RFA-HS-99-005: HEALTH CARE ACCESS, QUALITY AND INSURANCE FOR LOW-INCOME CHILDREN

Department of Health
and Human Services (HHS)

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HEALTH CARE ACCESS, QUALITY AND INSURANCE FOR LOW-INCOME CHILDREN Release Date: January 20, 1999 RFA: HS-99-005 P.T. Agency for Health Care Policy and Research Letter of Intent Receipt Date: February 25, 1999 Application Receipt Date: April 22, 1999 PURPOSE The Agency for Health Care Policy and Research (AHCPR) and the David and Lucile Packard Foundation (Packard) invite applications for cooperative agreements to conduct research that will generate information useful to purchasers and designers of health insurance and health care delivery systems for low-income children. Specifically, answers are sought to the policy question: How do features of U.S. health care insurance and delivery systems improve health care access and quality for low-income children, particularly racial and ethnic minority children or those with special health care needs? HEALTHY PEOPLE 2000 The Public Health Service (PHS) is committed to achieving the health promotion and disease prevention objectives of "Healthy People 2000," a PHS-led national activity for setting priority areas. AHCPR encourages applicants to submit grant applications with relevance to the specific objectives of this initiative. Potential applicants may obtain a copy of "Healthy People 2000" (Full Report: Stock No. 017-001-00474-0 or Summary Report: Stock No. 017-001-00473-1) through the Superintendent of Documents, Government Printing Office, Washington, DC 20402-9325, telephone 202-512-1800. ELIGIBILITY REQUIREMENTS Applications may be submitted by domestic and foreign, public and private non- profit organizations, including universities, clinics, units of State and local governments, and other non-profit organizations and foundations. For-profit organizations are not eligible as applicants, but may participate 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 to receive grant/cooperative agreement awards. AHCPR encourages women, members of minority groups, and persons with disabilities to apply as Principal Investigators. MECHANISM OF SUPPORT The administrative and funding mechanism to be used for this program will be a cooperative agreement (U01), an "assistance" mechanism (rather than an "acquisition" mechanism), in which substantial AHCPR and Packard scientific and/or programmatic involvement with the awardee is anticipated during performance of the activity. Under the cooperative agreement, the AHCPR and Packard purpose is to support and/or stimulate the recipient"s activity by involvement in and otherwise working jointly with the award recipient in a partner role, but it is not to assume direction, prime responsibility, or a dominant role in the activity. Responsibilities and relationships under cooperative agreement(s) are set out later in this document under the section "Terms and Conditions of Award." FUNDS AVAILABLE Depending upon the availability of funds, AHCPR and the David and Lucile Packard Foundation each expect to contribute up to $1 million in fiscal years 1999, 2000, and 2001, for a combined total of $2 million per year or $6 million over the three-year period to fund five to eight projects under this RFA. These awards will cover total (both direct and indirect) costs. The total project period for an application submitted in response to this RFA may not exceed 3 years. Funding beyond the first year will depend upon satisfactory annual progress reviews and the continued availability of funds. The earliest anticipated award date is August 1999. Because the nature and scope of the research proposed in response to this RFA may vary, it is anticipated that the size of awards will vary also. While it is anticipated that five to eight projects will be funded, awards and level of support depend on receipt of a sufficient number of applications of high scientific merit. Although this program is provided for in the financial plans of AHCPR and the David and Lucile Packard Foundation, awards pursuant to this RFA are contingent upon the availability of funds for this purpose. RESEARCH OBJECTIVES Background In response to the large and growing number of uninsured persons, public insurance programs for children have been expanded. At the same time, there have been changes in the financing and delivery of health care, in particular, a shift to managed care delivery systems. Public and private policy-makers and the general public have questioned the impact of these developments on children"s health care access and quality. There is concern about why many children who are eligible for free or heavily subsidized insurance fail to take advantage of such programs. There is also concern about how low-income children, especially minority children or those with special health care needs, fare under managed care (Szilagyi 1998). Managed systems of care are increasingly serving children with special health care needs and minority children. However, there is little research on managed care"s impact on these populations, and none that attempts to isolate the effects of the different features of managed care delivery systems (Simpson and Fraser forthcoming). For example, there has been no work on what delivery system features