Skilled Nursing Facilities: CMS Should Improve Accessibility and Reliability of Expenditure Data
Released: 2016-10-06T00:00:00

Letter

Background

To qualify for SNF care, Medicare beneficiaries typically need to be admitted to a SNF within 30 days after discharge from a hospital stay of at least 3 days and need care for a condition that was treated during the hospital stay or that arose while receiving SNF care. Medicare may cover up to 100 days per episode of SNF care. Many SNFs also provide long- term care, which Medicare does not cover, to Medicaid or private paying residents. Medicaid, the joint federal-state program for certain low-income individuals, is the primary payer for over 60 percent of SNF residents. Industry advocates have raised questions about Medicaid payment rates in many states being lower than the costs of providing care. While Medicare and Medicaid separately certify SNFs, nearly all SNFs have dual certification and participate in both programs. SNF residents who do not qualify for Medicare or Medicaid may have private insurance pay for their care or they may pay out of pocket.

SNF Characteristics

SNFs differ by type of ownership. As of 2014, 70 percent of SNFs were for-profit, 24 percent were nonprofit, and 5 percent were operated by government agencies. In general, for-profit SNFs have a goal of making profits that are distributed among their owners and stockholders. For example, several studies have demonstrated that for-profit SNFs generally have lower nurse-to-resident staffing ratios compared with nonprofit SNFs, likely allowing them to reduce their personnel costs and increase their margins. Nonprofit SNFs receive favorable tax status because they are not allowed to operate for the benefit of private interests.

SNFs also vary by chain affiliation. About three-fifths of SNFs were owned or operated by chains (entities that own multiple facilities), while the remainder were independent in 2014, the latest year for which data were available. While most chain-affiliated SNFs are for-profit, some are nonprofit or government-operated. Chains may develop complex administrative structures to spread expenses across multiple SNFs. Researchers have raised questions about the effects of chain ownership on SNF quality of care.

SNF Nurse Staffing and Quality of Care

SNFs employ three types of nursing staff: RNs, LPNs, and CNAs. As we have previously reported, the responsibilities and salaries of these three types of nurses are related to their levels of education. The staffing mix, or the balance SNFs maintain among RNs, LPNs, and CNAs, is generally related to the needs of the residents served. For example, a higher proportion of RNs may be employed to meet residents’ needs in SNFs that serve more residents with acute care needs or in SNFs with specialty care units (such as units for residents who require ventilators). However, SNFs may be unable to pursue their ideal staffing mix for reasons such as high turnover among LPNs and CNAs.

Licensed Nurses and Nurse Aides

Registered nurses (RN) have at least a 2-year degree and are licensed in a state. Because of their advanced training and ability to provide skilled nursing care, RNs are paid more than other nursing staff. Generally, RNs are responsible for managing residents’ nursing care and performing complex procedures, such as starting intravenous feeding or fluids.

Licensed practical nurses (LPN) have a 1-year degree, are also licensed by the state, and typically provide routine bedside care, such as taking vital signs.

Certified nursing assistants (CNA) are nurse aides or orderlies who work under the direction of licensed nurses, have at least 75 hours of training, and have passed a competency exam. CNAs’ responsibilities usually include assisting residents with eating, dressing, bathing, and toileting. CNAs typically have more contact with residents than other nursing staff and provide the greatest number of hours of care per resident day. CNAs generally are paid less than RNs and LPNs.

There are no federal minimum standards linking SNFs’ nurse staffing to the number of residents, but SNFs that participate in both Medicare and Medicaid are required to have sufficient nursing staff to provide nursing and related services to allow each resident to attain or maintain the highest practicable physical, mental, and psychosocial well-being. In general, every SNF must have licensed nurses (RNs or LPNs) on duty around the clock, including one RN on duty for at least 8 consecutive hours per day, 7 days per week. According to one study, 34 states had established additional minimum requirements for the number of nursing hours per resident day as of 2010.

