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CHAPTER EIGHT HEALTH SERVICES RESEARCH PERSONNEL Health services research is an interdisciplinary field of research that seeks to understand the impact of organiza- tional characteristics, financing, health personnel, and tech- nology on the use of health services, quality of care, patient outcomes, and cost. The field draws on a wide range of disciplines, including biostatistics, epidemiology, sociology, health economics, medicine, nursing, engineering, manage- ment, and psychology. Its national importance is broadly recognized by providers, administrators, employers, insur- ers, and state and national policymakers who are seeking solutions to problems of escalating health care costs, ero- sion of access to care, concerns about the quality of care, and the overall health status of Americans. This field pro- vides the information that is being used to design health care reform proposals and will be the source of information on the impact of any future health care reforms. In recognition of increasing need for policy-relevant in- formation that comes from health services research, the Agency for Health Care Policy and Research (AHCPR) was established in 1989 as an organizational locus for federal leadership and funding. In addition, health services research studies are funded by institutes at the National Institutes of Health (NIH) in specific disease categories, by the Depart- ment of Veterans Affairs, by Centers for Disease Control, and by private foundations and the health industry. Levels of funding have increased dramatically over the past 5 years, escalating the demand for well-trained researchers who can work in interdisciplinary teams. The committee recommends that training in health ser- vices research be given higher priority and an increased allocation of National Research Service Award (NRSA) po- sitions. In 1992, AHCPR had 92 positions, or approxi- mately 0.5 percent of all NRSA awards. The NIH Revital- ization Act of 1993 increased the allocation of NRSA awards to AHCPR to 1 percent, or approximately 180 posi 81 lions in 1993. It is recommended that this be increased over the period 1994-1996 to 360 positions. Initially, priority should be given to increasing postdoctoral training opportu- nities as predoctoral training opportunities are expanded. ADVANCES IN HEALTH SERVICES RESEARCH Health services research has expanded our understand- ing of organizational and financial factors that affect access to care, appropriateness of services, quality, cost, and pa- tient outcomes. Methods have been developed and applied for comparing the cost and effectiveness of alternative diag- nostic and treatment technologies and for assessing the im- pact of health services on health status and quality of life. Advances in health services research have influenced the direction of national and state policies and have contributed to dramatic changes in the health care industry over the past decade. The rate of change in health care is ever increasing and the demand for new information on the impact of policy options and the effects of past changes is growing. The current national discussions regarding health reform are sharpening policymakers' understandings of the need for accelerating the investment in health services research and in its dissemination. Organization and Financing Health services research provides information on the quality and cost of alternative types of health care organiza- tions. For example, health services research provides policy- relevant information on health maintenance organizations (HMOs) and other managed-care arrangements. Research has shown HMOs to be effective in controlling costs and providing high-quality care. However, research has also shown the rate of inflation in health care costs in HMOs to

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MEETING THE NATION' S NEEDS FOR BIOMEDICAL AND BEHAVIORAL SCIENTISTS be similar to more traditional fee-for-service care. This has stimulated innovations in managed care, some of which come directly from products of research, including the use of appropriateness criteria for making coverage decisions, advances in the design of management-information systems and analytic methods for monitoring quality indicators and cost, and methods for profiling providers to compare pro outcomes and cost. Among the products of this research are best-practice guidelines for specific conditions Hat are being widely disseminated to providers, insurers, and con- sumers to improve knowledge and state-of-the-art practice. Quality of Care and Patient Outcomes vider performance in terms of cost and quality. These meth ods are supporting a new generation of managed care that emphasizes He provision of effective high-quality care at a reasonable cost. Our knowledge of the impact of financial incentives on patient access to care, provider practice patterns, and orga nizational productivity come from health services research. For example, research has demonstrated He power of f~nan cial incentives and disincentives on patient care seeking and provider practice. Health services researchers developed the payment classification systems used by Medicare to pay hospitals (DRGs) and to pay physicians (RBRVs). Current research work is improving case mix and severity measure ment in ambulatory care. These measures can be used to adjust payment to HMOs and other providers and represent long-term investments in health services research. Our understanding of public heals issues regarding ac- measurement in organized efforts to improve quality are based cess to appropriate and needed services comes primarily on what is being learned through health