can best ensure access and quality for minority populations. There is now an historic opportunity to fill some of these important knowledge gaps. As part of the Balanced Budget Act of 1997, the State Child Health Insurance Program (CHIP) was created. CHIP represents the largest expansion in children"s health coverage since passage of Medicaid over 30 years ago. It reserves considerable autonomy for states in terms of insurance program design. As a result, states are apt to make different choices about how health care is delivered. Most, if not all, of the programs are likely to involve some form of managed care, and these managed care features are likely to vary considerably. The diversity of CHIP insurance design and health care delivery system features, coupled with the diversity already existing among Medicaid programs, will facilitate our ability to learn about the effect of these program features on children"s access to health care and the quality of care they receive. Studies of CHIP and other public programs can provide information about what enhances access and quality of care that will be useful to policy-makers who are designing and modifying health care programs for low-income children. Specifically, attention should be paid to two kinds of variables: (1) the structural features of insurance programs - who is eligible, how outreach and enrollment are conducted, what benefits are covered, what cost sharing requirements are in place, etc., and (2) the organizational features of health care delivery systems what organizational entity is responsible for delivering care, what financial incentives providers have, what initiatives are in place to assure that culturally competent care is delivered, how care is coordinated and linked to non-medical services. These variables have been neglected by previous research and are likely to have a major impact on access to and quality of care for low-income children. Insurance program and delivery system features can also affect those who are not enrolled in the programs. Introduction of large new programs into a low-income community may affect the entire community"s system of health care delivery. For example, changes in the Medicaid program might affect the provider network in the community, thereby affecting access and quality of care for low-income children with no insurance. Most studies of the impact of financing and delivery system changes have not looked at these broader system effects. To examine these effects, studies should focus on the community level, ascertaining the impact of programs on both the delivery system and the entire population of low-income children. Again, CHIP provides an opportunity to engage in these community-level studies. CHIP not only provides a useful environment for research, but the program can also benefit from the results. Offering low-income children insurance coverage is but a means to the goal of providing children with appropriate services delivered in a timely and coordinated manner that lead to improvements in health. Currently, however, states are having to structure their CHIP programs and organize their CHIP delivery systems in the absence of evidence about the impact of their choices on this goal. The large, coordinated research projects initiated under these cooperative agreements should provide some answers to the question of what works for low-income children, and in particular what works for low-income minority children or children with special health care needs. Objectives and Scope Under this RFA, studies will examine how the features of U.S. insurance programs and the organization of the health care delivery systems associated with these programs affect access to services and the quality of care received by low-income children, particularly minority children or those with special health care needs. Studies will fall into one of two categories: 1) those examining the impact on low-income children enrolled in these insurance programs (enrollee impact), and 2) those examining the impact on a low-income community"s health care delivery system and all the children that it serves (community impact). Applicants may propose research that falls into one or both of these categories. Care should be taken not to replicate the work of other major health care studies, such as the Urban Institute"s Assessing the New Federalism or the Center for Health System Change"s Community Tracking Study. Applicants may choose to focus on the structure of insurance programs, such as the scope of the benefits package and premium- and cost-sharing requirements. Alternatively, or additionally, applicants may choose to focus on the organizational features of the delivery system, such as the organizational form of the entity that is responsible for the delivery of care, the network of providers, provider compensation arrangements, gatekeeper arrangements, procedures to access pediatric subspecialists, provisions for culturally competent care, and mechanisms to coordinate care and/or link to social services. Proposed research should be able to answer such questions as: Which features of insurance programs and delivery systems increase the probability that children receive appropriate health services? Which features improve satisfaction? Which features improve health outcomes? Which