This Program Announcement expires on July 24, 2004, unless reissued. IMPACT OF PAYMENT AND ORGANIZATION ON COST, QUALITY AND EQUITY Release Date: July 31, 2001 PA NUMBER: PA-01-125 (This PA has been deactivated, see NOT-HS-05-009) Agency for Healthcare Research and Quality PURPOSE The Agency for Healthcare Research and Quality (AHRQ) invites applications to conduct research related to the effects of payment and organizational structures and processes on the cost, quality and equity of health care services. Research results are intended to 1) improve clinical practice, 2) improve the health care system"s ability to provide access to and deliver high quality, high-value health care, and 3) provide policymakers with the ability to assess the impact of payment and organizational changes on outcomes, quality, access, cost, and use of health care services. Responding to the Institute of Medicine’s (IOM) report, Crossing the Quality Chasm, this Program Announcement (PA) expresses AHRQ’s highest priority interests in research that would provide rigorous, objective, and essential evidence required by public and private decision-makers seeking to understand and improve the health care system, to make changes in health care delivery, insurance, and financing, and to manage the system in a manner that would induce efficient, effective, equitable, accessible and timely health care. Important issues to be addressed by such research include: 1) How do different payment methodologies and financial incentives within the health care system affect health care quality, costs, and access? a) How do payment methodologies affect the behavior of health care organizations and individual providers? b) Which payment arrangements among patients, providers, and health plans enhance patient-centered knowledge of and involvement with treatment regimens? c) How do payment policies affect decisions about the purchase and selection of health services and health insurance? What is the role of quality in such decisions? What are the effects of such decisions on health care costs? 2) What has been the impact of purchaser and public sector initiatives on quality, costs, and access to health care and health insurance? Of particular interest would be the impact of employer and coalition efforts on the quality and cost-effectiveness of care in the marketplace, the impact of State efforts to monitor and improve access and quality, and the impact of public and private payment changes on access to health care and to health insurance for vulnerable populations. 3) What organizational structures and processes are most likely to sustain high- quality, efficient, effective, timely, and accessible health care? 4) How do different patterns and levels of market competition affect the quality and cost of care? This PA also expresses AHRQ’s interest in basic methodological work to support such research, including: development of payment methodologies, improvements in analytical and empirical methods required to simultaneously address issues of efficiency, quality, and equity, and improvement in data collection methods and qualitative methods needed to understand the structure of new health care organizations and an evolving health care system. Projects that develop these and other relevant methods are encouraged. However, grant applications for research projects that use existing methods to answer more immediate questions are also encouraged. HEALTHY PEOPLE 2010 The Public Health Service (PHS) is committed to achieving the health promotion and disease prevention objectives of Healthy People 2010, a PHS- led national activity for setting health improvement priorities for the United States (U.S.). AHRQ encourages applicants to submit grant applications with relevance to the specific objectives of this initiative. Potential applicants may obtain a copy of Health People 2010 at http://www.health.gov/healthypeople. ELIGIBILITY REQUIREMENTS Applications may be submitted by domestic or foreign, public or private not- for-profit organizations, including universities, clinics, units of State and local governments, and eligible agencies of the Federal government. AHRQ, by statute, can make grants only to not-for-profit organizations, however, for- profit organizations may participate in grant projects as members of consortia or as subcontractors. Organizations described in section 501(c) 4 of the Internal Revenue Code that engage in lobbying are not eligible. AHRQ encourages investigators who are women, members of minority groups and persons with disabilities to apply as Principal Investigators. MECHANISM OF SUPPORT The mechanism of support for this PA generally will be the research project grant (RO1). Responsibility for planning, direction and execution of the proposed project will be solely that of the applicant. The total project period for an application submitted in response to this PA may not exceed five years. Awards will be administered under PHS grants policy as stated in the PHS Grants Policy statement. Some of the topics or development of projects encouraged in this PA may also be more suitable for a small project grant (projects requesting total costs of $100,000 or less) (R03). If so, applicants are encouraged to apply under the procedures outlined in the AHRQ Small Research Grant Program PA, published in the NIH Guide for Grants and Contracts (NIH Guide), January 2, 2001. Program Announcements and grants policy statements listed above are available through the AHRQ Web site http://www.AHRQ.gov (Funding Opportunities) and from the AHRQ Publications Clearinghouse (see INQUIRIES). RESEARCH OBJECTIVES Background The combination of rapid advances in medical knowledge and increased use of evidence-based decision making in medicine holds great promise for improving health care. Developments in genomics, pharmaceuticals, informatics and other technologies promise increased longevity and better health and functioning. Health care, however, can only be as good as the systems that provide it. Much health care in the U.S. is provided within large but often fragmented systems with complex funding streams. While the U.S. has an excellent health care system in many ways, it also exhibits waste and inefficiency which in turn exacerbates health care costs, affordability, and access problems (IOM, 2001). People with low incomes, from rural or urban areas and those who lack health insurance are particularly likely to experience these problems. In addition, the current health care system lacks the continuity of services that the chronically ill patient needs. One result of the current health care system is an increased incidence of injuries to patients from the care that is intended to help them, as documented in a 1999 IOM report To Err is Human: Building a Safer Health System. Problems with patient safety, however, reflect only a small part of the unfolding story of quality in American health care, according to a more recent IOM report Crossing the Quality Chasm (IOM, 2001). As emphasized in this latter report, the current health care system also has an impact on other dimensions of quality, such as efficiency, effectiveness, equity, timeliness and patient-centeredness. Specifically, Crossing the Quality Chasm draws attention to problems in the health care system, identifying a quality chasm between the health care we have and the health care we could have (IOM, 2001). The report points out that this chasm to a large extent springs from two overarching system features: the way we pay for care, and the way we structure the organizations that provide it. Although payment is just one of many factors that affect provider and patient behavior, it is an important one that subsequently influences the quality of health care. The current payment mechanisms, the IOM asserts do not adequately support or encourage the provision of high quality care. In addition, the report acknowledges that the structure of health care systems and processes within them also make the attainment of high-quality care difficult. The result of current payment and organization strategies, according to the IOM, is that health care harms too frequently and routinely fails to deliver its potential benefits. At the same time, public and private decision-makers are concerned about recent increases in the cost of care. Summarizing these widespread quality problems, Crossing the Quality Chasm declares that the American health care delivery system is in need of fundamental change. The report calls for action to improve the American health care delivery system as a whole, in all of its quality dimensions (i.e., efficiency, effectiveness, equitability, timeliness, patient- centeredness, and safety), for all Americans. Improvements in these six key dimensions of health care would address not only concerns about quality but also concerns