expedited.
Interpersonal skills, which are highly dependent upon
physical appearance, as well as effective communication, can be
enhanced by improving the patient's appearance and by properly
aligning and restoring the anterior teeth to maintain clarity
of speech. The goals for oral/dental care are consistent with
all disciplines involved in geriatrics--to maximize function
and foster independence in living. Dentistry needs to be an
integral part of any comprehensive health care program for the
elderly.
The nature of dental disease is often chronic and often
asymptomatic even in advanced stages. It can be aggravated by
coexistent medical problems, and perceived as a low priority by
health care funding agencies. Innovative, individualized,
preventive dental care programs are necessary for each patient.
Preventive modalities can include the use of home-applied
fluoride solutions, anti-microbial mouth rinses, specially
fabricated tooth brushes, instruction to family or care givers
on oral hygiene techniques, and more frequent dental
examinations. These are low cost yet effective measures that
can reduce the need for future expensive or invasive dental
care. VA has been a world leader in developing preventive
dental therapies and field testing them for clinical efficacy.
Oral cancer is a disabling and disfiguring disease that
primarily affects middle-aged and older adults. Ninety-five
percent of cases occur in those over 40. Alcohol, tobacco, and
advanced age are important risk factors in the development of
this disease. Early detection of frequently asymptomatic
lesions can significantly reduce the disease's morbidity.
Through a long-standing program of oral screening examinations,
VA dentists have been able to expeditiously detect incipient
oral cancers. Such interventions minimize the need for ablative
surgery, which often results in disfigurement and difficulties
in swallowing and eating. Early detection also reduces
mortality rates.
Most VA Medical Centers have established Geriatric
Evaluation and Management (GEM) Programs. Dental Services
contribute to the GEM's interdisciplinary team effort by
conducting admission oral assessments, collaborating on
treatment planning, providing specially consultations and
needed care, and preparing summaries or oral care protocols to
be maintained after discharge. Oral examinations conducted
during GEM admissions commonly identify problems that can
impede chewing efficiency, safe swallowing, and clearly
articulated speech. Interdisciplinary treatment planning takes
advantage of the synergy associated with group efforts.
Patients are rehabilitated more rapidly with properly staged
and coordinated care. New problems and unexpected outcomesare
better addressed by geriatric interdisciplinary teams. For matters
involving the oral-dental complex, dentistry has responded with timely
assessments, definitive diagnosis, and recommended treatment. At
discharge a review of the patient's response to treatment, plan for
maintenance, and guidance for future care is prepared. The GEM Program
has been an ideal environment for dentistry to demonstrate its relative
merit and range of contributions to the interdisciplinary team.
The VA Program Guide, ``Oral Health Guidelines for Long-
Term Care Patients'' developed by the Office of Patient Care
Services, Dentistry and Geriatrics and Extended Care, continues
to serve as the primary handbook for management of the
multidisciplinary oral health efforts. It descries the goals,
implementation, and monitoring of oral care provision for
patients in VA long-term care programs.
The impact of VA programs in geriatric dentistry is not
limited to its own health care system, but extends to a broader
level. VA dentistry is represented on both National Institute
of Dental Research (NIDR) reviews and a U.S. Surgeon General's
workshop on oral health promotion and disease prevention. The
American Association of Dental Schools (AADS) has an ongoing
Geriatric Education Project that has developed guidelines for
teaching concepts in gerontology and geriatrics to dental and
dental hygiene students. VA dentists have been noteworthy
contributors to these efforts to define geriatric educational
objectives and identify resource materials for dental faculty
members.
VA dentists have been active participants in recent
projects involving both basic research and health services
research. One investigator has developed measures to assess the
relationship between oral health and overall quality of life in
older patients. Another has surveyed VA dental services to
determine the effectiveness of smoking cessation interventions.
Finally, research is ongoing to discover biological markers for
the detection of oral cancer.
In summary, VA's Office of Dentistry continues to support
efforts that will benefit older veterans in three general
areas. First, optimizing the quality of dental care received by
elderly patients at VA facilities is a priority. Second,
education in geriatric oral health will continue to be made
available to patients, dental staff, and non-dental care
providers such as nurses, physicians, and family members.
Thirds, research with promise to broaden our understanding of
oral disease and its treatment in older adults will be
encouraged.
Hospital Based Acute Care Strategic Healthcare Group (SHG)
Hospital Based Acute Care serves as the primary source of
physicians for the care of all veterans, including elderly
patients. Due to the growing proportion of older veterans,
Hospital Based Acute Care is increasingly involved in all
aspects of the delivery of health care to this patient
population. Acute and intermediate medical wards, coronary and
intensive care units, and outpatient clinics are all seeing an
increased proportion of elderly patients with acute and chronic
illnesses. While some care is provided specifically by
geriatricians, as the population ages, all internists are
seeing an older veteran population.
Some subspecialty areas are particularly impacted, such as
cardiology, endocrinology (diabetes), rheumatology and
oncology. Hospital Based Acute Care provides necessary
subspecialty care in inpatient and outpatient settings in
addition to participation in Geriatric Evaluation and
Management (GEM) Programs, Hospice, Respite, Nursing Home,
Adult Day Health Care and Home-Based Primary Care. The
specialized care required by elderly patients with complex
problems has been recognized by Hospital Based Acute Care at a
number of medical centers by their establishment of Geriatric
Medicine Sections which emphasize clinical care, as well as
coordinate research and education efforts related to
geriatrics.
Age alone is less frequently used as a determinant of an
individual patient's care. Geriatric patients undergo invasive
diagnostic procedures as well. For example, the Sunbelt is
experiencing an increasingly heavy cardiac catheterization
workload. The average age of patients treated in coronary and
intensive care units is increasing, producing a concomitant
demand for cardiac rehabilitation and physical fitness programs
that are targeted to the frail elderly and the physically
handicapped of all ages. The special interest and involvement
of Hospital Based Acute Care in geriatrics has also resulted in
participation of internists in research studies such as
nutrition problems in the elderly and treatment of
hypertension.
Smoking cessation has been shown to benefit even elderly
patients. Thus, the role of Preventive Medicine for this
patient population has expanded. Hospital Based Acute Care
staff have been active in implementing preventive strategies in
smoking cessation, immunization (influenza and pneumococcal
vaccines), and colorectal screening (for cancer). Lipid control
is an emerging area that may benefit this population.
Participation in evaluation and treatment of elderly
patients by interdisciplinary teams during intermediate-length
hospital stays will be an increasingly important role for
physicians in the Hospital Based Acute Care Strategic
Healthcare Group.
Geriatrics and Extended Care Strategic Healthcare Group (SHG)
Geriatrics and Extended Care has developed an extensive
continuum of clinical services including specialized and
primary geriatric care, residential rehabilitation, community-
based long-term care, and nursing home care. The shared purpose
of all geriatrics and extended care programs is to prevent or
lessen the burden of disability on older, frail, chronically
ill patients and their families/caregivers, and to maximize
each patient's functional independence.
The following is a description of VA's geriatrics and
extended care programs and activities within each.
VA nursing home care
VA nursing home care units (NHCU), which are based at VA
facilities, provide skilled nursing care and related medical
services. Patients in NHCUs may require shorter or longer
periods of care and rehabilitation services to attain and/or
maintain optimal functioning. An interdisciplinary approach to
care is utilized in order to meet the multiple physical,
social, psychological and spiritual needs of patients.
In fiscal year 1996, more than 35,900 veterans were treated
in VA's 133 NHCUs. The average daily census of patients
provided on these units was 13,605.
VA is continuing to offer NHCU staff educational programs
to enhance the care of the mentally ill nursing home patient.
Interest in the use of the Resident Assessment Instrument/
Minimum Data Set remains high, and while not mandated, many
NHCUs have adopted it.
Community nursing home care
This is a community-based contract program for veterans who
require skilled nursing care when making a transition from a
hospital setting to the community. Veterans who have been
hospitalized in a VA facility for treatment, primarily for a
service-connected condition, may be placed at VA expense in
community facilities for as long as they need nursing home
care. Other veterans may be eligible for community placement at
VA expense for a period not to exceed 6 months. Selection of
nursing homes for a VA contract requires the prior assessment
of participating facilities to ensure quality services are
offered. Follow-up visits are made to veterans by staff from VA
medical centers to monitor patient programs and quality of
care.
VA has added multi-state contracts (MSC) to the Community
Nursing Home (CNH) Program. Multi-state and single state
nursing home contracts have been developed to reduce the
administrative and direct care costs while improving access to
nursing home care for veterans. Administrative costs associated
with maintaining 3,200 separate nursing home contracts and the
annual inspection process will be reduced. Direct care costs
are expected to be reduced by providing a more competitive rate
for nursing home care. Access to community nursing homes will
be improved by adding nursing homes, adding specialized
services in selected nursing homes, and guaranteeing placement
within 48 hours.