features improve child and parental well-being? Applicants will measure the impact of insurance plan and delivery system features on low-income children"s access to services and quality of care using both process and outcome measures. Examples of such measures include: utilization of appropriate preventive and other primary care services, continuity of source of medical and/or dental care, hospitalization for ambulatory care sensitive conditions, emergency room use, level of unmet health needs or delayed care, lost school days due to health problems, number of unintentional child injuries, self- reported health status, enrollee or parent satisfaction and experiences with care, limitations on enrollee"s activities, parental stress related to potential health expenses, and percent of income spent on medical and dental care. Coordination with State and Local Governments States are charged with evaluating their CHIP programs. Research conducted under this RFA should complement state activities and yield information helpful to states. In order to ensure that research findings will assist policy makers in their continued program implementation and are not duplicative of other evaluation efforts, applicants need to coordinate with the states and localities they are studying. Applicants must demonstrate in their applications that their research responds to unmet needs, and should bear this in mind when selecting study sites. Applicants who do not themselves represent government entities should obtain a letter of support from appropriate government officials, including a statement of how findings are expected to be used. Applications should also include a plan for state and community involvement, detailing how government officials have been and will continue be involved in the design of the study and dissemination of findings. Applicants are encouraged to collaborate with researchers in other locations to facilitate cross-state analyses. Policy Relevance and Dissemination Studies under this RFA are expected not only to contribute to our understanding of health care delivery for low-income children, but also to answer questions of policy relevance and produce information in formats useful to policy makers. Applicants should clearly state how their research will assist policy makers who purchase, design, and implement health insurance and delivery systems for low- income children. Applicants should be as concrete as possible in describing the audience they are targeting and how they anticipate their results being used for policy purposes. Applications should also include a plan (including personnel, budgets and timetables) for disseminating research findings to policy audiences. Dissemination strategies should not be limited to publication in peer-reviewed journals, but should 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 the mass media. Children with Special Health Care Needs Children with special health care needs are of particular interest as subjects for study under this RFA. Children with special health care needs are those who have or are at increased risk for a chronic physical, developmental, behavioral or emotional condition and who also require health and related services of a type or amount beyond that required by children generally. Little is known about the impact of changes in health care delivery systems on children with special health care needs. This is in part because few children in any given health care system have special health care needs, making generalizable research difficult. Because of the scarcity of research findings on this group of children, and in acknowledgment of the impediments to conducting research on children with special health care needs, special consideration will be given by reviewers to applicants who focus on this population. Ethnic and Racial Minority Children Ethnic and racial minority children are also of particular interest as subjects for study under this RFA. Over 62 percent of poor children are ethnic or racial minorities and past research has shown that minority children can face greater barriers to care than non-minority children. For example, minority children are less likely to have a usual source of care, and are more likely to be in poor or fair health (Weigers, Weinick, and Cohen 1998). Understanding whether and how features of insurance programs and delivery systems differentially affect minority access to health care and the quality of care they receive is an essential first step to remedying these disparities. Research proposed under this RFA, however, should go beyond merely documenting the existence of disparities. For example, proposed research could identify features of insurance programs and organizational delivery systems that contribute to the provision of culturally competent care care that acknowledges the importance of culture, assesses cross-cultural relations, is alert to cultural differences and their repercussions, and adapts services to meet cultural needs (Cross et al. 1989). Applicants choosing to focus on minority children should include in their analysis plans not only how they will conduct comparisons of ethnic and racial groups, but also how they will identify the causes of disparities and suggest strategies that will lead to better health care access and quality