regarding the rising costs of care. Crossing the Quality Chasm and similar calls for action immediately raise research questions about public and private sector changes in the health care system that would most likely yield desired improvement. Payment changes under consideration include new methods of reimbursement for providers, practical and effective risk adjustment methods, alternative approaches to addressing capital requirements for improving the delivery of health care, and changes in public and private purchasing efforts. Organizational and system changes include more efficiently designed care processes, effective use of information technologies, the development of effective teams, improved coordination of care across patient conditions, services, and settings, network affiliations and alliances that promote high-quality care and different market rules and incentives. Given the importance of payment and organization on the cost, quality and equity of health care, evidence-based decision making will be as important in the policy and management arena as it is in medicine (Kovner et al., 2001). In choosing among alternative methods for financing and organizing health care, it will be critical for public and private policymakers to have recent, evidence on the impact of differing payment methods and organizational structures, and in particular on how these variables affect cost, quality and equity of health care. Achieving this knowledge will be a sizeable and continuing task, given the complexity and frequent change in the marketplace. Adding to the importance and difficulty of the task is the need to be able to identify the impact of payment and organizational structure not just in the aggregate but for particular priority populations (e.g., inner-city areas, rural areas, including frontier areas, low-income groups, minority groups, women, children, the elderly, and individuals with special health care needs, including individuals with disabilities and individuals who need chronic care or end-of-life health care). It is not enough to improve health care on average. A systematic examination of ways to improve health care for all is essential. Some of the evidence for answering these questions will come from research AHRQ has supported in the recent past through a series of Requests for Applications (RFAs) ( Market Forces in a Changing Health Care System (RFA-HS- 95-005), Referrals from Primary to Specialty Care (RFA-HS-96-006), Quality of Care Under Varying Features of Managed Care Organizations (RFA-HS-98- 005), Health Care Access, Quality and Insurance for Low-Income Children (RFA-HS-99-005), Health Care Markets and Managed Care (RFA-HS-00-001)). In addition, research funded by more recent AHRQ initiatives will inform processes related to two (i.e., patient-centeredness and safety) of the six quality dimensions of health care (e.g., Patient-Centered Care: Customizing Care to Meet Patients Needs , Improving Patient Safety: Health Systems Reporting, Analysis, and Safety Improvement Research Demonstrations (RFA-HS- 01-003)). Given the magnitude and complexity of recent payment, market, and delivery system changes, and given the IOM-documented impact of these variables on the efficiency, effectiveness, equitability and timeliness of health care, AHRQ believes a broader, continuing and more sustained research effort is needed. Objectives and Scope of Activity To improve the quality of the health care system, providers, purchasers, system managers and policymakers need knowledge of the impact of different payment and organizational arrangements on the cost, quality and equity of health care. AHRQ seeks to support research in four areas including: 1) payment methods and policies, 2) public and private purchasing initiatives, 3) organizational structures and processes, and 4) market forces. 1. Payment Methods and Policies Payment methodologies and policies are a critical determinant of the success of any health care system. They strongly influence the delivery of care by health care organizations and professionals and the selection and utilization of services by patients. For example, under a fee-for-service system, there is an incentive to overuse services that are not necessary or may harm a patient. On the other hand, under a capitated system, there is an incentive to under use necessary services. Other reimbursement strategies and methodologies (e.g., diagnostic related groups (DRGs), risk adjustment, carve-outs, tax policies, physician reimbursement) also can affect the cost and quality of care. As suggested in the IOM’s Crossing the Quality Chasm report, current payment mechanisms often create obstacles to the goal of achieving efficient, high quality care. Payment methods often do not adequately support or compensate health care professionals for providing high quality care, or reward providers for quality improvements. Financial barriers embedded in payment policies reinforce fragmentation by paying separately according to the setting of care and provider type, and by not giving providers the flexibility to customize care for individual patients (IOM, 2001). While there has been a great deal of research on the incentives of payment methods with respect to cost and utilization, there has been comparatively little on how payment methods and incentives affect quality of care from the perspective of the provider, patient or family. The IOM’s report, Crossing the Quality Chasm, specifically suggests that private and public purchasers should examine their current payment methods to remove barriers that currently impede quality improvement, and to build in stronger incentives for quality enhancements. AHRQ encourages studies that will a) examine existing payment methodologies and incentives designed to reduce barriers to quality and incorporate stronger incentives for quality enhancement, b) examine processes needed to remove barriers to providing high quality, efficient, effective care under new payment systems that reward providers for integrated care, c) examine methodological issues surrounding the definition of provider and the economic unit at which payment methodologies have their effect, d) pilot test and evaluate innovative financing systems that provide incentives for a high quality, cost-effective and efficient mix of preventive, acute and long-term care (Cohen and Spector, 1996), e) pilot test and evaluate innovative payment mechanisms such as: blended methods of payments for providers, multi-year contracts, payment modifications to encourage the use of electronic interaction among clinicians and between clinicians and patients, risk adjustment, bundled payments for priority conditions and alternative approaches for addressing the capital investments needed to improve quality (IOM, 2001), and/or f) pilot test or evaluate innovative financing systems that provide incentives for enhanced patient/family participation in medical care decisionmaking and long term care planning. In particular, AHRQ encourages researchers to examine the influence of payment methodologies and policies on the behavior of health care organizations and providers, patient participation in care and employee decision making. Illustrative questions in each of the areas include: a) Behavior of Health Care Organizations and Providers o How do payment methodologies affect integration of care? What payment methodologies do a better job of integrating physical and mental health? Acute and long-term care? What financial incentives increase continuity of care and access to appropriate services for particular groups, such as children, people with low incomes, the elderly, people with disabilities or people with chronic illness? o How can barriers to providing high quality, efficient, effective care be removed under new payment systems that reward providers for integrated care? o How do different payment systems affect the distribution of health care services? (e.g., Cohen and Cunningham, 1995). o What impacts do different payment arrangements have on the organization of providers? o How can reimbursement strategies be used to increase quality of care and reduce caregiver burden for families with long-term health care needs (e.g., home health, respite care, nursing home and other residential facilities, assisted living facilities)? o How do payment strategies affect staff turnover and supply (e.g., nursing shortages in hospitals, staff shortages in long-term care facilities and home care)? b) Patient Involvement in Care o Which payment arrangements among patients, providers, and health plans enhance patients knowledge of and involvement in treatment regimens? o How have existing payment arrangements affected patient participation in care? Does the use of these arrangements encourage patient involvement in care? o What payment arrangements do patients