In September 1996, VA awarded 6 multi-state contracts and
one single state contract to corporations for quality community
nursing home care in 1,053 facilities. This includes new
contracts with 588 nursing homes. Multi-state contracts have
been awarded to: Beverly Health Care and Rehabilitation
Services; Vencor; Sun Health Care Group; Genesis Health
Ventures; Integrated Health Services; and, Unicare Health
Facilities/Park Associates. A single state contract was awarded
in California to Harmony, Inc. Together, these corporations
span 43 states.
In fiscal year 1996, 26,201 veterans were treated in the
CNH program. The number of nursing homes under contract was
3,200 and the average daily census of veterans in these homes
was 7,379.
VA domiciliary care
Domiciliary care in VA facilities provides necessary
medical and other professional care for eligible ambulatory
veterans who are disabled by disease, injury, or age and are in
need of care but do not require hospitalization or the skilled
nursing services of a nursing home.
The domiciliary offers specialized interdisciplinary
treatment programs that are designed to facilitate the
rehabilitation of patients who suffer from head trauma, stroke,
mental illness, chronic alcoholism, heart disease and a wide
range of other disabling conditions. With increasing frequency,
the domiciliary is viewed as the treatment setting of choice
for many older veterans.
Implementation of rehabilitation-oriented programs has
provided a better quality of care and life for veterans who
require prolonged domiciliary care and has prepared increasing
number of veterans for return to independent or semi-
independent community living.
Special attention is being given to older veterans in
domiciliaries with a goal of keeping them active and productive
as well as integrated into the community. The older veterans
are encouraged to utilize senior centers and other resources in
the community where the domiciliary is located. Patients at
several domiciliaries are involved in senior center activities
as part of VA's community integration program. Other
specialized programs in which older veterans are involved
include Foster Grandparents, Handyman Assistance to senior
citizens in the community, and Adopt-A-Vet.
In fiscal year 1996, 19,229 veterans were treated in 40 VA
domiciliaries resulting in an average daily census of 5,521. Of
these numbers, approximately 3,410 veterans and an average
daily census of more than 1,500 were admitted to the
domiciliaries for specialized care for homelessness. The
average age of this latter group was 43 years, while the
overall average age of domiciliary patients was 59 years.
State homes
The State Home Program has grown from 10 homes in 10 states
in 1888 to 89 state homes in 42 States. Currently, a total of
23,248 State home beds is authorized by VA to provide hospital,
nursing home, and domiciliary care. VA's relationship to State
veterans homes is based upon two grant programs. The per diem
grant program enables VA to assist the states in providing care
to eligible veterans who require domiciliary, nursing home or
hospital care. The other VA grant program provides up to 65
percent federal funding to States to assist in the cost of
construction or acquisition of new domiciliary and nursing home
care facilities, or the expansion, remodeling, or alteration of
existing facilities.
In fiscal year 1996, State veterans homes provided care to
6,095 veterans in the domiciliaries and 20,260 in the nursing
homes. The average daily census of veteran patients was 3,349
for domiciliary care and 12,749 for nursing home care.
Hospice care
VA has developed programs that provide pain management,
symptom control, and other medical services to terminally ill
veterans, as well as bereavement counseling and respite care to
their families. The hospice concept of care is incorporated
into VA medical center approaches to the care of the terminally
ill. All VA medical centers have appointed a hospice
consultation team, which is responsible for planning,
developing, and implementing the hospice program.
Home based primary care
This program, formerly called Hospital Based Home Care,
provides in-home primary medical care to veterans with chronic
illnesses. The family provides the necessary personal care
under the coordinated supervision of a hospital-based
interdisciplinary treatment team. The team prescribes the
needed medical, nursing, social, rehabilitation, and dietetic
regimens, and provides the training of family members and the
patient in supportive care.
Seventy-five VA medical centers are providing home based
primary care (HBPC) services. In fiscal year 1996, home visits
were made by VA health professionals to an average daily census
of 5,100 patients.
Adult Day Health Care
Adult Day Health Care (ADHC) is a therapeutically-oriented,
ambulatory program that provides health maintenance and
rehabilitation services to veterans in a congregate setting
during the daytime hours. ADHC in VA is a medical model of
services, which in some circumstances may be a substitute for
nursing home care. VA operated 14 ADHC centers in fiscal year
1996 with an average attendance of 373 patients. VA also
continued a program of contracting for ADHC services in 83
medical centers. The average daily attendance in contract
programs was 613 in fiscal year 1996.
Community Residential Care/Assisted Living
The Community Residential Care/Assisted Living program
provides residential care, including room, board, personal
care, and general health care supervision to veterans who do
not require hospital or nursing home care but who, because of
health conditions, are not able to resume independent living
and have no suitable support system (e.g., family, friends) to
provide the needed care. All homes are inspected by a
multidisciplinary team prior to incorporation of the home into
the VA program and annually thereafter. Care is provided in
private homes that have been selected by VA, and is at the
veteran's own expense. Veterans receive monthly follow-up
visits from VA health care professionals. In fiscal year 1996,
an average daily census of 9,300 veterans was maintained in
this program, utilizing approximately 2,100 homes.
Homemaker/Home Health Aide (H/HHA)
In fiscal year 1996, VA provided homemaker/home health aide
services for veterans needing nursing home care. These services
are provided in the community by public and private agencies
under a system of case management provided directly by VA
staff.
One hundred eighteen VAMCs were purchasing H/HHA services
in fiscal year 1996 for approximately 1,500 veterans on any
given day.
Geriatric Evaluation and Management
The Geriatric Evaluation and Management (GEM) Program
includes inpatient units, outpatient clinics, and consultation
services. A GEM Unit is usually a functionally different group
of beds (ranging typically in number from 10 to 25 beds) on a
medical service or an intermediate care unit of the hospital
where an interdisciplinary health care team performs
comprehensive, multidimensional evaluations on a targeted group
of elderly patients who will most likely benefit from these
services. The GEM unit serves to improve the diagnosis,
treatment, rehabilitation, and discharge planning of older
patients who have functional impairments, multiple acute and
chronic diseases, and/or psychosocial problems. GEM clinics
provide similar comprehensive care for geriatric patients not
in need of hospitalization as well as provide follow-up care
for older patients to prevent their unnecessary
institutionalization. A GEM program also provides geriatric
training and research opportunities for physicians and other
health care professionals in VA facilities. Currently, there
are 121 GEM Programs.
Respite care
Respite care is a program designed to relieve the spouse or
other caregiver from the burden of caring for a chronically
disabled veteran at home. This is done by admitting the veteran
to a VA hospital or nursing home for planned, brief periods of
care. The long range benefit of this program is that it enables
the veteran to live at home with a higher quality of life than
would be possible in an institutional setting. It may also
provide the veteran with needed treatment during the period of
care in a VA facility, thus maintaining or improving functional
status and prolonging the veteran's capacity to remain at home
in the community. Nearly all VA facilities have a respite care
program.
A formal evaluation of the program, issued in 1995, found a
high level of satisfaction with the Respite Care Program by
family caregivers. The evaluation also found a high level of
enthusiasm for the program by medical center staff delivering
the care.
Alzheimer's disease and other dementias
VA's program for veterans with Alzheimer's disease and
other dementias is decentralized throughout the medical care
system, with coordination and direction provided by the
Geriatrics and Extended Care Strategic Healthcare Group in VA
Central Office. Veterans with these diagnoses participate in
all aspects of the health care system, including outpatient,
acute care, and extended care programs. Approximately 56
medical centers have established specialized programs for the
treatment of veterans with dementing illnesses. Policy guidance
concerning a continuum of dementia services to be provided in
VA's health care networks is currently under development.
In order to advance knowledge about the care for veterans
with dementia, VA investigators conduct basic biomedical,
applied clinical, health services, and rehabilitation research,
much of which occurs at VA's Geriatric Research, Education and
Clinical Centers (GRECC's), and which is supported through the
VA office of Research and Development as well as extramural
sources. In fiscal year 1996, VA investigators were involved in
approximately 200 funded research projects on Alzheimer's
disease and other dementias.