for minority children. Enrollee Impact and Community Impact Studies Other aspects of the objectives and scope of this RFA depend on which of the following two categories of research the applicant chooses to address: 1) enrollee impact, and/or 2) community impact. Enrollee Impact The subjects of the studies in this category will be low-income children who are enrolled in public (e.g., Medicaid or CHIP) insurance programs. Ideal studies would be both cross-sectional and longitudinal. For example, an applicant could study several plans serving the same state or community to measure how the plans" different delivery features affect access to health care and quality over time. In another example, a study of health plans with similar features that are operating in several states could examine how differences in insurance structure among states affect enrollees" access and quality of care over time. Community impact The focus of the studies in this category is the entire health care community, both the health care delivery system and all the low-income children it serves insured and uninsured. Applicants will focus their attention on communities where a high proportion of the families are low-income. Since state eligibility for CHIP and Medicaid programs will vary, applicants should consult with appropriate state officials and use a definition of low-income that is appropriate for the state(s) they are studying, but the upper limit for defining low-income is not expected to exceed 300 percent of the federal poverty level. Studies should describe how the decisions that states make regarding insurance program and organizational delivery system features affect health care organizations (e.g., insurers and health plans, hospitals, community health centers, clinics, health care organizations specializing in serving culturally diverse populations, physicians and physician organizations, tertiary care centers) in the community and the low-income children that they serve. Focusing studies at the community level allows researchers to address many issues that cannot be examined when only enrollees of a particular program are studied, such as the continuity of insurance coverage and transitions from one form of insurance to another. States" choices of eligibility criteria and their approaches for outreach and enrollment are other areas that lend themselves to study at the community level. Since children with special health care needs and minority children are of particular interest, applicants are encouraged to choose communities where there are relatively large numbers of these children. In addition, applicants are encouraged to choose communities whose health care systems have not been studied extensively. Ideal studies will be able to attribute changes in low-income children"s access to health care and the quality of care they receive to insurance program and organizational delivery system features and their corresponding impact on health care organizations. For example, a study of the effects of choosing a particular type of health care organization to deliver care would examine the market effects, such as the impact of the selection on the organization"s delivery of care to other enrollees, on other health care organizations" decisions to enter the market, on the financial viability of provider organizations which traditionally served those children, on physicians who traditionally served those children, etc. The study would then measure the impact on low-income children of these effects on the community"s delivery system. Methods Applicants are encouraged to use both quantitative and qualitative research methods. Qualitative methods are useful in studying rapidly changing environments and can be used on their own to deepen understanding of the transformation of health care delivery systems for low-income children, or to complement quantitative methods thereby strengthening the research design. Ideally, studies will be prospective. Applicants are urged to use established measures and instruments where possible, to facilitate cooperative work, to avoid duplication, and to save the time and expense of developing and testing new instruments. The use of existing data bases is also encouraged. Applicants should consider using measures, instruments, and data bases developed by AHCPR and other parts of the Department of Health and Human Services, but not to the exclusion of other existing private and public measures, instruments, and data bases that may be highly valuable, such as the Census Bureau"s Current Population Survey (CPS), Healthy People 2000, and instruments available in languages spoken by non- or limited-English-speaking populations under study. Departmental sources of measures and instruments include CAHPS (Consumer Assessment of Health Plans Study), CONQUEST (COmputerized Needs-oriented QUality measurement Evaluation SysTem), MEPS (Medical Expenditure Panel Study), NHIS (National Health Interview Survey), YRBSS (Youth Risk Behavior Surveillance System), and SLAITS (State and Local Integrated Telephone Survey). With the exception of CAHPS, CONQUEST, and SLAITS, databases resulting from the fielding of these instruments are also available. Other Departmental databases include HCUP (Healthcare Cost and Utilization Project) and ARF (Area Resource