services research. from health services research. For example, information on the growing numbers of uninsured people and Heir charac teristics has been critical to He formulation of heals care reform proposals. Furthermore, studies have shown that insurance coverage is necessary, but frequently not suffi cient to ensure appropriate access to care. High-risk popu lations will likely require special outreach services and heals education to gain He full benefit of available services. These findings are beginning to clarify end redefine He future role of public health agencies under health care reform. Medical Effectiveness Research New initiatives to allow better understanding of the ef fectiveness of health care services are advancing knowl edge regarding what works, for whom, and under what cir cumstances. The AHCPR is supporting a range of studies on specific conditions and procedures to encourage better understanding of variations in patterns of provider practice and their consequences for patient outcomes, both clinical and patient-reported. Validated measurement scales for pa tient-reported outcomes, including health status and satis faction, are products of years of research. Studies of acute myocardial infarction, cataract surgery, low bird weight, coronary artery disease, joint-replacement surgery, and other common conditions are providing new Insights Into the effectiveness and efficiency of our current health care delivery system as measured by improvements in patient Research is contributing to new and improved methods for measuring quality of heals services, including Heir im- pact on patient functioning, satisfaction, and quality of life. Quality of care is broadly conceived to include relevant characteristics of the organizational structure of Be heals care provider, the content of the care, and the outcomes experienced by individuals with specific health problems. One of He newer areas for research pertains to the use of patient-reported measures of outcomes in conjunction win clinical measures of outcome. Patient-reported outcomes information is being applied in organized efforts to improve the total quality of services, as well as being used by some regulatory authorities (e.g., He Food and Drug Administra- tion) for assessing quality of life effects of new treatments. The conceptual framework for measuring quality-of-care, He measures being applied, and the integration of quality Ethical and Legal Issues The advances in medical technology and Be need to pro- vide patients with state-of-the-art care have increased legal and ethical concerns. Research is clarifying the nature of ethical concerns with new technologies (e.g., genetic screen- ing) and providing new understandings regarding the mean- ing of informed consent and effective procedures for ob- taining informed consent. Among legal issues of greatest concern to providers has been He rapid escalation of malpractice claims and the over- all cost of malpractice insurance. Research has shown the importance of effective provider-patient communication in reducing He occurrence of malpractice claims and has pro- vided information that has helped shape malpractice reform legislation in several states. In conclusion, our understand- ing of the operation of the American health care system, its effectiveness, and its efficiency relies largely on the prod- ucts of health services research. Advances in our concep- tual understanding of the complexities of health care deliv- ery, methods of measuring quality of care, cost, and patient outcomes and the development of policy-relevant informa- tion have been highly significant over the past 25 years. Even so, there are many questions unanswered regarding how best to organize and provide health care services to ensure the highest possible heals status for all Americans at an affordable cost. 82

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HEALTH SERVICES RESEARCH PERSONNEL ASSESSMENT OF THE CURRENT MARKET FOR HEALTH SERVICES RESEARCH PERSONNEL The need for information coming from health services research is widely recognized and growing. The size and scope of He supply of highly trained researchers are not well documented but are inadequate in the view of the commit- tee to meet He current or projected future needs. In this section, He available information on supply is presented. This is followed by a discussion of factors contributing to an ex- panding need for well-trained health services researchers. Supply of Health Services Researchers Health services research is problem-oriented: practitio- ners examine and evaluate He delivery of heals care ser- vices in the United States. It is a distinct area of inquiry in which systematic methods are applied to problems of the allocation of finite health resources and the improvement of personal health care services. Individuals enter the field of health services research from a variety of backgrounds, in- cluding biostatistics, epidemiology and bioengineering, the behavioral sciences (anthropology, sociology, and psychol- ogy), the social sciences (economics, statistics, and urban planning), and other fields such as operations research, in- dustrial engineering, public administration, health educa- tion, and medicine. The number of health services research personnel in the U.S. labor force is not known, although attempts have been made by the National Research Council (NRC) and others to describe the composition of certain segments of the labor force.) The composition of health services research is largely determined by the availability of support for research and development. Thus, no stable estimates of He number of individuals in the work force can be generated unless specialized