prefer? How do these preferences vary? o How can payment arrangements encourage the use of innovative technologies to improve patient involvement in care? Where and when are specific payment arrangements appropriate? o How do payment arrangements influence the interaction between patients and clinicians? o What is the impact of enhanced patient involvement on the utilization of health care services and associated expenditures? c) Employee Behavior o How do payment policies (either current policies or alternative policies) affect employee decisions about the purchase and selection of health services and health insurance? For example, to what extent does benefit coverage, coverage of dependents and co-payments influence decisions about the purchase of health insurance? o How does employee behavior in response to payment policies subsequently influence quality of care? o How do payment systems affect employee access to specific health care services? o How do payment systems affect what employers and employees spend on health care? 2. Public and Private Purchasing Initiatives In any health care system, those who pay for care have a major impact on the cost, quality and equity of that care. In the U.S. market-driven system, the major payers are private employers and public purchasers. In 1999, 84.2 percent of all Americans in the civilian noninstitutionalized population had some type of private or public health insurance coverage. About 68.1 percent of Americans obtained health insurance from private sources. Another 16.1 percent had only public sources of coverage, primarily Medicare and Medicaid. (The remaining 15.8 percent of Americans, 42.8 million people, were uninsured (Rhoades and Chu, 2000).) The future behavior of these public and private purchasers will be a major determinant of our capacity to close the chasm identified by the IOM, to maximize quality and equity, and minimize waste and inefficiency, in the health care system. At this point, however, little is known about the present motivations, strategies and behaviors of these purchasers, and even less about the impact of such strategies on the quality of care (i.e., if and how purchasers are using their market power to drive quality improvements). For example, although some literature suggests that non-clinical quality markers may be a consideration of purchasers, little research exists about how, when and under what circumstances these private purchaser strategies affect individual, corporate and community health (Fraser, 2000), and even less knowledge is available about public purchasing efforts. To date, most purchaser efforts to improve quality and efficiency have been done individually or through regional health care coalitions. During the past year, however, a new national group of large purchasers and coalitions the Leapfrog Group (see www.leapfroggroup.org) has formed with the deliberate intent of combining forces to increase their purchasing power. The Leapfrog Group is a consortium of Fortune 500 companies and other large private and public health care purchasers sponsored by The Business Roundtable. Their explicit goal is to mobilize employer purchasing power to trigger breakthroughs in the safety and the overall value of health care to American consumers. Such an effort provides a natural demonstration that could prove extremely instructive to the purchasing and policy community seeking ways to close the quality chasm, but rigorous empirical evidence is not yet available. Closing these information gaps is critical to closing the Quality Chasm. Employers, coalitions and public purchasers need evidence of which strategies are effective, and under what circumstances, for maximizing quality, equity, and efficiency, and what the payoff for employee/family health, satisfaction and productivity can be. Federal and State policymakers who set the ground rules for the marketplace also need to know the extent and success of such activities so they can determine how to influence employer behavior and the market in which health care is bought and sold, and in fact so they can assess the likelihood that our market-based system ever will be able to close the quality chasm. Evidence-based decisionmaking by purchasers and policymakers requires rigorous qualitative and quantitative analyses of past purchaser behaviors as well as evaluations of future natural experiments, pilots, and demonstrations by private and public purchasers. Examples of particular questions include: o Motivation and extent of value-based purchasing efforts: To what extent and in what ways do purchasers factor particular dimensions of quality and efficiency into their purchasing decisions and relationships? How do these efforts vary by types of employer (public vs. private, small vs. large, national vs. local)? Are there market factors that affect employer and coalition decisions to pursue these efforts, and if so, what are they? How do employer efforts to purchase quality care differ across geographic regions? What are the organizational differences between purchasers who are implementing strategies to improve quality and those who are not? What are organizational barriers to implementing purchasing strategies aimed at improving quality or moderating cost? o Use of market-based purchasing strategies: What determines which strategies they pursue, and what is known about the extent and circumstances of success for alternative strategies? Do providers respond to purchasers demand for information, and if so, do they report information accurately? What types of purchaser strategies motivate providers to change behavior? Do purchasers change who they contract with when quality standards are not met by providers? Do providers take steps to improve care as a result of these efforts? What impact do these efforts have on the broader marketplace? o Impact on cost, quality, and equity: What is the impact of market-based purchaser strategies on cost, quality, and equity of care for a) employees and beneficiaries, b) the community as a whole, c) vulnerable populations? How much market share is required for purchasers to affect quality in the market as a whole? What is the impact of value-based purchasing efforts by public and private purchasers on access, quality and cost of care for the uninsured in the community? o Use of employee-based strategies: Some purchasers are focusing their efforts not on direct market leverage but on educating employees to make informed choices. What tools are purchasers using to communicate quality of health care information to employees, and how effective are these tools? Does the information communicated provide incentives for consumers to choose higher quality care, or only comparative information? Which incentives or types of information are most likely to motivate consumers to choose higher quality care? What is the impact of such strategies on employee choices? What is the impact on the marketplace and on employee health? o Use of community-based strategies: Another approach some purchasers are taking is to create or participate in community-wide efforts to improve health care and community health. What has been the concrete impact of such strategies, and what lessons can these efforts provide to other communities? o Business case for quality: Does higher quality health care improve employee health so that it in turn affects the corporate bottom line, and if so, to what extent does employee health affect corporate profits? Is there a business case for quality for providers, or a minimum threshold that would make the business case compelling for providers? 