Continuing education for staff is provided through training
classes sponsored by GRECCs and VA's continuing education field
units. In addition, VHA has disseminated a variety of dementia
patient care educational materials in the form of publications
and videotapes to all VA medical centers. These include
guidelines for the diagnosis and treatment of dementia,
videotapes concerning the management of Alzheimer's disease in
home and health care settings, videotapes on other geriatric
health care topics relevant to dementia patient care, and
videotapes of VA satellite teleconferences on diagnosis and
treatment of dementia. In addition to these VA-developed
materials, VA has also purchased and distributed to VA regional
libraries for use on a circulating basis throughout the VA
system a comprehensive instructional program, ``Keys to Better
Care,'' for health care providers caring for persons with
Alzheimer's disease and related disorders. Other dementia
program planning and resource materials have been distributed
to all VA medical centers, including a report on program
characteristics of a sample of VA inpatient dementia units.
In fiscal year 1996, VA conducted its second nationwide
satellite teleconference with national experts presenting
strategies for diagnosis and treatment of dementia from a
primary care perspective. In addition, a set of previously-
disseminated 21 dementia caregiver education pamphlets
developed by the Minneapolis GRECC became available via the
Internet on the home page established by the Bedford Division
of the Boston GRECC (http://med-www.bu.edu/alzheimer/). Also in
fiscal year 1996, a new videotape on natural feeding techniques
in Alzheimer's disease developed by the Bedford GRECC was
distributed to all VA medical centers. In addition, a joint VA/
University Healthsystem Consortium (UHC) technical advisory
group is working on an updated clinical guideline for primary
care practitioners on the identification and assessment of
dementia. This guideline, which is nearing completion, will be
distributed throughout the VA and UHC systems. Another project
currently under development is an Alzheimer's caregiver CD-ROM.
This interactive, multimedia program will provide basic
information on Alzheimer's disease, a staging tool, and stage-
specific strategies for care. This effort is being directed by
the VA Education Center in Minneapolis.
The comprehensive Center for Alzheimer's Disease and Other
Neurodegenerative Disorders at the Oklahoma City VA Medical
Center completed its second year of development during fiscal
year 1996. The center is progressing toward a goal to develop
and evaluate a rural health care model for the coordinated care
of patients with Alzheimer's disease or other degenerative
neurological disorders in the state of Oklahoma, using an
interdisciplinary, case-management approach.
Geriatric Research, Education, and Clinical Centers
Geriatric Research, Education and Clinical Centers (GRECCs)
are designed to enhance the VA's capability to develop state-
of-the-art care for the elderly through research, training and
education, and evaluation of alternative models of geriatric
care. First established by VA in 1975, the current 16 GRECCs
continue to serve an important role in further developing the
capability of the VA health care system to provide cost-
effective and appropriate care to older veterans.
GRECCs have established many interrelationships with other
programs to avoid fragmentation and duplication of efforts.
Important examples include the GRECCs coordination with VA's
Health Services Research and Development (HSR&D) Field Programs
and other research programs within VA and at affiliated health
science centers; coordination with VA Employee Education
Centers and Cooperative Health Manpower Education Programs, as
well as with Geriatric Education Centers at affiliated
universities; and coordination with clinical programs and
quality improvement efforts at each host VA facility and
throughout the VA network in which each GRECC is located.
In fiscal year 1996, GRECCs made a number of contributions
to the field of aging and care of the elderly. Examples include
the discovery of an Alzheimer's gene by researchers at the
Seattle, Washington GRECC; the development and dissemination by
the Bedford division of the Boston, Massachusetts GRECC of a
video on Natural Feeding Techniques for Alzheimer's Patients
for training of staff and students; and an evaluation by the
Miami, Florida, GRECC of an interdisciplinary model of care for
patients with prostate cancer.
Mental Health Strategic Healthcare Group (SHG)
Although the reported prevalence of mental illness among
the elderly varies, conservative estimates for those age 65
years or older include a minimum of 5 percent with Alzheimer's
disease or other dementias and an additional 15 to 30 percent
with other disabling psychiatric illnesses. If we use the 30
percent estimate, 2.3 to 2.7 million veterans can be expected
to need psychogeriatic care at any given time during the first
two decades of the next century. Mental Health Services
throughout VA have continued to provide care to older veterans
through a growing continuum of acute, subacute, and long-term
hospital programs, residential care, and both clinic and
community-based programs in each of the 22 new Veterans
Integrated Services Networks (VISNs). During a 1992 survey of
VA mental health programs, 192 psychogeriatric programs in 87
VA medical centers were identified. Some of the specific
activities in fiscal year 1996 are noted below:
Integrated psychogeriatric patient care
This 55 page VHA Program Guide (1103.22) was published
March 26, 1996, for primary care and mental health
professionals engaged in care of the elderly with mental health
problems. These guidelines, developed by a national VA
Psychogeriatric Field Advisory Group over a period of five
years, describe a continuum of programs for elderly
psychogeriatric patients including suggestions for treatment
modalities, organization, space, equipment, staffing,
education, research, and quality management in addition to an
overall introduction to the subject. It is recommended as a
resource for clinicians serving elderly veterans and non-
veterans alike.
UPBEAT (Unified Psychogeriatric Biopsychosocial Evaluation
and Treatment)
UPBEAT, a $2 million demonstration project currently in 10
VA facilities, is exploring clinical and economic outcomes as a
result of screening elderly patients in acute VA medical and
surgical hospital settings for depression, anxiety, and
substance abuse. Following an interdisciplinary psychogeriatric
team evaluation, case managers follow-up patients with positive
symptoms. Early findings suggest no fewer readmissions but
lower bed days of care and, consequently, significantly lower
overall costs, as compared to a ``usual care'' group.
Treatment guidelines for major depressive disorders
This algorithm-based treatment guideline for both primary
care practitioners and mental health specialist was developed
last year by a multidisciplinary group of VA and non-VA
professionals to enhance the uniformity and quality of VHA's
clinical interventions. A special depression screening exam for
veterans over 60 years of age and annotations regarding
pharmacological treatment of elders are major features of the
new guidelines. In addition, treatment of veterans with
substance abuse and post-traumatic stress disorder (PTSD) is
included. The Guideline built upon similar efforts published by
the American Psychiatric Association and the Agency for Health
Care Policy and Research (AHCPR) in 1993, and the VA Medical
Advisory Panel (Pharmacologic Management of Depression) in
1996. A ``Version I'' draft is being field tested at 30 VA
medical centers and sent to all VA facilities and a ``Version
II'' will be made available after feedback from the field test
is incorporated.
Clinical research
A MEDLINE search of medical research publications since
1990 on geriatric psychiatry in VA settings revealed 122
articles, of which 56 dealt exclusively with elderly veterans.
Of these, 21 addressed post-traumatic stress disorder (PTSD)
including studies of ex-prisoners of war, 14 primarily alcohol
abuse and its detection; 9 Alzheimer's and related diseases;
and the rest, other aspects of medical or mental illness.
Physical Medicine and Rehabilitation Strategic Healthcare Group (SHG)
Physical Medicine and Rehabilitation Therapy strives to
provide all referred older veterans with comprehensive
assessment, treatment and follow-up care for psychosocial and/
or physical disability affecting functional independence and
quality of life. The older veteran's abilities in the areas of
self-care, mobility, endurance, cognition and safety are
evaluated. Therapists utilize physical agents, therapeutic
modalities, exercise and the prescription of adaptive
equipment, to facilitate the veteran's ability to remain in the
most independent life setting. Rehabilitation personnel provide
education to the veteran and family members about adjustment to
a disability or physical limitations and instruct them in
techniques to maintain independence despite disability.
There are approximately 65 comprehensive inpatient medical
rehabilitation programs (both acute and subacute) within the
Veterans Health Administration. There are a growing number of
subacute rehabilitation programs being established at medical
centers across the nation. The subacute rehabilitation setting
affords us the ability to provide less intense rehabilitation
services for the older veteran, aimed at promoting an
individual's integration back into the community. On both acute
and subacute rehabilitation units, physicians, usually board
certified physiatrists, lead interdisciplinary teams of
professionals to focus on outcomes of functional restoration,
clinical stabilization, or avoidance of acute hospitalization
and medical complications.
A uniform assessment tool, the Functional Independence
Measure (FIM) is being implemented throughout the VA
rehabilitation system. Patients are evaluation on 18 elements
of function at the time of admission, regularly during
treatment and at discharge. Application of FIM results to
quality management activity will assist local and national
rehabilitation clinicians and managers to maximize effective
and efficient rehabilitation care delivery. An administrative
data base called the Uniform Data System for Medical
Rehabilitation (UDS/mr) monitors outcomes of care and increases
the accuracy of developing predictors and ideal methods of
treatment for the older veterans with various diagnoses.
Through a national contract with UDS/mr, facilities with
inpatient rehabilitation programs provide data and receive
outcome reports as part of a national and international USD/mr
data bank.