Researchers have found that higher total nurse staffing levels (RNs, LPNs, and CNAs combined) and higher RN staffing levels are typically associated with higher quality of care, as shown by a wide range of indicators. For example, lower total nurse and RN staffing levels have been linked to higher rates of deficiency citations, which may involve actual harm or immediate jeopardy to residents. In addition, higher total nurse and RN staffing levels have been associated with better health outcomes, such as fewer cases of pressure ulcers, urinary tract infections, malnutrition, and dehydration, as well as improved resident functional status. In 2001, a CMS contractor reported the effect of nurse staffing on quality of care in SNFs. The contractor identified staffing thresholds in both a short-stay sample of Medicare SNF admissions and a long-stay sample of nursing home residents who were in the facility for at least 90 days. These thresholds demonstrated incremental benefits of nurse staffing; once these thresholds were met, there were no additional benefits in terms of quality. For the short-stay sample, the thresholds were 0.55 hours per resident day for RNs and 3.51 hours per resident day for all nurses. For the long-stay sample, the thresholds were 0.75 hours per resident day for RNs and 4.08 hours per resident day for all nurses.

PPACA Requirements for Reporting SNF Expenditures

PPACA required SNFs to separately report expenditures for wages and benefits for direct care staff, including specific data on RNs, LPNs, CNAs, and other medical and therapy staff, and required CMS to redesign the cost report in consultation with private sector accountants experienced with SNF cost reports to meet this requirement. The act also required CMS, in consultation with others, to categorize the expenditures listed on the cost report, regardless of any source of payment for such expenditures, into four functional accounts—direct care (including nursing, therapy, and medical services), indirect care (including housekeeping and dietary services), capital assets (including building and land costs), and administrative services—annually. Finally, the act required CMS to make information on SNFs’ expenditures “readily available to interested parties upon request.”

CMS Has Not Made SNF Expenditure Data Readily Accessible and Does Not Adequately Ensure Data Reliability

CMS Has Not Taken Steps Needed to Make SNF Expenditure Data Posted on Its Website Readily Accessible

CMS collects detailed SNF expenditure data in Medicare cost reports and posts the raw data on its website for the public. On their cost reports, SNFs must disclose total costs and allocate general services costs such as housekeeping and nursing administration. CMS officials told us they modified the cost report as required by PPACA in December 2011. Effective for cost reporting periods beginning on or after January 1, 2012, CMS required SNFs to provide expenditure data for full-time and part- time direct care employees who are directly hired and under contract. CMS officials said the agency implemented the PPACA requirement to make information on SNFs’ expenditures “readily available to interested parties upon request” by posting the raw data on its website. The CMS website contains the raw cost report data that SNFs submitted for fiscal years 1995 through 2015. The website also notes that CMS “has made a reasonable effort to ensure that the provided data/records/reports are up- to-date, accurate, complete, and comprehensive at the time of disclosure.”

However, CMS has not taken two key steps to make SNF expenditure data readily accessible on the basis of our interviews with public stakeholders and our observations. First, CMS has not provided the expenditure data in an accessible way. The data’s format, volume, and organization can make it difficult for public stakeholders to use the data. CMS posts data for each fiscal year across three separate files. Because of how CMS formats the data, users need certain software packages and programming skills to analyze data for each fiscal year. In addition, CMS has acknowledged that the data files are so large that some users have been unable to download them. One of the researchers we interviewed stated that the amount of time needed to analyze the data typically requires a grant. CMS also does not organize SNF expenditures in a meaningful way for analysis. For example, 12 of the 15 cost centers in the general services category are related to indirect care, so a user must make additional calculations to determine a SNF’s total indirect care costs. Second, CMS has not provided the expenditure data in a place that is easy to find on its website. For example, representatives of the two beneficiary advocacy organizations we interviewed told us they were unable to find the cost report data on the CMS website and noted the importance of making the SNF expenditure data easy to locate.

CMS officials told us they did not know who would use SNF expenditure data or for what purpose. Public stakeholders could make better use of SNF expenditure data if CMS took steps to make the data more accessible. For example, representatives of the two beneficiary advocacy organizations and one researcher we interviewed said CMS could incorporate summary expenditure measures into Nursing Home Compare, the CMS website that contains summary measures of SNF quality. Prior research has demonstrated that presenting cost and finance measures in a manner that consumers can easily interpret, displaying them alongside quality data, and focusing on information that is relevant to consumers can help increase their effectiveness. For example, the California HealthCare Foundation’s CalQualityCare.org website provides ideas on how to communicate SNF expenditure measures to consumers. This website allows consumers to find facility data and compare long-term care providers across California.