surveys are conducted or special estimates are generated, as demonstrated by previous NRC surveys. Per- haps the best available estimate of He size of the heals services research labor force is the membership of the As- sociation for Health Services Research (AHSR), an organi- zation established in 1981 to promote the field of heals services research (Davidson, 19934. Although this most likely results in an undercount of the heals services re- search labor force, studying He number of AHSR members and their characteristics is helpful in understanding the in- frastructure of at least one segment of the labor force, a segment we might consider to be He "attentive" workers.2 Composition of the Attentive Health Services Research Labor Force: 1992 About 2,000 individuals were members of AHSR in 1992. Of these, 100 were students and He remainder were drawn from medicine, public heals, and research back- grounds. Most AHSR members hold doctoral degrees, whether research doctorates (922 members) or clinical doc- torates (448 members) (Table 8-1~. When asked to identify Heir discipline of specialization, TABLE 8-! Distribution of Degrees Among Members of the Association for Health Services Research: 1992 Degree Doctorate Masters Number 922 720 (Public Health) (Other Masters) Bachelors Practitioner (M.D. or D.O.) (Nursing) (M.S.W.) (Other) J.D. TOTAL (247) (473) 78 601 (448) (108) (17) (28) 24 2 ~ 345a Source: Davidson, 1993 aTotal exceeds 2.000 owing to multiple degrees of some members. 83

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MEETING THE NATION'S NEEDS FOR BIOMEDICAL AND BEHAVIORAL SCIENTISTS FIGURE 8-1 Disciplines of individual members (members with multiple disci- plines are counted more than once), 1992. SOURCE: Association for Health Servic- es Research, 1993. about one-~ird indicated that they work in what AHSR con- siders to be the social sciences, another third in the health professions, and He remainder in public health, public policy, or other health services research specialties. Among Hose classified as social scientists, about 33 percent work in economics, 15 percent in sociology, and 12 percent in psychology. About 22 percent (147 members) of the social scientists reported their discipline to be health services re- search, possibly reflecting He participation of that cohort of individuals formally trained in health services research in recent decades (Figure 8-1~. Employment Sector. Most AHSR members were em- ployed in university settings in 1992 (Figure 8-2~. How- ever, a host of non-prof~t and propriety health services re- search fees and non-prof~t professional organizations offer employment to health services research personnel. In 1988, the AHSR, together with the Federation for Health Services Research published the Directory of Health Services Re- search Organizations. That directory remains "~e only source of information on health services research centers in the United S tales" (Davidson, i 993) . Changes in Composition Over Time While the lack of data sets prevent an analysis of ~e composition of the health services research labor force over Total Individuals = 1,902 Health Care Industry (222) Health Care Deliverv Private Organization (168) Foundation (43) Government (208} University (939) FIGURE 8-2 Employment settings of members, 1992. NOTE: Data represents 98% of AHSR membership. SOURCE: Associa- tion for Health Services Research, 1993. All Members Social and Statistical Sciences Health Profession . - _ Social _ Sciences ,(669) Public Policy Other (55) ~ ~ - - - . HSR (147) Other (70) Economics ~ (205) Stats/Math _Ir ~ (44) ,, _ ,, r ~ Psychology =~ |_ Sociology en_ (99) Business - ~ -- - Operations Research (25) (1 1 1) time, the availability of previous work by the NRC (1977, 1985) suggests that comparative studies might be devel- oped. Because of He dynamic nature of this "labor force" and the importance to the national health effort, the Com- mittee believes Hat some investment in labor force studies of the health services research community would yield tre- mendous payoffs and, given the direction of national in- terest in He improvement of health care delivery, will be increasingly sought in the coming years. OUTLOOK FOR HEALTH SERVICES RESEARCH PERSONNEL The President's proposal for health care reform as well as Congressional proposals are pressing for change in the American health care system to remedy problems of spiral- ing costs, eroding access for the uninsured and underinsured, and uncertainty regarding the uniform quality of services. Many aspects of these proposals draw on infor- mation derived from health services research, as discussed above. Market forces are already requiring the pharmaccu- tical industry to consider issues of cost-effective outcomes of treatment as part of their business. However, as efforts are made to predict the consequences of alternative health care reform proposals, it is evident Hat much more infor- mation is needed if we are to make informed policy choices. Congress and the president have recognized this need and have increased substantially the funding of health services research by federal agencies and are expected to continue to increase funding into the future. Parallel increases in He funding of heals services research in the private sector are occurring and are likely to continue. Questions to which better answers are needed include a spectrum of issues that cut across all health care services. These include: Which models of health care organization and financ- ing work best and how does this vary across populations win different socioeconomic, ethnic, and health status char- acteristics? What impact do alternative organizational models 84