Rehabilitation therapists are leading and participating in
innovative treatment, clinical education, staff development and
research. Rehabilitation professionals work within Home-based
Primary Care Programs, Independent Living Centers, Geriatric
Evaluation and Management Units, Adult Day Health Care, Day
Treatment Centers, Domiciliaries, Interdisciplinary Team
Training Programs, Geriatric Research, Education, and Clinical
Centers (GRECCs), and Hospice Care Programs. Applying
principles of health education and fitness, rehabilitation
staff develop and provide programs aimed at promoting health
and wellness for the aging veteran.
Driver training centers are staffed at 40 VA medical
centers to meet the needs of aging and disabled veterans. With
the growing numbers of older drivers, the VA has put emphasis
on the training of the mature driver. Classroom education,
updates in laws and defensive driving techniques are supported
with behind-the-wheel evaluation by trained specialists.
Recreation therapy
Provided that adequate preventive and support services are
made available, older individuals can enjoy full and satisfying
lives. Studies have shown that isolation leads to depression,
and depression is the most common mental disorder affecting 20%
of persons aged 65 and older. Also, the highest suicide rate in
America is among persons aged 50 and over.
The Department of Veterans Affairs (VA) Recreation
Therapists are an integral part of interdisciplinary teams in
the treatment of illnesses in the elderly. Whether the patient
is in-patient,out-patient, residential or independent living,
therapeutic recreation services focus on restoring or maintaining
optimum independent living and quality of life. Recreation Therapists
assist patients in the following ways:
Promote physical health through therapeutic exercises
and gross motor activities;
Enhance mental functioning through the use of reality
orientation, sensory stimulation, remotivation therapy
and challenging therapeutic activities;
Use behavioral approaches to help older persons
replace maladaptive behaviors with effective functional
skills; and
Provide leisure skills training programs within the
patients' range of abilities and facilitate community
integration through the use of existing resources.
Since 1983, VA's Recreation Therapy Service has held the
National Veterans Golden Age Games (NVGAGs) for the benefit of
veterans age 55 and older. Sports and recreation are vital
components of rehabilitative medicine within VA medical
facilities, where recreation therapy plays an important role in
the lives of older patients.
The NVGAGs serve as a showcase for the preventive and
therapeutic medical value that sports and recreation provide in
the lives of all older Americans. Participants compete in a
variety of events that include but are not limited to,
swimming, tennis, shuffleboard, horseshoes, croquet, bowling
and bicycle races.
The NVGAGs are co-sponsored by VA and the Veterans of
Foreign Wars. Financial support is also provided by numerous
corporate sponsors and hundreds of local volunteers provide on-
site assistance each year.
The 1996 NVGAGs were hosted by the VA Medical Center in
Loma Linda, California. The 1997 program will be held in
Leavenworth, Kansas, during the week of July 27-August 2.
Nursing Strategic Healthcare Group (SHG)
Nursing Service, in support of VHA's reorganization and
``Prescription for Change'', continues to rank care of the
elderly veteran as a major priority. Nurses at every level of
the organization are committed to leadership in the clinical,
administrative, research, and educational components of
gerontological nursing. Powerful societal forces in both the
federal government and the private sector require even a
greater collaborative teamwork as nursing strives to integrate
advances in the technology, information management, and
participates in the transition from inpatient to outpatient
healthcare within the managed care model.
Nurses continue to participate in preventive care and
health promotion initiatives, to preserve both the veterans'
and their significant others' independence. Team approaches to
improving the health status of aging veterans have fostered
optimum levels of self-care, improved productivity, and
enhanced quality of life. Health screening, education, primary
care and referral of elderly veterans are critical functions
necessary to evaluate healthcare needs and properly place the
veteran in the most appropriate level of care. This may range
from the environment of personal care in the home as the least
restrictive setting to nursing home care as the most
restrictive environment. Nurses in wellness clinics, mobile
units and other ambulatory care settings provide supervision,
screening and health educational programs to assist veterans
and their significant others in fostering and maintaining
healthy lifestyles.
Effective utilization of Advanced Practice Nurses (APN) in
the provision of healthcare services is a critical component of
VHA's mission to provide primary care in a seamless system
across a continuum of care. This continuum of care for aging
veterans includes primary care, acute care, long-term care,
rehabilitative care and mental health care. Nurses are a vital
part of interdisciplinary teams that coordinate and provide
care in settings such as Geriatric Evaluation and Management
Programs (GEMs), ambulatory care, acute care, long-term care,
mobile care units, and community agencies. Gerontological
advanced practice nurses provide primary care and continuity of
care in the role as clinical care managers, coordinators of
care, and case managers. Through sustained patient
partnerships, APNs provide health care for aging patients in
diverse settings minimizing illness and disabilities and
focusing on health promotion, disease prevention and health
maintenance.
Primary care may be provided to aging veterans by a
physician or a nurse practitioner primary care provider and
followed by a care team including psychiatry, psychology,
social work, rehabilitative medicine and others. Primary care
services are based on long-term care needs of aging patients
including those with multiple and chronic medical problems,
functional disabilities, cognitive impairments and weakened
social support systems. Services are provided across the
continuum from health promotion and disease prevention to
screening for community services including hospice care
evaluation.
Nurses facilitate the restoration of functional abilities
of veterans with chronic illnesses and disabilities. Programs
for the physically disabled and cognitively impaired are
administered by nurses and advanced practice nurses in settings
representing ambulatory care, inpatient care and home care.
Treatment programs and rehabilitation teams are goal-directed
with physical and psychosocial reconditioning or retraining of
patients. Patient and family teaching are a major part of each
program. Family/significant others have a key role in providing
support to veterans. Both are assisted in learning and in
maintaining appropriate patient/caregiver rights and
responsibilities. VA nurses contribute to planning,
implementing and evaluating healthcare services for veterans in
the community-at-large. They serve on task forces and
participate in self-help and support groups. These include
those related to specific diseases such as Alzheimer's, cancer,
AIDS, diabetes, stroke, and spinal cord injury. VA nurses serve
in a variety of roles in their work and private volunteer
activities.
Committed to leadership in education, VA nurses provide
creative learning, experiences for both undergraduate and
graduate nursing students. Nursing education initiatives
including ``distance learning'' are being developed to provide
skills and competencies necessary to function in primary and
managed care settings. Students are able to work and study with
VA nurses who have clinical and administrative expertise in
aging and long-term care. These include nurses in various
organizational and leadership roles. These collaborative
experiences promote a culture and image of an agency that is
committed to quality care and quality of life for aging.
A recent national VA Nursing Home Care Unit (NHCU) study
revealed that over the last three years there has been a
significant decrease in restraint usage. Decreased restraint
usage is attributed to interdisciplinary reassessment of the
patient's treatment. Each patient/resident has a comprehensive
interdisciplinary plan of care which facilitates reduced
restraining usage. Resident outcomes include a decrease in the
number of falls and injuries with an increase in residents'
alertness, happiness, muscle strength, independence and pride.
Nurses and other members of the interdisciplinary team are
proud of these clinical outcomes as VA NHCUs strive to become a
restraint free environment. Such an environment enhances
resident behaviors in independence, decision making and
socialization.
Committed to research, VA nurses continue to change and
reshape clinical nursing practices. Nursing research is
improving care delivery and health promotion in the following
areas:
Alternatives to Institutional Care;
Wound Care and Effectiveness of Treatment Regimens;
Risk Assessment for Falls;
Restraint Minimization and Interdisciplinary
Assessment Tool Effectiveness;
Patient Education, Health Promotion and Maintenance;
and
Clinical Pathways
Timely application of research findings to clinical care in
all practice settings will improve the quality care and quality
of life to aging veterans. Quality of life is an essential
component for evaluating the effects of nursing care in both
research and clinical practice. Research by nurses as a
discipline and in collaboration with other members of the
health care team must focus on specific patient care outcomes
including quality of life, effectiveness of care interventions,
cost effectiveness and patient satisfaction.
Pharmacy and Benefits Management Strategic Healthcare Group (SHG)
The Under Secretary for Health established the Pharmacy
Benefits Management (PBM) Service line in FY 1996 to provide a
focus within the Veterans Health Administration (VHA)
concerning the appropriate use of pharmaceuticals in the health
care of veterans. A secondary goal is to decrease the overall
cost of health care through achievement of the PBM's primary
goal. As the VHA transitions from an emphasis on inpatient care
to ambulatory/primary care, pharmaceutical utilization will
increase dramatically.