File). Databases can be particularly useful for providing benchmarks for comparison purposes. Technical support in the use of AHCPR and other Department instruments and databases will be available both during the application preparation period and after awards are made. (See the Inquiries section of this RFA.) SPECIAL REQUIREMENTS Terms and Conditions of Award These special Terms of Award are in addition to and not in lieu of otherwise applicable OMB administrative guidelines, HHS grants administration regulations, 45 CFR Parts 74 and 92, and other HHS and PHS grants administration policies. Applicants should be familiar with the Agency"s grant regulation, 42 CFR Part 67 Subpart A, and particularly sections 67.18-67.22. Consistent with the concept of cooperative agreements, described under MECHANISM OF SUPPORT, the dominant role and prime responsibility for the activity resides with the awardee(s) for the project as a whole, although specific tasks and activities in carrying out the studies will be shared among the awardees and the AHCPR and Packard Project Officers. 1. Cooperative Activities Cooperative activities are intended to strengthen individual studies and at the same time generate generalizable results across projects, locations, populations, and insurance design and organizational delivery system features. Each Principal Investigator (PI) will participate with AHCPR and Packard Project Officers in the Coordinating Committee (CC), which will serve as the core mechanism for cooperative planning and coordination of research. The CC will hold up to four meetings a year to identify cross-cutting research questions and common measures and methods to answer the questions. The group will make joint decisions to promote uniformity in research functions, sampling design for any surveys, study measures, analytic methods, and other methodologic and substantive issues that affect generalizability across projects. For budget purposes, applicants should assume that the CC will meet in the Washington, D.C. area, although CC meetings may also take place in the San Francisco Bay area. While CC meetings will usually last one day, once or twice a year the CC may have two-day meetings so that it can meet with the Users Group (UG). The UG, consisting of federal, state and local government representatives who are the ultimate users of the data and research findings produced by the studies funded under this RFA, will serve to provide systematic feedback on both research designs and dissemination plans. Meetings with the UG will augment each PI"s individual coordination efforts with state and local officials in their study sites. 2. Awardee Responsibilities The awardee will conduct research in accordance with the terms and conditions of the Notice of Grant Award, and cooperate with other key parties, including the Project Officers and other awardees. As members of the CC, PIs will actively participate in the formulation of plans to promote generalizability across projects. Awardees will refine and revise, as necessary, selected methodologic procedures in accord with plans developed collaboratively by the CC. Specifically, the awardee will undertake or participate in collection of data on measures agreed upon jointly with others in the CC. Each PI will participate in CC meetings. The CC will meet up to four times in the first year, and up to two times in years 2 and 3, including the CC"s meetings with the UG, in addition to telephone conferences and electronic exchanges. Awardees will nominate public officials to serve on the UG. Awardees are expected to follow through on their plans for state and community involvement and dissemination of research findings to policy audiences. Applicants should include information in their application demonstrating their ability to discharge these responsibilities. For example, applicants might describe a history of working collaboratively with other researchers. 3. AHCPR/Packard Responsibilities AHCPR and Packard Project Officer will have substantial scientific and programmatic involvement during the conduct of these projects. They will provide technical assistance, advice, and support to awardees, and guide the cooperative work of the projects beyond the usual program stewardship for grants. The Project Officers are responsible for coordination of the work of the awardees to ensure that all projects funded under this RFA complement each other and to maximize the generalizability of findings. Specifically, the Project Officers will convene the CC, set the agenda for CC meetings, and preside over them. Project Officers will attempt to forge consensus around collaborative plans and corresponding modifications to individual projects. While a consensus model of decision making will be used for the CC, Project Officers will be the final arbiters of what constitutes a joint decision that will be binding upon all awardees. The Project Officers will maintain contact with PIs in between CC meetings to consult on key project decisions to trouble-shoot problems and confirm that projects are proceeding according to plan. The Project Officers will select the federal, state and local government representatives to serve on the UG, considering awardee nominations and other qualified individuals. The Project Officers will also disseminate