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HEALTH SERVICES RESEARCH PERSONNEL have on the provision of preventive services, acute and long- term care, and quality of care and costs? What are the effects of licensing and regulatory mechanisms on access to care, quality, and cost and how should these rules be changed, if at all? Which health care professionals, with what types of training, are needed to provide high quality and efficient primary care, specialty services, long-term care, and reha- bilitative services? How can accountability be improved? Can a useful report card on quality of care and costs be provided to pa- tients and consumers to assist in making informed choices? What are other mechanisms to improve accountability in the health care system? What would be the impact of global budget con- straints? Are there other means for reducing the rate of cost increases while providing appropriate services to all who need them (e.g., eliminating inappropriate services and re- ducing administrative inefficiencies)? These and other questions are sharpening the issues that need to be addressed through interdisciplinary health ser- vices research and demonstration studies. As changes con- tinue to occur in the provision of health care services, there will be growing needs for rigorous evaluations of the im- pact of innovations on the quality, cost, and patient out- comes of care. Evaluations studies can clarify positive and negative aspects of innovations in health care delivery as well as point to opportunities to introduce improved models of care. Numerous organizational and financing changes are being introduced by states that are seeking tailored ap- proaches to health care reform. These state initiatives also will need information on which to shape policy and evalu- ate progress. The source of this information is the field of health services research. Future Employment Conditions The growing demand for health services researchers can be seen in multiple areas, including both public and private sectors. The AHCPR was created in 1989. Since then its budget for research has doubled and is expected to continue to grow as the demands for information relevant to health ~ . care reform Increase. Other federal agencies fund health services research, but AHCPR is viewed as the lead agency. Among the NIH institutes, there are increasing commitments to health ser- vices research. NIMH, National Institute of Alcohol Abuse and Alcoholism, and the National Institute on Drug Abuse were mandated by Congress to spend 12 percent of their budgets in 1993 and 15 percent in 1994 and 1995 to support services research in their respective areas. In 1994 this will amount to over $200 million in research funding. Other 85 institutes fund health services research but do not identify it as such. The National Cancer Institute, National Heart, Lung, and Blood Institute, and National Institute on Aging all have significant research activities concerned with the provision of services and the effectiveness of care within their categorical disease responsibilities. It is anticipated that health services research funding will grow to represent a small but significant proportion of NIH funding. NIH currently spends substantially more on health services re- search than does AHCPR and is expected to continue to be a major source of funding for studies concerned with the organization of services, treatment, and outcomes of care for individuals with specific diseases and injuries. In addition to NIH, other components of the Department of Health and Human Services fund health services research. The Centers for Disease Control are making new invest- ments in preventive services research and the Office of Re- search and Demonstrations at the Health Care Financing Administration supports a substantial health services dem- onstration and evaluation research program. Other federal agencies also fund health services research, including the Department of Veterans Affairs, which has an expanding health services research program. The investment of private industry in health services re- search also is rapidly growing. Insurers are seeking im- proved methods for reviewing claims and profiting provid- ers. Managed care organizations are investing in improved methods for monitoring services, provider practices, and patient needs. The pharmaceutical industry is assessing out- comes of care related to drug therapies by using health sta- tus instruments and is investing in cost-effectiveness stud- ies to demonstrate the comparative benefits of treatment. Every indication is that these investments will increase as managed care organizations demand better information to guide decisions regarding preferred treatments, appropriate- ness of services for different patients, and Heir impact on total costs of care. The health care industry accounts for 14 percent of He gross domestic product and is growing, possibly reaching 19-20 percent of He GDP early in the next century. Not only is it a large domestic industry, it is a significant source of international Bade. Methods and techniques developed in America (e.g., DRGs for hospital payment) are being adapted and used in many other countries. Health status measurement indices developed here are being translated and validated for use in other languages. There is general consensus that there are similar problems being faced by all nations as each attempts to meet He growing needs for heath care services. Our past investments in health services re- search have made us an international leader. Other coun- tries have begun to make investments in this area because of their needs for information and the demonstrated success of the American investments.