VHA's PBM is organized around a group of field-based
physicians called the Medical Advisory Panel (MAP). The MAP
provides leadership and guidance to the PBM in addressing the
four functions of the PBM. These functions are (1) to enhance
the efficiency and effectiveness of the drug use process; (2)
to enhance the distribution systems for pharmaceuticals used in
both the inpatient and outpatient settings; (3) to consistently
bring best pharmaceutical practices into the VA health care
system, and (4) to maintain and enhance VA's drug pricing
capabilities.
The PBM serves a qualitative and quantitative role in
addressing the needs of older veterans. In a patient population
who frequently has co-morbidities and multiple drug therapies,
the actions of pharmacists to improve the drug use process are
essential in realizing the goal of the appropriate use of
pharmaceuticals. In collaboration with other health
professionals and the use of adjunct tools such as drug
treatment guidelines, acute and chronic conditions facing
geriatric patients are addressed in an efficient and effective
manner with emphasis on the clinical condition as well as
issues related to customer service and access.
Substantial gains have occurred in addressing the
timeliness of pharmaceutical services at VA medical facilities
through the use of automated distribution systems for mail
prescriptions and improved work flow processes for patients who
present at pharmacy counters. In addition, serious discussion
is underway to further improve customer service, access and
clinical care for all veteran patients through entering into
relationships with community-based pharmacists to act as
nonresident members of the facility-based primary care team.
While still in the conceptual stage this practice has the
potential to accomplish quality patient care, improve access
and customer service and improve on the efficiency of care
delivery.
Allied Clinical Services Strategic Healthcare Group (SHG)
Nutrition and food service
Medical nutrition care saves money, improves patient
outcomes and enhances the quality of life for our older
veterans. To better serve the veteran and identity nutritional
needs, many VA health care professionals are now using
Determine Your Nutritional Health Checklist and Level I and II
Nutrition System developed by the American Dietetic
Association, American Academy of Family Physicians and National
Council on Aging National Screening Initiative. The Checklist
or Level I Screen identifies those at high risk for poor
nutritional status, while Level II Screen provides specific
diagnostic nutritional information. The National Screening
Initiative emphasizes educating the physician in nutritional
care. The booklet, Incorporating Nutrition Screening and
Interventions into Medical Practice, has been nationally
disseminated to doctors. This information complements the
handbook, Geriatric Pocket Pal, developed in collaboration with
the Geriatrics and Extended Care SHG.
Many medical centers have Geriatric Nutrition Specialists
positions. Dietitians in these positions have developed easy-
to-read educational materials for their audience and shared
this information with other medical centers. Several medical
centers are providing outreach services for the elderly in
their community. For example, the Bronx VAMC provides outreach
to local senior centers, and the Dallas VAMC has bi-monthly
visits by their health screening team to facilities in their
area. Feeding dependency is highly associated with malnutrition
among nursing hone residents. Silver Spoons is one of the
successful programs instituted by the Miami VAMC nursing home
aimed at intervention before severe nutritional problems
develop in feeding dependent residents. The program uses
volunteers to fee residents and to ensure adequate nutrition.
This is an interdisciplinary program including dietary,
nursing, voluntary, medical, recreation and dental services.
The Brockton/West Roxbury VAMC developed a pureed product line
to enhance the appearance, taste, quality and acceptability of
foods for geriatric patients with dysphagia.
Social Work Service
Meeting the biopsychosocial health care needs of an aging
population of veterans and caregivers continues to be a major
priority of Social Work Service and the Veterans Health
Administration. The need to be competitive in a challenging and
changing health care environment, as well as cost-effective and
efficient in addressing the social components of health care,
has led to a re-examination of social work priorities and their
relevance to the VA health care mission, with special reference
to the needs of chronically ill, older veterans. Without a
support network of family, friends, and community health and
social services, health care gains would be lost and VHA acute
care resources would be over-burdened. It is frequently not the
degree of illness that determines the need for hospital care,
but rather the presence or absence of family and community
resources.
The expansion of homemaker/home health aide services is
evidence of the importance of non-institutionalized support
networks in maintaining the veteran in the community. Social
workers continue to coordinate discharge planning and to serve
as the focal point of contact between the VA medical center,
the veteran patient, family members, and the larger community
health and social services network. The veteran and family
members have, in many respects, become the ``unit of care'' for
social work intervention. It is this ``customer'' focus which
will undergird social work programming for vulnerable
populations, including older veterans who are demanding that
VHA be more responsive and sensitive to their psychosocial
needs and those of their caregivers.
The role of the caregiver as a member of the VA health care
team and as a key player in the provision of health care
services continues to be a major area of social work practice
and will continue to be in the immediate future. This is
consistent with the recognition that 80 percent of care of the
elderly is provided in the home by family, neighbors, etc., and
that the family, ordinarily theveteran's spouse, is the key
decision-maker concerning health insurance issues, and, most probably,
access to health and community support services.
As VHA transitions from an acute care to a primary care/
community interactive health care delivery system, Social Work
Service has placed increased emphasis on its pivotal role in
community services coordination, development, and integration.
The development of a ``seamless garment of care,'' with case
management services as its centerpiece, is being given
increased emphasis by Social Work Service and its National
Committee. The National Committee published Social Work
Practice Guidelines, Number 2: Social Work Case Management, in
September 13, 1995. These standards are used as a starting
point and part of the educational process that takes place at
each medical center, as we move into interdisciplinary clinical
paths and practice guidelines. The National Committee functions
in an advisory capacity concerning social work and systems
issues, priorities, and practice concerns. While case
management services have been a central component of social
work practice in VHA, this service modality is being ``re-
discovered'' by the VA health care system as an essential
component of services provided to ``at-risk'' veterans and
their caregivers. Case management, also known as care
coordination, was identified in veterans' discussion groups as
a very important ingredient in meeting the veterans' health
care needs and those of their caregivers. During 1997 and
beyond, VHA, and particularly Social Work Service, will be
challenged to expand case management services in concert with
other community providers and to provide a perspective that
addresses this critical ingredient in health care in terms of
its absolute relevance to successful health care outcomes. In a
revitalized and reconfigured VA health care system, issues of
coordination, access, cost, and appropriateness of VA and
community services will be determined not only by the needs of
the customers, but also by the experience and expertise of the
providers.
Diagnostic Services Strategic Healthcare Group (SHG)
The clinical services of Pathology and Laboratory Medicine,
Radiology, and Nuclear Medicine constitute the Diagnostic
Services Group. Each of these clinical services provides direct
services to veteran patients and to clinician-led teams in
ambulatory/primary care, acute care, mental health, geriatrics
and long-term care, and rehabilitation medicine.
Diagnostic Services' staff are educated on special care of
the elderly. Pathology and Laboratory staff, for example,
receive special training on phlebotomy with the elderly. In
addition, normal values of various laboratory tests may be
different in the elderly. These differences are incorporated
into each VA facility's reference on normal ranges for tests.
Prosthetic and Sensory Aids Strategic Healthcare Group (SHG)
The mission of the Prosthetic and Sensory Aids Service
(PSAS) Strategic Healthcare Group is to provide specialized,
quality patient care by furnishing properly prescribed
prosthetic equipment, sensory aids and devices in the most
economical and timely manner in accordance with authorizing
laws, regulations and policies. PSAS serves as the pharmacy for
assistive aids and PSAS prosthetic representatives serve as
case managers for prosthetic equipment needs of the disabled
veteran.
Today, the majority of amputations performed in VA medical
centers are a result of peripheral vascular disease and
diabetes as opposed to traumatic amputations related to war
injuries dating back to World War II. Elderly veterans make up
roughly 90 percent of this patient population. For some of
these elderly veterans, the transition to learning the mobility
requirements of an artificial limb can be difficult. For
others, the adjustment to a different type artificial limb due
to the amputation of the residual limb or an amputation of
another extremity can be just as traumatic. Prosthetic
representatives exercise good logic in filling prosthetic
prescriptions for both groups of veterans, taking into account
the veteran's present quality of life, mobility, and
dependence.
PSAS is an integral member of health care teams providing
prevention, treatment, and follow-up care to our aging veteran
population. An example of this would be VHA's Preservation-
Amputation Care and Treatment (PACT) Program. It was
established to provide a model of at-risk limb care which
essentially expands the scope of care and treatment of veterans
who are at risk for limb loss or who have sustained
amputations. The PACT incorporates interdisciplinary
coordination of surgeon, rehabilitation physician, nurse,
podiatrist, therapist, and prosthetic/orthotic personnel to
track every patient with amputations, or those at risk for limb
loss, from the day of entry into the VA healthcare system,
through all appropriate care levels, back into the community.
