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.
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