3. Organizational Structures and Processes The health care system has undergone tremendous changes over the last decade. Consolidations among health plans, hospitals and physician practices have significantly altered the market structure. In coping with environmental turbulence, health care organizations have tried various survival strategies, ranging from building strategic alliances to enhancing internal capabilities (Luke et al., 2000). Consolidation and integration has been pursued by many health care organizations. Prior research in this area has focused on the impact on cost while little is known about the effects on quality of care. For example, studies on system integration or network affiliation have revealed mixed results on the effectiveness of such interorganizational arrangements on cost control (Bazzoli et al., 2000, Clement et al., 1997). Building physician and clinical integration, which has been suggested as a promising mechanism for improving quality of care and efficiency, were found highly prevalent among urban hospitals but with little impact on hospital costs (Burns et al., 1998, Alexander et al., 1999, Bazzoli et al., 2000). As new organizational forms continue to evolve in the health care sector, policymakers and health care managers need to understand the interrelationships among providers, health plans, and purchasers that are represented by these new forms and the implications for cost and quality of care. Refining internal capabilities is another widely adopted strategy by health care organizations. The most common emphasis has been on improving process of care through implementation of reengineering programs such as continuous quality improvement (CQI)/ total quality management (TQM). The literature, however, has yet to demonstrate the success of reengineering in lowering cost and improving patient outcomes (Walston and Bogue, 1999, Walston et al., 2000). This points to the need for more research to understand the role of organizational design at different levels (i.e., system, organization, department and individual practitioner) in influencing the process and quality of care. Effective organizational design results from a match with the specific environment and the nature of technologies involved in providing care. Empirical studies have shown the utility of employing such a perspective to study changes within health care organizations. For example, researchers have found that the inclusion of clinical staff in strategic decisionmaking was associated with lower hospital costs (Ashmos et al., 1998) and better resident outcomes in nursing homes (Anderson and McDaniel, 1999). Despite these changes, the current design of the health care system is poorly organized and highly fragmented. The health care system and organizations lack rudimentary clinical information capabilities (IOM, 2001), resulting in poor quality of care that is characterized by unnecessary duplication of services, long waiting times and overuse, underuse or misuse of services. In addition, care delivery processes are overly complex. Care processes waste resources, leave unaccountable gaps in coverage, result in loss of information, and fail to build on the strengths of all health professionals involved to ensure that care is timely, safe and appropriate (IOM, 2001). The 2001 IOM report calls for a fundamental redesign in the organization and delivery of health care. Specifically, the report challenges representatives from health care organizations (e.g., health care systems, health care networks, managed care organizations, health plans hospitals, medical groups, multi-specialty clinics, integrated delivery systems) to identify, adapt and implement state-of-the art approaches . . . [that] redesign care processes based on best practices, use information technologies to improve access to clinical information and support clinical decisionmaking, enhance knowledge and skills management, develop effective teams, coordinate care across patient conditions, services and settings over time and incorporate performance and outcome measures for improvement and accountability. To support the fundamental redesign of the organization and delivery of health care and support evidence-based management, health care organizations and institutions, clinicians and policymakers need rigorous research on the impact of organizational structures and processes on the cost, quality and equity of care. Illustrative questions are as follows: o How can organizational structures and processes (e.g., network affiliations and alliances, clinical integration, provider consolidation and integration, case management, care coordination, interaction between physicians and non-physician members of the care team, development of effective teams, leadership within organizations, organizational culture) reduce fragmentation and increase continuity of care across settings and services for children? For chronically ill individuals? For the disabled and elderly needing long-term care? o How do various strategic activities pursued by health care organizations (e.g., hospitals, assisted living facilities, long-term care facilities, mental health facilities, community health facilities) influence the cost and quality of care? For example, what impact do system integration, network affiliation, and alliance formation have on internal organizational aspects of individuals and providers and the subsequent care processes? o Given many of the challenges currently faced by health care organizations (e.g., long-term care staffing shortages, growth of the uninsured population, provision of care in non-traditional sectors, including social welfare, criminal justice and education), what are effective innovative approaches that can be taken to organize the delivery of care that will increase efficiency and improve quality? o How can organizational structures and processes be modified to increase access to services by under-served minority members? To improve the quality of care to minority populations and decrease racial and ethnic disparities? o How can organizational structures and processes be modified to decrease staffing shortages that compromise quality care and to maximize the quality and efficiency of care in the face of such shortages? o What is the impact of changes in ownership and restructuring of health care organizations on organizational culture and climate and the subsequent care processes? 4. Market Forces Organizational structures, payment, and associated processes operate within the context of market forces, such as increasing managed care, incentive driven behavior, and general market competition. Legislative, regulatory, and other public sector activities (e.g., decreased funding for Federal, State and local providers and regulatory and legal actions) interact with market forces to provide additional environmental effects on the health care system (IOM, 2001, Appendix B). In the last several years, with the absence of major national health care reforms, relatively unconstrained market forces have driven periods of relatively frequent mergers, acquisitions and affiliations within and between health plans, hospitals and physician practices, and other organizational changes. Recently some observers, however, have offered evidence of re- fragmentation in some of these sectors (Robinson, 1996). In addition purchasers and health plans also have been experimenting with new affiliations and partnerships. Taken together, such activities have led to increased complexity in both the financing and organization of the health care system. These changes in the health care marketplace raise a number of research questions concerning the extent and nature of market forces, the role of market forces in payment policies, the effect of market forces on financing and organization, and the associated organizational effects of these market forces on health care costs, quality and access. In order to make desirable fundamental changes in America’s health care system and avoid unintended consequences of decisionmaking, public and private policy leaders need evidence not only on payment mechanisms and organizational structures affecting cost, quality and access, but also on policy-relevant characteristics of the environment that shape health care financing and organization. Illustrative questions are as follows: o Market Forces: How do market forces (e.g., new broader forms of managed care, consolidation in certain health care sectors, fragmentation in others, changes in prices of pharmaceuticals, economic characteristics of new health care technology, changes in the supply of physicians, nurses, and allied health professionals, availability of capital for improvements, variation in contractual arrangements, and especially payment arrangements) affect organizational structure (e.g., HMOs, PPOs and new organizational types), behavior (e.g., integration of services, choices of technology including informatics and use of resources) and outcomes (e.g., efficiency, financial stability of organizations serving disadvantaged and priority populations)? Specifically, how do different patterns and levels of market competition affect the organization and delivery of health care and its cost and quality? Similarly, how have competitive factors affected cost and quality of care in rural markets? In urban markets? In long-term care markets? What is the impact of market competition operating through organizational change on the quality of care provided to the poor? How has the consolidation of facilities and institutions and rise in bankruptcies affected access, quality and cost of long-term care? What features of health care markets have demonstrated improvements in the efficient use of resources used in providing health services? What are the consequences of such improvements for the distribution of costs across providers, plans, patients and purchasers? Who really pays? What are the associated consequences of market-driven organizational change for health care quality and access to care? How has the growth of the assisted living