There are 139 PACT Programs VA-wide.
Some of the most common prosthetic appliances provided to
elderly patients are artificial limbs, wheelchairs, braces,
hospital beds, environmental controls, oxygen and respiratory
equipment, eyeglasses, hearing aids, speech prostheses, talking
machines, reading machines, home safety equipment, walking
canes, crutches, and custom molded shoes.
Office of Research and Development
Medical research
Within the Office of Research and Development, the mission
of Medical Research Service is to support and enhance patient
care at VA health care facilities by seeking improvements in
the prevention, diagnosis, and treatment of diseases and
disorders. In order to focus efforts on medical problems most
prevalent within the veteran population and establish
priorities for future funding, the service has conducted a
thorough review of its research portfolio. As a result of this
study, aging has been established as one of the 17 priority
areas for funding by Medical Research Service.
Although the number of funded projects identified with a
primary focus on aging remains relatively constant, research
efforts with a secondary focus on aging include studies on a
multitude of diseases and disorders affecting older veterans.
Examples of such conditions are Alzheimer's Disease, prostate
and other cancers, depression, heart disease, and Parkinson's
Disease. Studies on these and other conditions which affect
older veterans constitute a large portion of the Medical
Research Service budget.
Among the current efforts focusing on aging in research
conducted by Gerard Schellenberg, Ph.D., Associate Director for
Research, VA Puget Sound Geriatric Research, Education and
Clinical Center (GRECC), who recently discovered the first
human gene associated with aging. The gene causes a rare
disorder, i.e., Werner's Syndrome, which results in premature
aging. This important discovery follows a previous one by Dr.
Schellenberg and colleagues--the discovery of an Alzheimer's
gene which may allow a better understanding of the disease and
lead to improved treatments.
Health Services Research and Development
Health Services Research and Development (HSR&D) is an area
of research designed to enhance veterans' health by improving
the quality and cost effectiveness of the care provided by the
Department of Veterans Affairs. The focus of VA HSR&D is on (1)
advancing the state of knowledge about health services in VA
and the nation and (2) disseminating that knowledge for
practical use. The large number of aging veterans and their
increasing health care needs make this population particularly
important for HSR&D to study. The Service's four major program
areas emphasized aging during FY 1996, as described in the
following pages.
(1) The Investigator Initiated Research (IIR) program
encourages and supports projects proposed and conducted by VA
researchers, clinicians, and administrators from throughout the
Nation. In this intramural program of HSR&D, researchers
conduct merit reviewed and approved projects in VA Medical
Centers with advice from VA Headquarters staff. The IIR program
includes career development which guarantees salary support to
clinicians and researchers interested in pursuing research
careers in VA.
Thirty-two percent of the 53 HSR&D IIR projects addressed
questions important to aging veterans. Five newly initiated
projects included an evaluation study of the effectiveness of
screening for prostatic cancer; a controlled trial of a
physical restoration intervention (SAFE-GRIP) to reduce the
likelihood of falls in the elderly after hospitalization; a
study of the differences in coronary angioplasty outcomes
between veterans and non-veterans; a study of the impact of
oral health conditions and quality of life in older veterans;
and a study to improve the management of patients with chronic
obstructive pulmonary disease.
Ongoing geriatric related investigations included studies
affecting veterans with cardiac related illnesses such as:
appropriateness and necessity of cardiac procedure use after
acute myocardial infarction; quality of life outcomes after
coronary artery bypass graft (CABG) surgery; the role of social
factors in the occurrence of cardiac events; and two studies
addressing utilization of cardiac procedures (carotid
endarterectomy and CABG) in Africian-American veterans.
Researchers are examining pressure ulcer incidence rates as
a measure for long-term care in VA facilities; examining
strategies to improve the quality of nutritional care to
elderly hospitalized patients; and developing reliable and
valid health status measures for skin disease to improve
outcomes of care.
Five IIR projects related to aging were completed. These
projects included a study of the magnitude, costs, treatment,
and prevention strategies of diabetic foot problems; a study of
quality of life outcomes after coronary artery bypass graft
surgery; Simulated Presence Therapy (SPT), a new non-
pharmacologic technique to reduce problem behaviors in
Alzheimer's disease patients; and the effects of exercise
training on frail, elderly veterans. Also completed was a study
of home monitoring of peak expiratory flow rates to detect
early respiratory decompensation in patients with chronic
obstructive pulmonary disease. This study revealed that home
monitoring is feasible, and that symptoms and peak flows can be
used to forecast respiratory status in three to seven days.
(2) The HSR&D Cooperative Studies in Health Services (CSHS)
projects are multi-site health services research studies based
on the model of VA's Cooperative Studies Program for biomedical
research. Because of VA's health care system size, complexity,
and data availability, if offers unique opportunities to
conduct large-scale research projects, such as the CSHS. These
studies are likely to yield more definitive findings than may
be available in other health care environments. Three Centers
for Cooperative Studies in Health Services (CCSHS) provide
scientific, technical, and management support to CSHS
investigators. Examples of Cooperative Studies in Health
Services projects relevant to the concerns of the aging
population include: a comparison of the cost and effectiveness
of team-managed Home Based Primary Care (HBPC) to customary
care for severely disabled and terminally ill patients; and a
study of whether the combination of inpatient care provided by
Geriatric Evaluation and Management (GEM) Units and outpatient
care provided by GEM Clinics as compared with usual care
provided to hospitalized veterans will reduce mortality and
enhance health-related quality of life for veterans.
Researchers are examining which processes and structures of
cardiac care are predictive of positive health outcomes; and
comparing costs and health outcomes of telephone care to face-
to-face clinic visits. Funding ended for one project that
tested whether providing discharged patients with ``rapid
access'' to high quality primary car would affect health
services utilization, health-related quality of life, patient
satisfaction with care, and health care costs.
(3) The HSR&D Field Program is a network of core VA staff
assigned to selected medical centers. In 1996, the Service
funded nine ongoing HSR&D Field Programs. Field Program staff
conduct independent research projects and collaborate with
community institutions in support of program objectives.
Field Programs serve as Centers of Excellence in selected
subject matter areas. Although some Field Programs have aging
as one of their primary research foci, Field Programs have
research interests in health care issues affecting aging
veterans. The Northwest Center for Outcomes Research in Older
Adults at Puget Sound Healthcare System examines issues
affecting the elderly such as, improving the quality of
ambulatory care, prevention and treatment for chronic
illnesses, and long-term care. The Midwest Center for Health
Services and Policy Research at Hines VAMC in Illinois
continues to emphasize gerontology and rehabilitation issues.
The Field Program in Bedford, Massachusetts, is a Center for
Quality, Outcomes and Economic Research with interests in the
quality of long-term care, cost effectiveness, health outcomes
and health related quality of life issues. the Center for
Health Services Research in Primary Care at Durham VAMC
emphasizes research that enhances the delivery, quality and
efficiency of primary care provided to veterans. The Center is
focusing on topics such as access to health care for ethnic
groups, process and outcomes of care relative to such diseases
as stroke, diabetes and breast cancer, and cost-effective
management of chronic diseases.
In addition to supporting Field Program investigations,
HSR&D Service provided core support funding for the Normative
Aging Study (NAS), a multidisciplinary, longitudinal
investigation of human aging, and the Dental Longitudinal
Study, a companion study addressing oral health and risk
factors for oral disease in an aging population.
(4) The Special Projects Program encompasses the HSR&D
Service Directed Research (SDR) Program, Management Decision
Research Center (MDRC), and special activities such as
conferences and seminars. Special projects may include
evaluation research, information syntheses, feasibility
studies, special initiatives and other research projects
responsive to specific needs identified by Congress, other
federal agencies, or Department of Veterans Affairs executive
and management staff. This is a centrally directed program of
health services research conducted by VA field staff, VHA
Headquarters staff, and/or contractors engaged to analyze
specific problems.
Ongoing HSR&D Service Directed Research (SDR) projects
focus on issues relevant to the aging veteran population. These
projects include an evaluation of the diagnosis, treatment, and
outcomes of veterans hospitalized for acute ischemic stroke;
and a study of health related quality of life. Additionally,
three SDR projects focus on prostate cancer. One assesses the
impact of an educational intervention on patient preferences
for treatment. Another investigates familial patterns in
prostate cancer, and another studies patient preferences in
advanced metastatic prostate cancer.
Seven continuing projects related to women's health are
expected to benefit aging female veterans. These projects
address issues of access to VA care; cancers of the
reproductive system relating to military experience and Post
Traumatic Stress Disorder; quality of life; long-term care;
workforce participation, health insurance and health care use;
and development of a Registry of Women Veterans.