project findings to research and policy audiences. The progress of work by each awardee will be reviewed at least annually. Awards may be terminated in cases of documented under-performance where the awardee has been given adequate notification about performance and failed to take sufficient corrective actions. Data Privacy Information obtained in the course of this study that identifies an individual or entity must be treated as confidential in accordance with section 903(c) of the Public Health Service Act (42 U.S.C. 299a-1(c)). Applicants must describe in the Human Subjects section of the application procedures for ensuring the confidentiality of 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 will be safeguarded. Rights in Data AHCPR grantees may copyright or seek patents, as appropriate, for final and interim products and materials including, but not limited to, methodologic tools, measures, software with documentation, literature searches, and analyses, which are developed in whole or in part with AHCPR funds. Such copyrights and patents are subject to a Federal Government license to use and permit others to use these products and materials for AHCPR purposes. In accordance with its legislative dissemination mandate, AHCPR purposes may include, subject to statutory confidentiality protections, making research materials, databases, and algorithms available for verification or replication by other researchers, and subject to AHCPR budget constraints, final products may be made available to the health care community and the public by AHCPR, or its agents, if such distribution would significantly increase access to a product and thereby produce public health benefits. Ordinarily, to accomplish distribution, AHCPR 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 INVOLVING HUMAN SUBJECTS It is the policy of AHCPR that women and members of minority groups be included in all AHCPR-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. Because this RFA applies solely to children, the policy on women applies to female children, adolescents, and youth. All investigators proposing research involving human subjects should read the "NIH Guidelines on the Inclusion of Women and Minorities as Subjects in Clinical Research," published in the Federal Register of March 28, 1994 (FR 59 14508-14513), and printed in the NIH GUIDE FOR GRANTS AND CONTRACTS of March 18, 1994, Volume 23, Number 11. AHCPR follows the NIH Guidelines, as applicable. Applicants may obtain copies from the above sources or from the AHCPR contractor, Equals Three Communications, Inc., listed under "INQUIRIES." AHCPR announced in the NIH Guide for Grants and Contracts, May 9, 1997, that it is developing a policy and implementation plan on the inclusion of children in health services research. This notice is available through AHCPR"s Web site http://www.ahcpr.gov/ (Funding Opportunities) and InstantFAX (see instructions under "INQUIRIES"). Because this RFA applies solely to children, any applications not on children will be considered non-responsive to the RFA. If applicants propose to study a subset of all children (defined by NIH policy as persons under the age of 21), they should explain the appropriateness of the age ranges of the proposed study population. LETTER OF INTENT Prospective applicants are asked to submit, by February 25, 1999, a letter of intent that includes a descriptive title of the proposed research, the name, address, and telephone number of the proposed Principal Investigator and other key personnel including subcontractors, and the number and title of this RFA. Although a letter of intent is not required, is not binding, and does not enter into the consideration of any subsequent application, the information allows AHCPR to estimate the potential review workload and avoid conflicts of interest in the review. It also allows AHCPR and Packard to provide responses to questions posed by any prospective applicant to all prospective applicants. AHCPR will not provide responses to letters of intent. The letter of intent is to be addressed to: Cindy Brach Center for Organization and Delivery Studies Agency for Health Care Policy and Research 2101 East Jefferson Street, Suite 605 Rockville, MD 20852-4908 telephone: 301/594-6816 fax: 301/594-2314 E-mail: cbrach@ahcpr.gov APPLICATION PROCEDURES The research grant application form PHS 398 (rev. 4/98) is to be used in applying for these grants. State and local government applicants may use form PHS-5161-1, Application for Federal Assistance (rev. 5/96), and follow those requirements for copy submission. Application kits are available at most institutional offices of sponsored research and may be obtained from the Division of Extramural Outreach and Information Resources, Office of Extramural Research, National Institutes of Health, 6701 Rockledge Drive, MSC 7910, Bethesda, MD 20892-7910, telephone 301/710-0267, E-mail: Grantsinfo@nih.gov. AHCPR applicants are encouraged to obtain application materials from the AHCPR contractor: Equals Three Communications, Inc. (see "INQUIRIES"). The RFA label available in the form PHS 398 (rev. 4/98) must be affixed to the bottom of the face page of the original application. Failure to do so could result in delayed processing of the application such that it may not reach the review