industry influenced the use, quality and cost of nursing homes? What has been its impact on the long-term care needs of families? o Interaction of Market Forces with Public Sector Initiatives: How does the legislative, regulatory and judicial environment (e.g., Employee Retirement Income Security Act (ERISA), Health Insurance Portability and Accountability Act of 1996 (HIPAA), Balanced Budget Act of 1997 (BBA), Olmstead decision of 1999) interact with market forces as described above to effect organization and payment? What are the effects of regulatory and legislative changes on public sector initiatives to provide incentives for quality-enhancing organizational structure and processes? On the distribution of organizational types? On features of health care organizations? On payment arrangements and associated consequences for health care costs, quality and equity? How have regulatory policies that encourage or restrict civil lawsuits influenced provider behavior? What is the impact on quality and cost? How has the Olmstead decision impacted the financing and organization of health care delivered to individuals with disabilities? What has been the subsequent affects on cost, quality and access? Methods 1. Types of Research Individual projects may use rigorous qualitative or quantitative methods, or a combination of the two. Qualitative methods may be especially useful in studying complex multi-tiered organizations and can either be used alone to deepen understanding of how organizational characteristics are connected to the quality and efficiency of health services or to complement quantitative methods and thereby strengthen the research design. For a detailed discussion of the use of qualitative methods in health services research, see Health Services Research, 1999, Issue No. 5, Part II. Quantitative methods should be rigorous and use state-of-the-art methodologies. Projects using such methods should be grounded in appropriate theoretical frameworks. Hypotheses-testing projects should present competing hypotheses clearly. Applied and new quantitative methods are expected to address methodologic problems, such as endogeneity, selection bias, confounding variables, and clustering. AHRQ encourages basic methodologic research including development of tools and methods as well as more applied research. For example, the development of new measurement tools to permit accurate and valid estimates of health care utilization, expenditures and sources of payment for care received under a more patient-centered system are encouraged, as are the identification of cost efficient and feasible modifications to existing data systems to obtain the necessary linkages in episodic provider and patient specific data that facilitate more accurate estimates of expenditures. 2. Data Sources For research that is designed to use existing data, AHRQ encourages research applications that will use data from the Medical Expenditure Panel Survey, or MEPS (http://www.meps.ahrq.gov/), the Healthcare Cost and Utilization Project, or HCUP (http://www.ahrq.gov/data/hcup/), and other AHRQ sources. Additional information is listed below in the AHRQ Data Section under Application Procedures. Development of large new surveys is not discouraged, but it is expected that most research supported under this initiative will use existing data, where possible, for several reasons: 1) Such data may be quite appropriate for research expected under this PA, given that they are often connected to reimbursement, 2) Use of such data is efficient and expedient, since they do not require collection and are relatively available, 3) Given rapid changes in health care organizations and commensurate changes in the legislative and regulatory environments, both the research questions and the decisionmaking context for some research encouraged under this PA imposes demands for timeliness in conducting such research and on the reporting of results, thus making existing data sources attractive, 4) Application of rigorous statistical techniques can be used to address certain inherent weaknesses in the use of existing data. Thus, investigators are expected to acquire, process, and use existing data from multiple sources to capture complex interactions within organizations and between organizations. Investigators interested in larger data acquisition efforts are urged to contact program staff. Note that proposed projects with direct costs exceeding $500,000 in any one year require permission from AHRQ program staff two months prior to submission of the application. (See INQUIRIES). 3. Partnerships and Co-Sponsors AHRQ also encourages partnerships with private and public organizations to facilitate development and sharing of scientific knowledge and resources, including cost-sharing mechanisms, projects that will produce results within two to three years, and results that can be integrated rapidly into practice or policy. AHRQ encourages investigators to consider evaluations of Federal- and State- level initiatives (e.g., demonstrations) intended to align current payment methods and purchaser strategies with quality improvement goals. In addition, State governments with access to unique data that would contribute to the research areas described in this PA are encouraged to partner with research institutions, especially if proposed research could be generalized to other State health care experiences. In the case of evaluation of Federal or State public programs, applications should include letters of support and cooperation from the appropriate Agency and show how the information will be disseminated to inform subsequent efforts. AHRQ is interested in co-funding projects with other public and private agencies. In particular, the National Cancer Institute (NCI) has expressed interest in co-sponsoring selected projects that have the potential to improve the translation of research evidence to improved cancer care services. The PA is consistent with the extramural program focus of both the Outcomes Research and Health Services and Economics Branches of the Applied Research Program in Division of Cancer Control and Population Sciences (DCCPS). Efforts to make cancer care and other health services more efficient, effective, equitable, timely, patient-centered and safer should draw on the best evidence about how to accomplish these objectives, and successes should be well documented and widely disseminated. Interested applicants should contact a program officer in the Center for Organization and Delivery Studies (CODS) for further details (see INQUIRIES). In addition, the Changes in Health Care Financing and Organization (HCFO) initiative at the Robert Wood Johnson (RWJ) Foundation has expressed an interest in co-sponsoring selected projects on the Leapfrog Group to evaluate the effect of current program efforts on quality of care. Interested applicants should contact a program officer in the CODS for further details (see INQUIRIES). 4. Special Considerations In addition, AHRQ has identified, as a special focus of research, those health payment and organizational issues related to the following priority populations: low income groups, racial and ethnic minority groups, women, children, the elderly, individuals with special health care needs, including individuals with disabilities and those who need chronic care and end-of-life care, and individuals living in inner-city, rural and frontier areas. Research focused on specific conditions is also encouraged. Particular emphasis is placed on those conditions that are prevalent, expensive to manage, or policy relevant. Policy Relevance and Dissemination Studies under this PA are expected (1) to contribute to our basic understanding of recent changes in health care payments, markets and organizations, (2) to build capacity research tools, data, and teams-- to answer associated questions of policy relevance, and (3) to produce information in formats useful to participants in the formulation of public and private policy. Applicants should be concrete in describing (1) the decision making audiences that potentially would be most interested in the proposed research and (2) how applicants anticipate their results being used for public and private policy purposes. Dissemination strategies should not be limited to publication in peer-reviewed journals but may encompass a variety of approaches, such as translating results into non-technical monographs and distributing them through associations of private and public officials, educating legislators, public administrators, health plan executives, employers, and others in seminars, and outreach to mass media. Plans, time lines, personnel, and budgets for such dissemination efforts should be explicitly presented. SPECIAL REQUIREMENTS Data Privacy Pursuant to section 903(c) of the Public Health Service Act (42 USC 