Since many veterans, including older veterans, suffer from
chronic diseases, VA researchers are looking for efficient and
effective ways to manage their care. A new HSR&D Service
Directed Research project is investigating the effectiveness of
telecare in the management of diabetes.
The Under Secretary for Health proposed the nursing
research initiative to encourage new research on nursing topics
and to expand the pool of nurse investigators within the
Department ofVeterans Affairs. The Research and Development
Office in collaboration with the Nursing Service staff implemented a
research program that targets nursing investigators. This effort would
invite research proposals for health services research, medical
research and rehabilitation research. In 1995 Health Services Research
Service issued a formal Request for Applications inviting nurses at VA
medical centers to submit research proposals. The first nursing
research project was funded in 1996 related to the psychophysiology of
Post Traumatic Stress Disorder in female nurse Vietnam veterans. It is
expected that this initiative will increase the number of projects
related to aging veterans in fiscal year 1997.
In addition to these special research initiatives, MDRC is
developing primers to explain specific health services-related
or health care-related issues relevant to VA's efforts at
delivering high quality care. The first primer on Primary Care
was released in September 1995. The second primer on Technology
Assessment in VA was released in July 1996. Two forthcoming
primers will be on outcomes and program evaluation for
managers.
Management Briefs and Practice Matters are new MDRC
projects. The purpose of the Management Brief is to provide
managers with a concise overview of HSR&D study findings in a
particular research area as well as provide contact information
and important citations. Practice Matters summarizes the
results of important research within VA and promotes its
application to managers by describing the potential impact and
possible implementation strategies and resources.
In FY 1996, the MDRC, through its Management Consultation
Program conducted three studies at the request of the Office of
Geriatrics and Extended Care. Two were completed including one
study that analyzed the differences in costs between VA nursing
home care units and community nursing homes; and a second study
that assessed the extent of subacute care provided in VA
facilities and community nursing homes. One ongoing study is
evaluating the national multi-state nursing home contract
initiative. The evaluation is assessing costs, access, quality
of care and administration burden of new contracts. The MDRC
also will conduct a Congressionally-mandated analysis of VA
hospice care in 1997.
Future HSR&D initiatives expected to increase research on
aging relate to improving veterans access to VHA services; the
effects of managed care on patient and system outcomes;
alternative strategies for implementing evidence-based clinical
practice guidelines; investigating ethnic and cultural
variations in health care and designing interventions; and
exploring gender differences in health care and evaluating
interventions for improving women's health services in VA.
Rehabilitation Research and Development
The mission of the Rehabilitation Research and Development
(Rehab R&D) Service is to investigate and develop concepts,
products and processes that promote greater functional
independence and improve the quality of life for impaired and
disabled veterans. Aging, particularly the aging of persons
with disabilities, is a high priority of the service. Efforts
in this area include:
A national VA program of merit-reviewed,
investigator-initiated research, development and
evaluation projects targeted to meet the needs of aging
veterans with disabilities;
Support of a Rehabilitation Research and Development
Center on Aging at Decatur, Georgia, VA Medical Center;
and
Transfer into the VA health care delivery system of
developed rehabilitation technology and dissemination
of information to assist the population of aging
veterans and those who care for them.
In addition to specific projects on aging, many of the
investigations supported through the Service's nationwide
network of research at VAMCs and at four Rehabilitation
Research and Development Centers have relevance for impairments
commonly associated with aging.
Some examples of investigator-initiated studies currently
being carrier out are:
A Low-Vision Enhancement System (LVES);
Liquid Crystal Dark-Adapting Eyeglasses;
Upper Body Motion Analysis for Amelioration of Falls
in the Elderly;
Non-Auditory Factors Affecting Hearing Aid Use in
Elderly Veterans;
The Influence of Strength Training on Balance and
Function in the Aged; and an
Epidemiologic Study of Aging in Spinal Cord Injured
Veterans.
The Rehab R&D Center on Aging is structured around five
interdisciplinary research sections to address the multi-
dimensional nature inherent in problems of aging and
disability: Environmental Research; Vision Rehabilitation;
Neuro-Physiology; Engineering and Computer Science; and Social,
Behavioral, and Health Research. Areas of study include:
Design-related problems that affect the quality of
life of older people, including least restrictive
environments, falls, independence and safety;
Orientation and mobility for the blind, low vision,
and rehabilitation outcomes measurement for older
persons with visual impairment;
The neurologic and physiologic changes that accompany
aging and behavioral coping problems; and
Development and application of new technologies to a
variety of prototypes for the design of assistive
devices and assistive software.
Office of Academic Affiliations
All short- and long-range plans for VHA that address health
care needs of the Nation's growing population of elderly
veterans include training activities supported by the Office of
Academic Affiliations (OAA). The training of health care
professionals in the area of geriatrics/gerontology is an
important component for a variety of programs conducted at VA
medical centers in collaboration with affiliated academic
institutions. Clinical experiences with geriatric patients are
an integral part of health care education for the almost
107,000 health trainees, including 33,000 resident physicians
and fellows, 20,000 medical students, and 54,000 nursing and
associated health students. These residents and students train
in VA medical centers annually as part of affiliation
agreements between VA and nearly 1,000 health professional
schools, colleges, and university health science centers.
Recognizing the challenges presented by that ever-increasing
size of the aging veteran population, the OAA has made great
strides in promoting and coordinating interdisciplinary
geriatric and gerontologic programs in VA medical centers and
in their affiliated medical institutions.
The Office of Academic Affiliations, in VHA, supports
selected geriatric education and training activities through
the VA fellowship and residency programs for physicians and
dentists.
Geriatric medicine
The issue of whether or not geriatrics should be a separate
medical specialty or a subspecialty was resolved in September
1987, when the Accreditation Council for Graduate Medical
Education (ACGME) approved Geriatric Medicine as an area of
special competence. Effective January 1988, the American Board
of Internal Medicine and the American Board of Family Practice
specified procedures for the certification of added
qualifications in geriatric medicine. VA played a critical role
in the development and recognition of geriatric medicine in the
United States, and since 1989, any VA medical center may
conduct training in geriatrics providing an ACGME accredited
program is in place.
The demand for physicians with special training in
geriatrics and gerontology continues unabated because of the
rapidly advancing numbers of elderly veterans and aging
Americans. TheVA health care system offers clinical,
rehabilitation, and follow-up patient care services as well as
education, research, and interdisciplinary programs that constitute the
support elements that are required for the training of physicians in
geriatrics. This special training was accomplished through the VA
Fellowship Program in Geriatrics from Fiscal Year 1978-89 and through
the specialty residency training since Fiscal Year 1990. In Fiscal Year
1996, VA supported 104 physicians receiving advanced education in
geriatric medicine and 19 physicians receiving advanced education in
geriatric psychiatry. VA also supported 15 physicians pursuing post
residency fellowship education in geriatric neurology and geriatric
psychiatry.
Geriatric dentistry
In July 1982, a two-year Dentist Geriatric Fellowship
Program commenced at five medical centers affiliated with
Schools of Dentistry. The goals of this program were similar to
those described for the Physician Fellowship Program in
Geriatrics. In Fiscal Year 1988, the number of training sites
increased to six for a final 3-year cycle. As of June 1994, 52
Geriatric Dentistry Fellows had completed their special
training.
The VA Dentist Geriatric Fellowship Program ended in 1994.
It proved to be an excellent recruitment source for dentists
uniquely trained in the care of the elderly. Approximately
thirty of these graduated fellows currently serve as staff
dentists throughout the VA system. Others have assumed
leadership positions in geriatric dentistry at academic
institutions. They have enhanced patient care and other
geriatric initiatives at their own as well as regional medical
centers, and have also contributed to the geriatric efforts at
affiliated health centers and in the community. Nationally,
former fellows have made significant contributions to the
professional literature and are actively involved in geriatric
dental research.
Since the Dentist Geriatric Fellowship Program ended at
designated VA sites, individual awards in dental research have
been initiated. Candidates from any VA medical center with the
appropriate resources may now compete for postdoctoral
fellowships for dental research.
Nursing and associated health professions
Based on the demographics of its veteran patient
population, all affiliation students receive experience in
caring for the elderly. VA also has special programs which
focus on geriatrics.
Interdisciplinary Team Training Program
The interdisciplinary Team Training Program (ITTP) is a
nationwide systematic educational program that is designed to
include didactic and clinical instruction for VA facility
practitioners and affiliated students from three or more health
professions such as physicians, nurses, psychologists, social
workers, pharmacists, and occupational and physical therapists.