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MEETING THE NATION' S NEEDS FOR BIOMEDICAL AND BEHAVIORAL SCIENTISTS ENSURING DIVERSITY OF HUMAN RESOURCES There is limited information currently available on the supply of heals services researchers. Efforts need to be made to improve the completeness of information on indi- viduals being trained in health services research and ac- tively involved in research careers. On the basis of avail- able information, it appears Hat career opportunities are open for women and men in this field. However, there is no information available regarding ethnic minorities. It is rec- ommended that efforts be made to expand opportunities for ethnic minorities to pursue education and careers in this field. The NRSA awards can be used to leverage increased diversity among individuals entering this field and this should be encouraged. Training of Health Professionals Another concern relates to the lack of active involve- ment of the full range of health professions in the conduct of health services research studies. Much of past research has focused on physician-provided services or Rose del- egated by physicians to physician assistants or nurse practi- tioners. The breadth of research needs to be expanded to include services provided by the full range of health profes- sions, including occupational therapy, optometry, podiatry, physical therapy, and social work. In addition, services pro- vided by practitioners of alternative medicine need to be included. A recent national survey reported that one-third of all Americans have used alternative medicine services and paid for most of this care out-of-pocket. One way to increase He diversity of research on the full range of heals services provided in this counay is to attract practitioners in these professions into heals services re- search careers. The NRSA awards should be used to ac- complish this goal. THE NRSA PROGRAM IN HEALTH SERVICES RESEARCH The information on current NRSA awards and the rec- ommendations for future award levels in health services re- search relate solely to those awards made by AHCPR. The numbers of awards and funding levels of the program within AHCPR are shown in Table 8-2. The numbers of awards have grown rapidly yet remain small relative to He total needs for heals services researchers. The current AHCPR program funds about 35 predoctoral and 59 postdoctoral positions, up from only 12 postdoctoral awards in fiscal 1990. The AHCPR program is relatively young and has given priority to postdoctoral Gaining, particularly of health professionals, as an efficient strategy for more rapidly ex- panding He numbers of qualified health services research- ers. It is expected Hat this should change over time to give increased emphasis to predoctoral Gaining of individuals for careers in health services research. This Gaining may occur either in academic disciplinary departments Hat have the capacity to Lain in health services research or in aca- demic health services research departments that draw to- ge~er faculty representing the range of disciplines applied in this field. NRSA awards in the NIH institutes also support the train- ing of some heals services researchers. NIMH supports TABLE 8-2 Aggregated Numbers of NRSA Supported Trainees and Fellows in Health Services Research for FY 1991 through FY 1993 Fiscal Type of Support TOTAL Tra~neeship Fellowship 12 Year Level of Tra~n~g 1991 Number of awards Predoctoral Postdoctoral o 12 o o o 12 o 12 1992 Number of awards 94 82 12 Predoctoral 35 35 0 Postdoctoral 59 47 12 1993 Number of awards 96 79 17 Predoctoral 30 30 0 Postdoctoral 66 49 17 NOTE: Based on estimates provided by the National Institutes of Health. See Summary Table 1 86

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HEALTH SERVICES RESEARCH PERSONNEL training in mental health services research, and the National Institute of Alcohol Abuse and Alcoholism is now solicit ing Gaining grant proposals in alcohol services research. In addition, He National Institute of Nursing Research sup ports training in health services research and to a lesser extent so do other institutes. NRSA Paining supported by the institutes should be encouraged; He numbers of current trainees is unknown because the classification of training awards in behavioral, clinical, nursing, and oral health does not discriminate which programs and fellows are pursuing RECOMMENDATION: The committee recommends training in heals services research methods and their ap- that He number of NRSA positions allocated to AHCPR plication. increase to 360 in fiscal 