299a- 1(c)), information obtained in the course of any AHRQ-supported study that identifies an individual or entity must be treated as confidential in accordance with any promises made or implied regarding the use and purposes of the data collection. Applicants must describe in the Human Subjects section of the application procedures for ensuring the confidentiality of such identifying information. The description of the procedures should include a discussion of who will be permitted access to the information, both raw data and machine readable files, and how personal identifiers and other identifying or identifiable data will be safeguarded. The grantee should ensure that computer systems containing confidential data have a level and scope of security that equals or exceeds those established by the Office of Management and Budget (OMB) in OMB Circular No. A-130, Appendix III - Security of Federal Automated Information Systems. The National Institute of Standards and Technology (NIST) has published several implementation guides for this circular. They are : An Introduction to Practices for Securing Information Technology Systems, and Guide for Developing Security Plans for Information Technology Systems. The circular and guides are available on the web at: http://csrc.nist.gov/publications/nistpubs/800-12/. Rights in Data AHRQ grantees may copyright or seek patents, as appropriate, for final and interim products and materials including, but not limited to, methodological tools, measures, software with documentation, literature searches, and analyses, which are developed in whole or in part with AHRQ funds. Such copyrights and patents are subject to a Federal government license to use these products and materials for AHRQ purposes. In accordance with its legislative dissemination mandate, AHRQ purposes may include, subject to statutory confidentiality protections, making research materials, data bases, and algorithms available for verification or replication by other researchers, and subject to AHRQ budget constraints, final products maybe made available to the health care community and the public by AHRQ, or its agents, if such distribution would significantly increase access to a product and thereby produce public health benefits. Ordinarily, to accomplish distribution, AHRQ publicizes research findings but relies on grantees to publish in peer-reviewed journals and to market grant-supported products. INCLUSION OF WOMEN, MINORITIES AND CHILDREN IN RESEARCH STUDY POPULATIONS It is the policy of AHRQ that women and members of minority groups be included in all AHRQ-supported research projects involving human subjects, unless a clear and compelling rationale and justification are provided that inclusion is inappropriate with respect to the health of the subjects or the purpose of the research. All investigators proposing research involving human subjects should read the UPDATED NIH Guidelines for Inclusion of Women and Minorities as Subjects in Clinical Research, published in the NIH Guide for Grants and Contracts on August 2, 2000 (http://grants.nih.gov/grants/guide/notice-files/NOT-OD-00-048.html), a complete copy of the updated Guidelines are available at http://grants.nih.gov/grants/funding/women_min/guidelines_update.htm: The revisions relate to NIH defined Phase III clinical trials and require: a) all applications or proposals and/or protocols to provide a description of plans to conduct analyses, as appropriate, to address differences by sex/gender and/or racial/ethnic groups, including subgroups if applicable, and b) all investigators to report accrual, and to conduct and report analyses, as appropriate, by sex/gender and/or racial/ethnic group differences. To the extent possible, AHRQ requires adherence to these NIH Guidelines. Investigators may obtain copies from the above sources or from the AHRQ Publications Clearinghouse, listed under INQUIRIES, or from the NIH Guide Web site http://grants.nih.gov/grants/guide/index.html. AHRQ program staff may also provide additional information concerning these policies (see INQUIRIES). APPLICATION PROCEDURES Applications are to be submitted on the research grant application form PHS 398 (rev. 5/01) available at http://grants.nih.gov/grants/funding/phs398/phs398.html. Although applicants are strongly encouraged to use the 05/01 revision of the PHS 398 as soon as possible, the 4/98 version may be used for receipt dates until January 9, 2002. State and local government applicants may use PHS 5161-1, Application for Federal Assistance (rev.5/96), and follow those requirements for copy submission. Applicants are encouraged to read all PHS Form 398 instructions prior to preparing an application in response to this PA. Submit a signed, typewritten original of the application, including the checklist, and five signed photocopies, in one package to: Center for Scientific Review National Institutes of Health 6701 Rockledge Drive, Room 1040-MSC 7710 Bethesda, MD 29892-7710 (20817 for express/courier service) AHRQ is not using the Modular Grant Application and Award process. Applicants for funding from AHRQ should prepare applications according to instructions provided within form PHS 398. Beginning with applications for AHRQ submitted for the February 1, 2001 receipt date, Institutional Review Board (IRB) approval of human subjects is not required prior to peer review of an application unless otherwise indicated by the Agency (http://grants.nih.gov/grants/guide/notice-files/NOT-HS-00-003.html.) All investigators/applicants proposing research involving human subjects should pay particular attention to the instructions in the form PHS 398 regarding human subject involvement. The PHS 398 research grant application instructions and forms (rev. 5/2001) at http://grants.nih.gov/grants/funding/phs398/phs398.html are to be used in applying for these grants and will be accepted at the standard application deadlines (http://grants.nih.gov/grants/dates.htm) as indicated in the application kit. This version of the PHS 398 is available in an interactive, searchable PDF format. Although applicants are encouraged to begin using the 5/2001 revision of the PHS 398 as soon as possible, the NIH will continue to accept applications prepared using the 4/1998 revision until January 9, 2002. Beginning January 10, 2002, however, the NIH will return applications that are not submitted on the 5/2001 version. For further assistance contact GrantsInfo, Telephone 301/710-0267, Email: GrantsInfo@nih.gov. AHRQ applicants are encouraged to obtain application materials from the AHRQ Publications Clearinghouse (see INQUIRIES). On line 2 of the face page of the application, mark the yes box and type the PA number and title in the space provided. AHRQ encourages applicants to review all application Form 398 instruction prior to completing an application. The PHS 398 type size requirements (p.6) will be enforced rigorously and non-compliant applications will be returned. Receipt dates for R01 grant applications are three times annually: October 1, February 1, and June 1. The last date for submitting initial R01 applications in response to this PA is June 1, 2004. R03 grant applications are received on March 24, July 24, and November 24. The last date for initial R03 applications in response to this PA is July 24, 2004. Application Preparation (for Using Center for Medicare and Medicaid Services (CMS) Data) For applications that propose to use Medicare and Medicaid data that are individually identifiable, applicants should state explicitly in the Research Design and Methods section of the Research Plan (form 398) the specific files, time periods, and cohorts proposed for the research. In consultation with the Center for Medicare and Medicaid Services (CMS), formerly Health Care Financing Administration (HCFA), AHRQ will use this information to develop a cost estimate for obtaining the data. This estimate will be included in the estimated total cost of the grant at the time funding decisions are made. To avoid double counting, applicants should not include the cost of the data in the budget. Applicants should be aware that for individually identifiable Medicare and Medicaid data, Principal Investigators and their grantee institutions will be required to enter into a Data Use Agreement (DUA) with CMS to protect the confidentiality of data in accordance with standards set out in OMB Circular A-130, Appendix III-Security of Federal Automated Information Systems. The use of the data is restricted to the purposes and time period specified in the DUA. At the end of this time period, the grantee is required to return the data to CMS or certify that the data have been destroyed. For the sole purpose of assuring that data confidentiality is maintained, included in the DUA is the requirement that the User agrees to submit to CMS, a copy of