CMS officials told us that adding SNF expenditure measures to Nursing Home Compare is a possibility in the next 2 to 5 years. The officials noted that, as of December 2015, CMS had not begun considering the posting of SNF expenditure data on Nursing Home Compare nor begun systematically evaluating how to publicly report expenditure measures. The officials explained that the agency is currently focused on implementing an electronic system for collecting SNF direct care staffing data (known as the Payroll-Based Journal) and making changes to existing measures in Nursing Home Compare this year. In March 2016, CMS released a public data set on its website that contains information on utilization, payments, and submitted charges for services SNFs provided to Medicare beneficiaries in 2013. Upon releasing the data set, CMS officials stated they were committed to greater data transparency.

In making data accessible to public stakeholders, federal internal control standards related to external communication suggest that agencies consider the audience, nature of information, availability, cost, and legal or regulatory requirements to ensure that information is communicated in a quality manner. Until CMS takes steps to make SNF expenditure data easier to use and locate, public stakeholders will have difficulty accessing the only publicly available source of financial data for many SNFs.

CMS Does Not Adequately Ensure the Reliability of SNF Expenditure Data

Despite CMS’s statement that it has made a reasonable effort to ensure the accuracy of SNF cost report data, we found that the agency performs minimal quality control of the SNF expenditure data in the Medicare cost reports to ensure data reliability. Instead, CMS largely relies on SNFs to validate their own data. CMS requires SNFs to self-certify to the accuracy and completeness of their cost report data. However, according to CMS officials and one researcher we interviewed, there is little incentive for SNFs to ensure the accuracy and completeness of their data because the data do not affect the amount of Medicare payments each SNF receives. However, CMS does use the cost report data to update overall SNF payment rates. Despite this, CMS officials told us the agency conducts “extremely limited” reviews of cost report data because of funding and resource constraints. The officials said they rarely adjust SNFs’ reported costs and focus instead on improper payment reviews. For these reasons, CMS officials and the two researchers we interviewed told us they could not place full confidence in the reliability of the SNF expenditure data in the cost reports.

Federal internal control standards require agencies to use quality information. The standards highlight the importance of processing obtained data into quality information, central to which is its accessibility and reliability. Reliable information that is accurate and complete can help agencies evaluate performance, make informed decisions, address risks, and achieve key objectives. Until CMS takes steps to ensure the accuracy and completeness of the SNF expenditure data, the data’s reliability cannot be ensured.

For-Profit SNFs Generally Had Lower Direct and Indirect Care Costs as a Percentage of Revenue and Higher Margins than Did Nonprofit and Government SNFs

Our analysis found that, for each fiscal year from 2011 through 2014, direct and indirect care costs were lower as a percentage of revenue, on average, at for-profit SNFs compared with nonprofit and government SNFs. Costs were similarly lower at chain SNFs compared with independent SNFs. Over the 4-year period we examined, the percentage of revenue spent on direct and indirect care remained relatively constant, on average, at for-profit and nonprofit SNFs but decreased at government SNFs. For both chain and independent SNFs, the percentage of revenue spent on direct and indirect care remained relatively constant, on average, from fiscal years 2011 through 2014. (See fig. 1.)

For for-profit and nonprofit SNFs, both overall costs and total revenues increased, on average, in each of the 4 years we examined. For example, for-profit and nonprofit SNFs generally had small annual increases in their direct care costs. However, because their revenue also increased slightly each year, on average, their direct care costs remained relatively constant as a percentage of revenue. Both overall costs and direct care costs decreased, on average, at government SNFs in each fiscal year from 2011 through 2014. Total revenues also decreased, on average, at government SNFs between fiscal years 2011 and 2014.

Regardless of ownership type and chain affiliation, SNFs’ costs for capital-related assets and administrative services accounted for a similar percentage of revenue, on average, during each fiscal year from 2011 through 2014. According to the cost report data, capital-related asset costs accounted for 4 percent to 7 percent of revenue, on average, at for- profit, nonprofit, and government SNFs in each year. Similarly, costs for capital-related assets at chain and independent SNFs generally accounted for 5 percent to 6 percent of revenue, on average, in each year. During these 4 years, costs for administrative services accounted for 8 percent to 9 percent of revenue, on average, regardless of ownership type and chain affiliation.