committee in time for review. In addition, the RFA title and number must be typed on line 2 of the face page of the application form, and the YES box must be marked. The PHS 398 type size requirements (p.6) will be enforced rigorously and noncompliant applications will be returned. Submit a signed, typewritten original of the application, including the Checklist, and three signed photocopies, in one package to: CENTER FOR SCIENTIFIC RESEARCH NATIONAL INSTITUTES OF HEALTH 6701 ROCKLEDGE DRIVE, ROOM 1040, MSC 7710 BETHESDA, MD 20892-7710 BETHESDA, MD 20817 (for express/courier service) Applications submitted under this RFA must be received in the Center for Scientific Research, NIH, by April 22, 1999. If an application is received after that date, it will be returned to the applicant without review. At the time of submission, two additional copies of the application must be sent to: Dawn French Center for Organization and Delivery Studies Agency for Health Care Policy and Research 2101 East Jefferson Street, Suite 605 Rockville, MD 20852-4908 Budget Preparation The following guidance will supplement the standard requirements in form PHS 398 (rev. 4/98). Applicants are strongly encouraged to seek additional funds to support their projects from other sources, such as local foundations and state governments. Applicants should specify on the application form pages DD and EE of the PHS 398 those funds requested specifically from AHCPR under this RFA. Project funds to be acquired from other sources should be detailed on a separate page, clearly indicating what will be supported with these funds, whether these funds have been secured or are still being pursued, and whether they are integral to the project (i.e., the project cannot be conducted without the additional funds), or whether they would be used to expand or augment the project. This will permit reviewers to assess the adequacy of the proposed budget. Assurance of any resources required to complete the research will be needed before awards can be issued, but are not needed at the time of submission of applications. Applicants will not be required to show proof that they have secured the funds prior to issuance of awards if funds sought from other sources are not integral to complete the research. AGREEMENT TO SHARE APPLICATIONS AND REVIEWS Submission of an application under this RFA constitutes agreement for AHCPR to share the full application, along with a summary of reviewer comments, with the David and Lucile Packard Foundation. Researchers wishing to apply for funds from AHCPR who are not willing for their applications to be shared with David and Lucile Packard Foundation should not respond to this RFA, but should pursue other funding opportunities. AHCPR funding opportunities, such as AHCPR"s Program Announcement PA:98-049, are listed on AHCPR"s Web site (http://www.ahcpr.gov). REVIEW CONSIDERATIONS Upon receipt, applications will be reviewed for completeness and responsiveness by AHCPR. Incomplete applications will be returned to the applicant without further consideration. Applications that are complete but are not responsive to the RFA will be returned to the applicant without further consideration, but applicants may submit an investigator-initiated grant application to AHCPR to compete with other unsolicited applications at the next review cycle. Applications that are complete and responsive to the RFA will be evaluated for scientific and technical merit in accordance with the review criteria stated below by an appropriate peer review group convened by AHCPR with input from the David and Lucile Packard Foundation. As part of the merit 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 general review criteria for any application are: significance and originality from a scientific and technical viewpoint, adequacy of the method(s), availability of data or a proposed plan to collect data required for the project, adequacy of the plan for organizing and carrying out the project, qualifications and experience of the Principal Investigator and proposed staff, reasonableness of the proposed budget, adequacy of the facilities and resources available to the applicant, and the adequacy of the proposed means for protecting human subjects. Special Review Criteria Reviewers will give special weight to applications that address the priority populations identified in this RFA: children with special health care needs and racial and ethnic minority children. Applicants choosing to focus on these populations will have their experience, skill, and sensitivity in conducting research on these populations assessed. Experience in using measures and data collection instruments with these populations will also be assessed. Reviewers will take into account that applicants who focus on children with special health care needs may be at a disadvantage in addressing racial and ethnic minority children, and vice-versa. Reviewers will factor these criteria into their overall evaluations: the adequacy of applicants" plans for state and community involvement, the policy relevance of the proposed project and the extent to which it responds to unmet information needs of policy makers, the adequacy of the dissemination plan, and the applicant"s ability to participate fully and constructively in cooperative activities. AWARD