The ITTP provides a structured approach to the delivery of
health services by emphasizing the knowledge and skills needed
to work in an interactive group. In addition, the program
promotes an understanding of the roles and functions of other
members of the team and how their collaborative contributions
influence both the delivery and outcomes of patient care.
Training includes the teaching of staff and students in
selected priority areas of VA health care needs, e.g.,
geriatrics, ambulatory care, management, and nutrition;
instruction in team teaching and group process skills for
clinical core staff; and clinical experiences in team care for
affiliated education students with the core team serving as
role models.
The ITTP, which began in 1978, has been activated at 12 VA
medical centers: Birmingham, AL; Buffalo, NY; Coatesville, PA;
Little Rock, AR; Madison, WI; Memphis, TN; Palo Alto, CA;
Portland, OR; Salt Lake City, UT; Sepulveda, CA; Tampa, FL; and
Tucson, AZ.
The goal of ITTP is to develop a cadre of health
practitioners with the knowledge and competencies required to
provide interdisciplinary team care to meet the wide spectrum
of health care and service needs for veterans, to provide
leadership in interdisciplinary team delivery and training to
other VA medical centers, and to provide role models for
affiliated students in medical and associated health
disciplines. During Fiscal Year 1996, more than 184 students
from a variety of health care disciplines were provided funding
support at the 12 ITTP sites.
Advanced Practice Nursing Program
Advanced Practice Nursing, i.e., master's level clinical
nurse specialist and nurse practitioner training, is another
facet of VA education programming in geriatrics. The need for
specialty trained graduate nurses is evidenced by the
sophisticated level of care needed by VA patient populations,
specifically in the area of geriatrics. Advanced nurse training
is a high priority within VA because of the shortage of such
nursing specialists who are capable of assuming positions in
specialized care and leadership.
The master's level Advanced Practice Nursing Program was
established in 1981 to attract specialized graduate nursing
students to VA and to help meet needs in the VA priority areas
of geriatrics, rehabilitation, psychiatric/mental health,
primary care, medical-surgical and critical care, all of which
impact on the care of the elderly veteran. Direct funding
support is provided to master's level nurse specialist students
for their clinical practicum at the VA medical centers that are
affiliated with the academic institutions in which they are
enrolled. During Fiscal Year 1996, 376 master's level advanced
practice nurse student positions were supported.
VA Predoctoral Nurse Fellowship Program
Gerontological nursing has been a nursing specialty since
the mid-1960's. As society changes, particularly in terms of
the demographic trends in aging, more attention is being
focused on both the area of gerontological nursing and the
education of nurses in this specialty. Doctoral level nurse
gerontologists are prepared for advanced clinical practice,
teaching, research, administration, and policy formulation in
adult development and aging.
In Fiscal Year 1985, a two-year nurse fellowship program
was initiated for registered nurses who were doctoral
candidates with dissertations focused on clinical research in
geriatrics/gerontology. The first competitive review was
conducted in 1986. One nurse fellow was selected for the Fiscal
Year 1996 funding cycle. Since that time, two nurse fellowship
positions have been available for selection at approved VA
medical center sites each fiscal year.
In FY 1994, the program was changed to Predoctoral Nurse
Fellowship to include all clinical areas that are relevant to
the care of veterans.
Expansion for associated health training in geriatrics
A special priority for geriatric education and training is
recognized in the allocation of associated health training
positions and funding support to VA medical centers hosting
GRECCs and to VA medical centers (non-ITTP/GRECC sites)
offering specific educational and clinical programs for the
care of older veterans. In Fiscal Year 1996, a total of 189
associated health students received funding support in the
following disciplines: Social Work, Psychology, Audiology/
Speech Pathology, Clinical Pharmacy, Advanced Practice Nursing,
Dietetics, and Occupational Therapy.
Geropsychology post-doctoral fellowship
In FY 1993, the Office of Academic Affairs initiated a one
year geropsychology post-doctoral fellowship program. The
purpose of the program is to develop a cadre of highly trained
geropsychologists who will contribute to the care of the
elderly both within and outside the Department of Veterans
Affairs. This pool of individuals should provide an excellent
source of recruitment for future VA psychologists.
One fellow is selected annually at each of the following 10
VA Medical Centers: Brockton, MA; Cleveland, OH; Gainesville
FL; Houston, TX; Knoxville, IA; Little Rock, AR; Milwaukee, WI;
Palo Alto, CA; Portland, OR; and San Antonio, TX. These VAMCs
have strong geriatric focus programs and accredited psychology
internship programs.
Office of Employee Education
In support of VA's mission to provide health care to the
aging veteran population, education and training opportunities
are offered to enhance the skills of medical center employees
in the area of geriatrics. These educational activities are
designed in response to the needs of health care personnel
throughout the entire Veterans Health Administration. Annually,
funding is provided for employee education and distributed to
three major levels of the organization to support continuing
education activities in priority areas.
First Level.--Funds are provided directly to each VA
medical center to meet the continuing education needs of their
employees. In FY 1996, 383 individual episodes of training were
received by medical center employees in the area of geriatrics.
An additional 2,393 employees attended locally sponsored
lectures, workshops and seminars. The total number trained
through local funding represents 4.3% of the total number of
individuals trained.
Second Level.--The Office of Employee Education, through
the Employee Education System meets education needs by
conducting programs at the VA network and local medical center
levels. In FY 1996, seven of the ten major employee education
system sites conducted a total of 35 programs in the area of
geriatrics. A total of 1,139 employees participated in these
programs. Examples of some of the more recent programs include:
Dementia, Depression, and Addiction;
Alzheimer's and Dementia;
Suicide and Depression in the Elderly;
Issues Facing Older Women; and
Myths of Aging.
Level Three.--Employee education programs are also
conducted in cooperation with the GRECCs. In FY 1996, the
GRECCs received $253,304 in training funds to support their
identified needs. This collaborative effort ensures the
efficient use of existing resources to meet the increasing
demands for training in geriatrics and gerontology.
Chief Information Office
Library and audiovisual communication
The widespread education and training activities in
geriatrics have generated a broad spectrum of requirements for
information throughout the VA system. Local library services
continue to perform hundreds of on-line searches on databases
such as MEDLINE and other bibliographic databases, and continue
to add books, journals, and audio visuals on topics related to
geriatrics and aging.
The Satellite Television network carried four live
broadcasts targeted to healthcare providers who work with aged
patients. The topics included elder abuse, PTSD in the older
adult, geriatric oral surgery and Alzheimer's Disease.
The AV Software Delivery Program partnered with the
Employee Education Network to produce and distribute two
programs on videocassette explaining the VA Patient Assessment
Instrument and Alzheimer's Feeding Techniques. Both are
available in VA Library Services.
III. Veterans Benefits Administration
compensation and pension
Disability and survivor benefits such as pension,
compensation, and dependency and indemnity compensation
administered by the Veterans Benefits Administration (VBA)
provide all, or part, of the income for 1,672,173 persons age
65 or older. This total includes 1,225,426 veterans, 430,864
surviving spouses, 14,152 mothers and 1,731 fathers.
The Veterans' and Survivors' Pension Improvement Act of
1978, effective January 1, 1979, provided for a restructured
pension program. Under this program, eligible veterans receive
a level of support meeting a national standard of need.
Pensioners generally receive benefits equal to the difference
between their annual income from other sources and the
appropriate income standard. Yearly cost of living adjustments
(COLAs) have kept the program current with economic needs.
This Act provides for a higher income standard for veterans
of World War I or the Mexican border period. This provision was
in acknowledgment of the special needs of the Nation's oldest
veterans. The current amount added to the basic pension rate is
$1,867 as of December 1, 1995.
veterans services program staff
VBA Regional Office personnel maintain an active liaison
with local nursing homes, senior citizen homes, and senior
citizen centers in an effort to ensure that older veterans and
their dependents understand and have access to VA benefits and
services.
Generally, regional office staff visit these facilities as
needed or when requested by the service providers. VA pamphlets
and application forms are provided to the facility management
and social work staff during visits and through frequent use of
regular mailings. State and area agencies on aging have been
identified and are provided information about VA benefits and
services through visits, workshops and pre-arranged training
sessions. Senior citizen seminars are conducted for nursing
home operations staff and other service providers that assist
and provide service to elderly patients. Regional office staff
regularly participate in senior citizens fairs and information
events, thereby visiting and participating in events where the
audience is primarily elderly citizens. VBA staff also visit
places where senior citizens congregate such as malls,
churches, and special luncheons or breakfasts to advise
veterans of their benefit entitlements. Regional office
outreach coordinators continue to serve on local and state task
forces and represent VA as members of special groups that deal
extensively with the problems of the elderly.