In addition, median margins were higher for for-profit and chain SNFs than for other SNFs. As a group, for-profit SNFs had a higher median margin (between 16 percent and 19 percent) than nonprofit and government SNFs (between 12 percent and 15 percent and between 3 percent and 13 percent, respectively) for each fiscal year between 2011 and 2014. Similarly, median margins were generally higher at chain SNFs (between 16 percent and 19 percent) than at independent SNFs (between 12 percent and 17 percent) in each year. All SNF organization types had positive median all-payer margins each year, meaning that their payments more than covered their costs.

Moreover, from fiscal years 2011 through 2014, median margins increased regardless of ownership type and chain affiliation, but the amount of the increase differed between organization types. The median margin increased more at government SNFs than at for-profit and nonprofit SNFs and more at independent SNFs than at chain SNFs. During the 4-year period, the median margin at government SNFs increased 10 percentage points (from 3 percent to 13 percent), while it increased 3 percentage points at for-profit SNFs (from 16 percent to 19 percent) and at nonprofit SNFs (from 12 percent to 15 percent). In addition, independent SNFs’ median margin increased by 5 percentage points (from 12 percent to 17 percent) and chain SNFs’ median margin increased by 3 percentage points (from 16 percent to 19 percent). (See fig. 2.)

For-Profit SNFs Had Lower Nurse Staffing Levels Than Other SNFs, and Nurse Staffing Levels Estimated to Decline Slightly as Margins Increase

SNFs’ nursing staff levels, as measured by nurse time per resident day, were relatively stable for fiscal years 2012 through 2014, but there was some variation by type of ownership. For-profit SNFs generally had less nursing time per resident day in each of the 3 years we examined. After our adjustment for resident case-mix, we continued to observe the same trends. These trends were generally consistent with the small annual increases in direct care costs we observed at for-profit and nonprofit SNFs during this period. Table 1 shows SNFs’ reported (unadjusted) and adjusted total nurse and RN time per resident day.

Examining each fiscal year separately, we estimated that a SNF’s margin generally had a small, but statistically significant, effect on its nursing time per resident day. After controlling for other factors, we estimated that a SNF’s case-mix adjusted total nurse and RN time per resident day (reflecting the time nurses spend on both direct patient care and administrative duties) decreased slightly as its margin increased. For fiscal year 2012, we estimated that if a SNF with a margin of 20 percent and a case-mix adjusted total nurse time of 4 hours per resident day increased its margin to 21 percent, its total nurse time would fall to 3 hours and 51.9 minutes per resident day (a decrease of 8.1 minutes). For the same year, we estimated that a SNF’s case-mix adjusted RN time per resident day decreased by 0.6 minutes for each percentage point increase in its margin. Similarly, for fiscal year 2013, we estimated that a 1 percentage point increase in a SNF’s margin decreased its case-mix adjusted total nurse time per resident day by 5.1 minutes and its case-mix adjusted RN time per resident day by 0.4 minutes. Finally, for fiscal year 2014, we estimated that a SNF’s case-mix adjusted total nurse time per resident day decreased by 7.4 minutes and its case-mix adjusted RN time per resident day decreased by 0.2 minutes for each percentage point increase in its margin.

In each of the 3 fiscal years, which we examined separately, the relationship between SNF nursing time and margins varied by ownership type. Table 2 shows our estimates for the change in a SNF’s case-mix adjusted total nurse and RN time per resident day for each percentage point increase in its margin. For example, for fiscal year 2012, we estimated that if a for-profit SNF with a margin of 20 percent and a case- mix adjusted total nurse time of 4 hours per resident day increased its margin to 21 percent, holding all other variables constant, its total nurse time would fall to 3 hours and 49 minutes per resident day (a decrease of 11.0 minutes).

The relationship between a SNF’s total nurse time per resident day and its margin also differed slightly by chain affiliation. We estimated that the total nurse time per resident day decreased slightly more at SNFs that were part of chains than at those that were independent. For example, we estimated that for each percentage point increase in a SNF’s margin, the case-mix adjusted total nurse time per resident day decreased by 6.9 minutes at chain-affiliated SNFs and by 4.3 minutes at independent SNFs in fiscal year 2014. For each of the 3 years we examined, a chain- affiliated SNF’s margin did not have a statistically significant effect on its RN time per resident day.