CRITERIA Applications will compete for available funds with all other applications under this RFA. The following will be considered in making funding decisions: 1) quality of the proposed project as determined by peer review, 2) availability of funds, 3) program balance with respect to types of insurance structure and organizational delivery system features, enrollee versus community studies, populations studied, geography including rural/urban mix, regional representation, and targeting understudied area with unmet evaluation needs, 4) compatibility with other awardees with respect to cooperative activities, and 5) policy relevance. INQUIRIES Written and telephone inquiries concerning this RFA are encouraged. Copies of the RFA are available from: Equals Three Communications, Inc. 7910 Woodmont Avenue, Suite 200 Bethesda, MD 20814-3015 Telephone 301/656-3100 FAX 301/652-5264 The RFA is available on AHCPR"s Web site, http://www.ahcpr.gov (Funding Opportunities), on the David and Lucile Packard Foundation"s Web site, http://www.packfound.org, and through AHCPR 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 RFA number). The RFA will be sent at the end of the ordering process. AHCPR InstantFAX operates 24 hours a day, 7 days a week. For questions about this service, call Judy Wilcox, Office of Health Care Information, at 301/594-1364 ext. 1389. Copies of AHCPR publications can be requested through the: AHCPR Publications Clearinghouse P. O. Box 8547 Silver Spring, Maryland 20907 TDY(toll free): 1-800-586-6340 or 301/586-6340 Telephone (toll free): 1-800-/358-9295 or 301/358-9295 Written and telephone inquiries concerning this RFA are encouraged. Direct inquiries regarding programmatic issues to: Cindy Brach Center for Organization and Delivery Studies Agency for Health Care Policy and Research 2101 East Jefferson Street, Suite 605 Rockville, MD 20852-4908 telephone: 301/594-6816 E-mail: cbrach@ahcpr.gov For technical assistance on the CONQUEST data base of performance measures and clinical conditions, direct inquiries to: Marge Keyes Center for Quality Measurement and Improvement Agency for Health Care Policy and Research 2101 East Jefferson Street, Suite 502 Rockville, MD 20852-4908 Telephone: 301/594-1824 Email: mkeyes@ahcpr.gov For technical assistance on CAHPS, direct inquiries to: Charles Darby or Christine Crofton Center for Quality Measurement and Improvement Agency for Health Care Policy and Research 2101 East Jefferson Street, Suite 502 Rockville, MD 20852-4908 Telephone: 301/594-2050 (Darby) or 301/594-2003(Crofton) Email: cdarby@ahcpr.gov or ccrofton@ahcpr.gov For technical assistance on HCUP, direct inquiries to: Kelly Carper Center for Cost and Financing Studies Agency for Health Care Policy and Research 2101 East Jefferson Street, Suite 502 Rockville, MD 20852-4908 Telephone: 301/594-3075 Email: kcarper@ahcpr.gov For technical assistance on MEPS, direct inquiries to: Nancy Krauss Center for Cost and Financing Studies Agency for Health Care Policy and Research 2101 East Jefferson Street, Suite 502 Rockville, MD 20852-4908 Telephone: 301/594-0846 Email: nkrauss@ahcpr.gov For technical assistance on NHIS or SLAITS, direct inquiries to: Trena M. Ezzati-Rice Office of Research and Methodology National Center for Health Statistics 6526 Belcrest Road - Room 915 Hyattsville, MD 20782 Telephone: 301/436-7022 ext 133 Email: TME1@cdc.gov For technical assistance on YRBSS, direct inquiries to: Laura Kann Division of Adolescent and School Health National Center for Chronic Disease Prevention and Health Promotion Center for Disease Control 4770 Buford Highway, NE, MS-K33 Atlanta, GA 30341 Telephone: 770/488-3202 Email: LKK1@cdc.gov For technical assistance on ARF, direct inquiries to: Inga Franklin Bureau of Health Professions Office of Research and Analysis Health Resources and Services Administration 5600 Fishers Lane, Room 855 Rockville, MD 20857 Telephone: 301/443-6663 Email: ifranklin@hrsa.gov Direct inquiries regarding fiscal matters to: Joan Metcalfe Grants Management Specialist Agency for Health Care Policy and Research 2101 East Jefferson Street, Suite 601 Rockville, MD 20852-4908 Telephone: 301/594-1841 FAX 301/594-3210 Email: jmetcalf@ahcpr.gov AUTHORITY AND REGULATIONS This program is described in the Catalog of Federal Domestic Assistance Number 93.226. Awards are made under authorization of Title IX of the Public Health Service Act (42 U.S.C. 299-299c-6) and Section 1142 of the Social Security Act (42 U.S.C. 1320b-12), as applicable. 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 cases, 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 Cross T., et al. 1989. Towards a Culturally Competent System of Care. Washington DC: CASSP Technical Assistance Center. Simpson L, Fraser I, forthcoming. Children and Managed Care: What Research Can, Can"t and Should Tell Us about Impact. Medical Care Research and Review. Szilagyi PG, 1998. Managed Care for Children: Effect on Access to Care and Utilization of Health Services. Future of Children. Los Altos: The David and Lucile Packard Foundation. Weigers ME, Weinick RM, Cohen JW, 1998. Children"s Health Insurance, Access to Care, and Health Status: New Findings. Health Affairs 17(2):127-36.

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NIH Funding Opportunities and Notices