1996. These positions should be phased in yearly as properly qualified candidates and training sites present themselves. to examine the impact of organization, finance, and use of technology on the utilization, cost, and quality of care. This field of research will need to grow substantially to meet the ever expanding demands for information by policymakers, administrators, providers and consumers. The questions raised regarding what impact different proposals for health care reform will have on access, cost, and quality of care are largely questions that will be answered by this field of research (Table 8-3~. RECOMMENDATIONS Program Size Health services research is critical to the future of heals care delivery in this country. Health services research is a relatively young field that uses interdisciplinary approaches TABLE 8-3 Committee Recommendations for Relative Distribution of Predoctoral arid Postdoctoral Trusteeship and Fellowship Awards for Health Services Research for FY 1994 through FY 1999 115 55 60 1995Recommended number of awards Predoctoral Postdoctoral 1996Recommended number of awards Predoctoral Postdoctoral 1997Recommended number of awards Predoctoral Predoctoral 1998Recommended number of awards Predoctoral Postdoctoral 1999Recommended number of awards Predoctoral Postdoctoral 240 180 60 360 300 60 300 60 60 360 300 60 360 300 60 95 45 50 145 95 50 190 140 50 140 50 50 190 140 50 190 140 50 20 10 10 95 85 10 170 160 10 160 10 10 170 160 10 170 160 10 Fiscal Year Level of Training 1994 Recommended number of awards Predoctoral Postdoctoral Type of Support TOTAL Traineeship Fellowship 87 Traineeships and Fellowships The institutional Raining grant permits the development of innovative interdisciplinary research training programs,

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MEETING THE NATION'S NEEDS FOR BIOMEDICAL AND BEHAVIORAL SCIENTISTS an essential feature of research in this area. However, given the anticipated growing demand for skilled specialists in health services research, the committee concludes that AHCPR should place significant emphasis on individual fel- lowships in He next few years in order to encourage quali- fied individuals win some experience in the area of heal care policy to pursue advanced Gaining. RECOMMENDATION: The committee recommends that individual fellowships represent about 45 percent of total NRSA support available through AHCPR in fiscal 1996, up from approximately 15 percent in fiscal 1993. NOTES 1. For example, in 1977 the NRC identified and surveyed about 900 individuals who had received support from the National Center for Health Services Research (NCHSR) between 1960 and 1976 and about 1000 indi- viduals who had received research training support from NCHSR or Alco- hol, Drug Abuse, and Mental Health Administration in the area of health services research between 1970 and 1977. About 77 percent of the former trainees and 81 percent of the former principal investigators were engaged in health services research at the time of the survey. (See NRC, 1977; Ebert-Flattau, 1981). 2. The concept of the "attentive" public was developed by Gabriel Almond, who applied it to understanding attitudes of Americans toward foreign policy issues (Almond, 1950). Jon Miller applied the concept to the formulation of science policy and has expanded the original conception 88 into a broader model of political specialization (Miller, 1983). The con- cept is extended for use here to refer to those members of the health ser- vices research labor force sufficiently interested in being identified as mem- bers of the field to have become members of AHSR. REFERENCES Association for Health Services Personnel 1993 AHSR Membership Directory. Washington, D.C.: Associa- tion for Health Services Research. Almond, G. 1950 Davidson, B. 1993 The American People and Foreign Policy. New York: Harcourt, Brace and Company. Personnel Needs and Training for Health Services Research. Paper prepared for the Committee on National Needs for Bio- medical and Behavioral Research Personnel. Ebert-Flattau, P. 1981 Some preliminary data on the health services research labor force in the United States. In Systems Science in Health Care, C. Tilquin (ed.), New York: Pergamon Press. Miller, J. 1983 The American People and Science Policy. New York: Pergamon Press. National Research Council 1977 Personnel Needs and Training for Biomedical and Behav- ioral Research. Washington, D.C.: National Academy Press. 1985 Personnel Needs and Training for Biomedical and Behav- ioral Research. Washington, D.C.: National Academy Press.