all findings within 30 days of making such findings. The user agrees not to submit these findings to any third party (including but not limited to any manuscript to be submitted for publication) until receiving CMSs approval to do so. Grantees must also comply with the confidentiality requirements of Section 903(c) of the PHS Act. See the Data Privacy section for details on these requirements as well as references to Circular A-130 and its implementation guides from the National Institute of Standards and Technology. In developing research plans, applicants should allow time for refining, approving and processing their data requests. Requests may take six months from the time they are submitted to complete. Applications proposing to contact beneficiaries or their providers require the approval of the CMS administrator and may require meeting(s) with CMS staff. CMS data are provided on IBM mainframe tapes using the record and data formats commonly employed on these computers. Applicants should either have the capability to process these tapes and formats or plan to make arrangements to securely convert them to other media and formats. Questions regarding CMS data should be directed to the AHRQ program official listed under INQUIRIES. AHRQ Data AHRQ encourages research applications that will use data from the Medical Expenditure Panel Survey, or MEPS (http://www.meps.ahrq.gov/), the Healthcare Cost and Utilization Project, or HCUP-3 (http://www.ahrq.gov/data/hcup/), and other AHRQ sources. MEPS is a rich data source for healthcare utilization, expenditure and insurance information. MEPS directly links data about persons and their families with information obtained from their employers, insurers and healthcare providers (Cohen et al., 1997). It is the third in a series of nationally representative surveys of medical care use and expenditures in the U.S.. Unlike its predecessors, MEPS is an ongoing survey. MEPS collects data on the specific health services that American use, how frequently they use them, the cost and source of payment for services, and information on the types and costs of private health insurance held by and available to the U.S. population. It provides a foundation for estimating the impact of changes in sources of payment and insurance coverage on different economic groups or special populations of interest, such as the poor, elderly, uninsured, and racial and ethnic minorities. Current information on the availability of MEPS data is on the MEPS section of the AHRQ Web site (http://www.ahrq.gov). The HCUP includes databases covering 1988-1997, with 1998 and 1999 data available in 2001. These all-payer databases were created through a Federal- State-industry partnership to build a multistate healthcare data system. The main HCUP databases contain discharge-level information for inpatient hospital stays in a uniform format with privacy protections. The Nationwide Inpatient Sample (NIS) is a nationwide probability sample fo about 1000 hospitals. The State Inpatient Databases (SID) contain inpatient records for all community hospitals in 22 states. Other HCUP databases contain ambulatory surgery data from nine states. These databases can be directly linked to county-level data form the Health Resources and Services Administration’s Area Resource File and to hospital-level data from the Annual Survey of the American Hospital Association. Special Application Instructions Specific instructions for Form 398 (rev. 4/98) are to be followed, with the following exceptions: o The section entitled Research Plan must not exceed 25 pages in length. Applicants determine the appropriate length of the areas that must be addressed in the Research Plan, but the statement must not exceed the 25 page limit. o In listing references, only literature immediately relevant to the application may be cited. The reference list is not counted as part of the 25 pages allotted for the Research Plan. o No appendices should be included with the application with the exception of proposed instruments. These should be attached only if they are judged to be crucial for the review of the project. The instruments will not count as part of the 25 pages. o If applicable, information such as letters of support, letters of participation, and statements of intent to establish a consortium can be placed directly before the Checklist page of the application. Submit a signed, typewritten original of the application, including the checklist, and five signed photocopies, in one package to: Center for Scientific Review National Institutes of Health 6701 Rockledge Drive, Room 1040-MSC 7710 Bethesda, MD 29892-7710 (20817 for express/courier service) In carrying out its stewardship of research programs, the AHRQ, at some point in the future, may begin requesting information essential to an assessment of the effectiveness of Agency research programs. Accordingly, grant recipients are hereby notified that they may be contacted after the completion of awards for periodic updates on publications resulting from AHRQ grant awards, and other information helpful in evaluating the impact of sponsored research. AHRQ expects grant recipients to keep the Agency informed of publications or the impact from Agency sponsored research. Applicants must also agree to notify AHRQ immediately when a manuscript based on research supported by the grant is accepted for publication, and to provide the expected date of publication as soon as it is known, regardless of whether or not the grant award is active or has ended. To receive an award, applicants must agree to submit an original and 2 copies of an abstract, executive summary, and full report of the research results in the format prescribed by AHRQ no later than 90 days after the end of the project period. The executive summary should be sent at the same time on a computer disk which specifies on the label the format used (WP5.1 or WP6.0 is preferable). REVIEW CONSIDERATIONS Upon receipt, applications will be reviewed for completeness and responsiveness to the PA by AHRQ staff. Incomplete and/or non-responsive applications or applications not following instructions given under Application Procedures will be returned to the applicant without further consideration. Accepted applications will be evaluated for scientific and technical merit by an appropriate peer review group convened in accordance with standard AHRQ peer review procedures. As part of the peer review, all applications will receive a written critique, and also may undergo a process in which only those applications deemed to have the highest scientific merit will be discussed and assigned a priority score. General Review Criteria The reviewers will be asked to discuss the following aspects of the application in their written critiques in order to judge the likelihood that the proposed projects will have a substantial impact on the pursuit of these goals. Each of these criteria will be addressed and considered by the reviewers in assigning the overall score, weighting them as appropriate for each application. Note that the application does not need to be strong in all categories to be judged likely to have a major scientific impact and thus attain a high priority score. For example, an investigator may propose to carry out important work that by its nature is not innovative but is essential to move a field forward. 1. Significance. Does this study address an important problem? If the aims of the application are achieved, how will scientific knowledge be advanced? What will the effect of these studies be on the concepts or methods driving this field? 2. Approach. Are the conceptual framework, design, methods, and analyses adequately developed, well integrated, and appropriate to the aims of the project? Are the proposed data sources appropriate and adequate? Does the applicant acknowledge potential problem areas and consider alternative tactics? 3. Innovation. Does the project employ innovative information technology applications, concepts, approaches or methods? Are the aims original and innovative? Does the project challenge existing paradigms or develop new methodologies or technologies? 4. Investigator. Is the investigator appropriately trained and well suited to carry out this work? Is the work proposed appropriate to the experience level of the principal investigator and other researchers? Is the project (or work plan) well organized? Does the proposed study team reflect the multi-disciplinary approach required to address patient safety issues? 5. Environment. Does the scientific environment in which the work will be done contribute to the probability of success? Do the proposed experiments take advantage of unique features of the scientific environment or employ useful collaborative arrangements? Is there evidence of institutional support? 