Although the effect of margins in our regression analyses was statistically significant, margins were not the strongest predictor of case-mix adjusted total nurse and RN time per resident day. Accounting for the state where each SNF was located was very important in explaining its nursing time. This could be attributable to variation across states in staffing requirements, Medicaid reimbursement rates, or other factors. Because of the strong effect of the state where each SNF was located, we needed to statistically control for a SNF’s state to isolate the effects of a SNF’s total nurse and RN time per resident day on its margin. In addition, we estimated that a SNF’s proportion of Medicare days increased its total nurse and RN time per resident day. See appendix I for additional detail on the methods and results of our expenditure analyses.

Conclusions

The collection of SNF expenditure data gives CMS the opportunity to provide information to the public on SNFs’ relative expenditures. Data that are readily accessible to the public and validated for completeness and accuracy to ensure reliability can contribute to SNF data transparency. However, public stakeholders have experienced difficulty accessing the data—including locating and using the data—and CMS efforts to ensure data accessibility and reliability have been limited.

Recommendations for Executive Action

To improve the accessibility and reliability of SNF expenditure data, we recommend the Acting Administrator of CMS take the following two actions: 1. Take steps to improve the accessibility of SNF expenditure data, making it easier for public stakeholders to locate and use the data. 2. Take steps to ensure the accuracy and completeness of SNF expenditure data.

Agency Comments and Our Evaluation

We provided a draft of this report to HHS for comment. In its written comments, HHS concurred with our recommendation to improve the accessibility of SNF expenditure data. HHS disagreed with our recommendation that it take steps to ensure the accuracy and completeness of the SNF expenditure data. HHS said that it has made a reasonable effort to ensure the accuracy of the expenditure data, that the data are used for general purposes, and that the amount of time and resources that may be required to verify the accuracy and completeness of the data could be substantial and might not create significant benefit to the agency or the public. However, during the course of our work, CMS told us that the agency conducts only “extremely limited” reviews of the expenditure data due to resource constraints. Moreover, we found that CMS uses the expenditure data to update overall SNF payment rates, in addition to more general purposes. Therefore, we continue to believe that CMS should take steps to ensure reliable expenditure data that are accurate and complete. HHS’s comments on a draft of this report are reproduced in appendix II.

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If you or your staffs have any questions about this report, please contact me at (202) 512-7114 or cosgrovej@gao.gov. Contact points for our Offices of Congressional Relations and Public Affairs may be found on the last page of this report. GAO staff who made key contributions to this report are listed in appendix III.

Appendix I: Additional Detail on the Methods and Results of Our Expenditure Analyses

This appendix describes our methodology for examining (1) how skilled nursing facility (SNF) costs and margins vary by facility characteristics and (2) how SNF nurse staffing levels vary by facility characteristics and the relationship between SNF nurse staffing levels and margins. The appendix also provides further details of the results of our analyses.

Examining SNF Costs and Margins by Facility Characteristics

To examine how SNF costs and margins vary by facility characteristics, we developed cost categories, calculated the total costs for each category as a percentage of revenue, and made comparisons across SNF groups. We organized each SNF’s costs into four categories: direct care, indirect care, capital-related assets, and administrative services. Officials from the Centers for Medicare & Medicaid Services (CMS) said the categories we used included the appropriate expenses listed on the cost reports. Table 3 provides a crosswalk between the cost categories we used and the cost centers from the cost report.

We then calculated each SNF’s costs as a percentage of revenue. We also computed each SNF’s margin, reflecting the percentage of revenue each SNF retained. While SNFs may be part of larger nursing homes that operate multiple lines of business (such as hospices, ancillary services, and home health care services), we focused our analyses on the SNF line of business. We compared SNF costs and margins by ownership type and chain affiliation.

Examining How SNF Nurse Staffing Levels Vary by Facility Characteristics and the Relationship between SNF Nurse Staffing Levels and Margins

To examine how SNF nurse staffing levels vary by facility characteristics and the relationship between SNF nurse staffing levels and margins, we performed statistical analyses to identify factors associated with each SNF’s total nurse and registered nurse (RN) staffing levels. To measure nurse staffing levels, we calculated each SNF’s total nurse and RN time per resident day. A SNF’s total nurse time per resident day reflects the number of hours that RNs, licensed practical nurses (LPN), and certified nursing assistants (CNA) worked per resident day. We computed each SNF’s total nurse and RN time per resident day using a complex formula. We first calculated a SNF’s total paid hours for full-time and part-time RNs, LPNs, and CNAs who are both directly hired and under contract. Because the time needed for treating residents varies with their clinical conditions and treatments, we then adjusted each SNF’s nursing time per resident day on the basis of its Medicare residents’ health care needs. This process is known as case-mix adjustment. We developed our formula based largely on CMS’s methodology for case-mix adjusting nurse staffing measures for Nursing Home Compare, the CMS website that contains summary measures of SNF quality data. CMS’s approach is based on the distribution of a SNF’s residents’ assignments into one of 53 different payment groups, called resource utilization groups. Each group describes residents with similar therapy, nursing, and special care needs. CMS’s model uses the estimated RN, LPN, and CNA minutes for each resource utilization group based on the results from the Staff Time Measurement Studies conducted in 1995 and 1997.

