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 þ 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  þ 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
þ 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 301/435-0714, 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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