6. Policy Relevance. Will the project provide Federal and State policymakers, and others participating in the formulation of such policy, with the evidence-based information they need to improve patient safety? Does the application provide a sound plan for achieving this purpose? The initial review group will also examine: proposed dissemination activities, the appropriateness of proposed project budget and duration, the adequacy of plans to include both genders and minorities and their subgroups as appropriate for the scientific goals of the research and plans for the recruitment and retention of subjects, the provisions for the protection of human and animal subjects, and the safety of the research environment. AWARD CRITERIA Applications will compete for available funds with other recommended applications. The following will be considered in making funding decisions: Quality of the proposed project as determined by peer review, availability of funds and program priority. INQUIRIES Copies of AHRQ publications can be requested through the: AHRQ Publications Clearinghouse P.O. Box 8547 Silver Spring, MD 20907 TDY(toll-free): 1-800-586-6340 or 301-586-6340 Telephone (toll-free): 1-800-358-9295 or 301-358-9295 The PA is also available on AHRQ’s Web site, http://www.AHRQ.gov, and through AHRQ InstantFAX at (301) 594-2800. To use InstantFAX, you must call from a facsimile (FAX) machine with a telephone handset. Follow the voice prompt to obtain a copy of the table of contents, which has the document order number (not the same as the PA number). The PA will be sent at the end of the ordering process. AHRQ InstantFAX operates 24 hours a day, 7 days a week. For comments or problems concerning AHRQ InstantFax, please call (301) 594- 6344. AHRQ welcomes the opportunity to clarify any issues or questions from potential applicants who have read the PA. Written and telephone inquiries concerning this PA are encouraged. Note that proposed projects with direct costs exceeding $500,000 in any one year require permission from AHRQ program staff two months prior to submission of the application. Direct inquiries regarding programmatic issues, including information on the inclusion of women, minorities, and children in study populations to: Direct inquiries regarding programmatic issues about 1a) Behavior of Health Care Organizations and Providers, 2) Public and Private Purchasing Initiatives, 3) Organizational Structures and Processes, and 4) Market Forces to: Irene Fraser, Ph.D. Center for Organization and Delivery Studies (CODS) Agency for Healthcare Research and Quality 2101 East Jefferson Street, Suite 605 Rockville, MD 20852-4908 Telephone: (301) 594-6192 Fax: (301) 594-2314 Email: cods@ahrq.gov Direct inquiries regarding programmatic issues about 1b) Patient Involvement in Care and 1c) Employee Behavior to: Steven Cohen, Ph.D. Center for Cost and Financing Studies (CCFS) Agency for Healthcare Research and Quality 2101 East Jefferson Street, Suite 500 Rockville, MD 20852-4908 Telephone: (301) 594-1400 Fax: (301) 594-2166 Email: mhender@ahrq.gov / ataylor@ahrq.gov For additional information on MEPS, email mepspd@ahrq.gov For additional information on HCUP, email hcup@ahrq.gov Direct inquiries regarding fiscal matters to: George Skip Moyer Grants Management Specialist Agency for Healthcare Research and Quality 2101 East Jefferson Street, Suite 601 Rockville, MD 20852-4908 Telephone: (301) 594-1842 Fax: (301) 594-3210 Email: smoyer@ahrq.gov AUTHORITY AND REGULATIONS This program is described in the Catalog of Federal Domestic Assistance No. 93.226. Awards are made under authorization of Title IX of the Public Health Service Act (42 USC 299-299c-7) as amended by P.L. 106-129 (1999). Awards are administered under the PHS Grants Policy Statement and Federal Regulations 42 CFR 67, Subpart A, and 45 CFR Parts 74 and 92. This program is not subject to the intergovernmental review requirements of Executive Order 12372 or Health Systems Agency review. The PHS strongly encourages all grant and contract recipients to provide a smoke-free workplace and promote the non-use of all tobacco products. In addition, Public Law 103-227, the Pro-Children Act of 1994, prohibits smoking in certain facilities (or in some case, any portion of a facility) in which regular or routine education, library, day care, health care or early childhood development services are provided to children. This is consistent with the PHS mission to protect and advance the physical and mental health of the American people. REFERENCES Alexander JA, Morrisey MA, Burns LR, Johnson V. Physician and clinical integration among rural hospitals. Journal of Rural Health. 1998,14(4):312- 26. Anderson RA, McDaniel RR Jr. RN participation in organizational decision making. Health Care Management Review. 1999,24(1):7-16. Ashmos DP, Huonker JW, McDaniel RR Jr. Participation as a complicating mechanism: The effect of clinical professional and middle manager participation on hospital performance. Health Care Management Review. 1998,23(4):7-20. Bazzoli GJ, Chan B, Shortell SM, D Aunno T. The financial performance of hospitals belonging to health networks and systems. Inquiry. 2000, 37(3):234-252. Bazzoli GJ, Dynan L, Burns LR, Lindrooth R. Is provider capitation working? Effects on physician-hospital integration and costs of care. Medical Care. 2000,38(3):311-24. Burns LR, Morrisey MA, Alexander JA, Johnson V. Managed care and processes to integrate physicians/hospitals. Health Care Management Review 1998,23(4):70-80. Clement JP, McCue MJ, Luke RD, Bramble JD, Rossiter LF, Ozcan YA, Pai CW. Strategic hospital alliances: impact on financial performance. Health Affairs. 1997,16(6):193-203. Cohen J, Beauregard K, Monheit A, Cohen S, et al., The Medical Expenditure Panel Survey: A National Health Information Resource, Inquiry. 1996/97, Winter. Cohen, J, Spector W, "The Effect of Medicaid Reimbursement on Quality of Care in Nursing Homes," Journal of Health Economics. 1996, May. Cohen, J, Cunningham P, "Medicaid Physician Fee Levels and Children"s Access to Care," Health Affairs. 1995, Spring. Fraser I., McNamara P. Employers: Quality takers or quality makers? Medical Care Research and Review. 2000, 57(Suppl 2):33-52. Health Services Research. 1999,5(Part II). Institute of Medicine (IOM). Committee on Health Care in America. Crossing the quality chasm: A new health system for the 21st century. National Academy Press: Institute of Medicine. 2001. Institute of Medicine (IOM). Kohn, Linda T., Corrigan, Janet M., and Donaldson, Molla S. (Eds). To err is human: Building a safer health system. National Academy Press: Institute of Medicine. 1999. Kovner AR, Elton JJ, Billings J. Evidence-based management. Frontiers of Health Services Management. 2001,16(4):3-46. Luke RD, Begun JW, Walston SL. Strategy Making in Health Care Organizations. In Health Care Management. eds. Shortell SM, Kaluzny AD. Delmar, NY: Thomson Learning, 2000:394- 431. McDaniel RR Jr. A view from complexity science. Frontiers of Health Services Management 1999, 16(1):44-48. PA - Patient-Centered Care: Customizing Care to Meet Patients Needs. 2001. Available at http://www.ahrq.gov (Funding Opportunities). RFA HS-00-001. Health care markets and managed care. 1999. Available: http://grants.nih.gov/grants/guide/rfa-files/RFA-HS-00-001.html RFA HS-01-003. Improving patient safety: Health systems reporting, analysis, and safety improvement research demonstrations. 2001. Available: http://grants.nih.gov/grants/guide/rfa-files/RFA-HS-01-003.html RFA HS-95-005. Market forces in a changing health care system. 1995. Available: http://grants.nih.gov/grants/guide/rfa-files/RFA-HS-95-005.html RFA HS-96-006. Referrals from primary to specialty care. 1996. Available: http://grants.nih.gov/grants/guide/notice-files/not96-078.html RFA HS-98-005. Quality of care under varying features of managed care organizations. 1998. Available: http://grants.nih.gov/grants/guide/notice-files/not97-224.html RFA HS-99-005. Health care access, quality and insurance for low-income children. 1999. Available: http://www.ahrq.gov/fund/hs99005.htm Rhoades J, Chu, M. Health insurance status of the civilian noninstitutionalized population: 1999. Rockville (MD): Agency for Healthcare Research and Quality, 2000 MEPS Research Findings No. 14. AHRQ Pub. No. 01.0011. Available: http://www.meps.ahrq.gov/papers/rf14_01-0011/rf14.pdf Robinson, JC. The Dynamics and limits of corporate growth in health care. Health Affairs. 1996,15:155-169. Walston SL, Bogue RJ. The effects of reengineering: fad or competitive factor? Journal of Health Care Management. 1999,44(6):456-474. Walston SL, Burns LR, Kimberly JR. Does reengineering really work? An examination of the context and outcomes of hospital reengineering initiatives. Health Services Research. 2000, 34(6):1363-1388.


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