For our analyses, we used a different source of data than what CMS uses for Nursing Home Compare. CMS obtains staffing data from Form CMS- 671 (Long Term Care Facility Application for Medicare and Medicaid) from the Certification and Survey Provider Enhanced Reports (CASPER) system and census data from Form CMS-672 (Resident Census and Conditions of Residents). CMS officials advised us against using the CASPER data. CMS has observed that the CASPER data, which are collected over a 2-week period at the time of a SNF’s annual inspection survey, generally indicate higher RN staffing levels and lower LPN and CNA staffing levels compared with the Medicare cost reports. Table 4 shows CMS’s analysis of the staffing levels using 2013 data from the Medicare cost reports and CASPER.

Because of the available data in the cost reports, there were some limitations with our case-mix adjustment calculation. While the cost reports include data on the resource needs for Medicare residents, they do not capture data on the resource needs for non-Medicare residents. Accordingly, we estimated a SNF’s resident case-mix based only on its Medicare residents’ resource utilization groups. In addition, the cost reports obtain data on 13 additional resource utilization groups that CMS implemented in 2010 to reflect updated staff time measurement data. For our calculation, we could not use Medicare days attributable to these groups on the cost reports. Finally, because SNFs’ staffing data on the cost reports were incomplete for fiscal year 2011 and were generally unavailable beyond fiscal year 2014 when we began our analyses, we limited our analyses to fiscal years 2012 through 2014.

HoursAdjusted is the case-mix adjusted total nurse or RN hours per resident day.

HoursReported is each SNF’s number of reported total nurse or RN hours per resident day.

HoursExpected is each SNF’s number of expected total nurse or RN hours per resident day.

HoursNational Average is the national average of reported total nurse or RN hours per resident day.

We then used multiple linear regression analysis, a statistical procedure that allowed us to assess the relationship between a SNF’s margin and its case-mix adjusted total nurse and RN time per resident day, controlling for other factors. The other factors in our models included a SNF’s average hourly RN wage, average resident length of stay, chain affiliation, number of beds, number of competitors within 15 miles, ownership type, proportion of Medicare days, and urban or rural status. Our models also accounted for the state where each SNF was located. We performed separate regressions for all SNFs in fiscal years 2012, 2013, and 2014. We also performed regressions by ownership type and chain affiliation.

Table 5 shows the results of our regressions for all SNFs where the dependent variable is the case-mix adjusted total nursing hours per resident day, and table 6 shows the results of our regressions for all SNFs where the dependent variable is the case-mix adjusted RN hours per resident day. The tables include regression coefficients and R2 statistics. Regression coefficients can be interpreted as the predicted change in nursing time per resident day for every unit change in the independent variable. In general, it is not meaningful to compare the size of these coefficients because our independent variables are on different scales. We used R statistics to estimate how much of the variation in the nursing time per resident day can be explained by all the independent variables in our models. Taken together, the independent variables explained between 27 percent and 31 percent of the variation in the case- mix adjusted total nursing hours per resident day and between 36 percent and 39 percent of the variation in the case-mix adjusted RN hours per resident day for fiscal years 2012 through 2014. Accounting for the state where each SNF was located was very important in explaining its nursing time per resident day. This could be attributable to variation across states in staffing requirements, Medicaid reimbursement rates, or other factors.

Appendix II: Comments from the Department of Health and Human Services

Appendix III: GAO Contact and Staff Acknowledgments

GAO Contact

Staff Acknowledgments

In addition to the contact named above, Martin T. Gahart, Assistant Director; David Grossman, Analyst-in-Charge; Todd D. Anderson; and Jane Eyre made key contributions to this report. Also contributing were Elizabeth T. Morrison, Vikki Porter, Eric Wedum, and Jennifer Whitworth.