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Summary Health services research is a multidisciplinary field that investigates the structure, processes, and effects of health care services. It draws on a variety of clinical and academic disciplines and, at its most creative, integrates their conceptual frameworks and methods to provide new ways of studying and understanding the health care system. This system is the product of scientific, technological, and social developments that have dramatically expanded the capabilities of medical care during the past century. Health services research and education were born of demands for better information and analysis to guide complex decisions about the organization, financing, and effectiveness of health care. Recently, the health care system has been experiencing a dramatic restructuring. Governments and employers have intensified their efforts to direct people into managed care plans that control patient access to practitioners and services, pay providers fixed amounts for a defined set of services to a defined set of patients, and otherwise manage the use and cost of care. Health care organizations are consolidating, expanding, shrinking, reorganizing, or otherwise changing in ways that are varied, sometimes perplexing, and unclear in their effects on the cost, quality, and accessibility of health care. In this environment of rapid change and uncertainty, health services research has an important contribution to make in documenting and evaluating the effects of health care restructuring. Furthermore, just as health services research has helped decisionmakers understand and shape the health care system of the past, so too can it continue to inform critical decisions by government officials, corporate leaders, clinicians, health plan managers, and even ordinary people making choices about health problems ranging from minor to catastrophic.
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2 / HEALTH SERVICES RESEARCH The federal government is the major sponsor as well as an important consumer of health services research. Funding for health services research and education has, however, been decreasing as a share of total health spending, comprising a smaller percentage of total health spending in 1990 than in 1970. As this report was being completed, the drive to balance the federal budget was intensifying pressures on this funding and threatening the existence of the lead federal agency for health services research. Private organizations, including foundations and managed care plans, can be expected to continue and possibly increase their investment in some areas of health services research. Nonetheless, foundations are facing heavy pressure to use their resources to offset some reductions in public spending for social programs. Among health care organizations, intense price competition limits resources for research that does not promise a short-term competitive advantage. Taken as a whole, private efforts are unlikely to substitute for more than a portion of government-supported research and training in magnitude, coherence, scope, or concern for long-term consequences. In this environment, sustaining the capacity for high-quality health services research and training will be a formidable task. ORIGINS OF THE STUDY This report focuses on one part of the field of health services research-its work force and its programs for educating and training that work force. The study originated in a request from the Agency for Health Care Policy and Research (AHCPR), which was created by Congress in 1989 to support research, data development, and other activities that will "enhance the quality, appropriateness, and effectiveness of health care services" (P.L. 101-239~. Other support was provided by the Robert Wood Johnson Foundation, the Department of Veterans Affairs, and the Baxter Foundation. AHCPR asked the Institute of Medicine (IOM) to investigate work force issues in health services research and prepare a report with recommendations to inform the agency's decisions about federal resources for educating and training health services researchers. Among the questions posed to the committee were: (1) What health services research personnel and training resources are available now? (2) What levels and types of personnel may be needed in the next decade? (3) What changes in programs and resources may be necessary to meet future demand for health services researchers? The IOM was not asked to evaluate the content of the nation's research agenda, the adequacy of overall research funding, or the productivity of research activities, although these issues are clearly worthy of examination in their own right.
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SUMMARY / 3 STUDY APPROACH To oversee the study, the IOM appointed a 12-member committee. It included individuals with expertise and experience in health services research, research training, health care delivery, public policy, and economics. The committee met in July 1994, January 1995, and March 1995. After discovering the paucity of current and trend data on the size and characteristics of the health services research work force, the committee obtained private funding to undertake quickly a number of information collection activities, including . a survey of directors of health services research training programs in the United States and Canada; and · creation of a database of health services researchers in the United States; · telephone interviews or panel discussions with key individuals in state governments, managed care organizations, hospital systems, consulting firms, and other nonacademic organizations. The committee also consulted two related studies by other units within the National Academy complex. One, Meeting the Nation's Needs for Biomedical and Behavioral Scientists (NRC, 1994), was the latest in a series of National Research Council (NRC) reports on this topic, and the other, Reshaping the Graduate Education of Scientists and Engineers (1995), focused broadly on challenges for graduate education in science and engineering. In September 1994, the committee published an interim statement that included a working definition of health services research and a review of important research questions. Responses to that statement contributed to the development of the committee's final report, which was reviewed and revised under the procedures of the NRC. DEFINING HEALTH SERVICES RESEARCH After reviewing various definitions of health services research, the committee formulated the following definition: Health services research is a multidisciplinary field of inquiry, both basic and applied, that examines the use, costs, quality, accessibility, delivery, organization, financing, and outcomes of health care services to increase knowledge and understanding of the structure, processes, and effects of health services for individuals and populations.
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4 / HEALTH SERVICES RESEARCH Several features of this definition are worth noting. First, health services research is a multidisciplinaryfield that draws from many distinct academic and clinical disciplines such as economics, epidemiology, biostatistics, and nursing. This characteristic of the field complicates efforts to catalog and analyze its processes, participants, and products. Second, the definition's reference to basic and applied research underscores the fact that health service research involves both questions about fundamental individual and institutional behaviors that may not produce practically useful knowledge in the short term, as well as questions of immediate practical interest to public and private decisionmakers. In general, health services research falls toward the applied end of the research continuum. Third, by referring to both knowledge and understanding, the definition stretches the boundaries of the field to include not only research that generates new knowledge but also analyses that contribute to the theoretical and conceptual frameworks for conducting, interpreting, and applying empirical research. Thus, the boundaries of health services research, health care management, and health policy are not sharp. Finally, this definition does not explicitly restrict research to personal health services. Rather, it makes clear that the health of populations as well as that of individuals- is a relevant research topic. As more individuals are enrolled in managed care plans, interest has grown in measuring and comparing quality and cost performance at the group level and in assessing the relative contribution of clinical interventions to the well-being of the group as well as that of its individual members. This report uses the terms education and training interchangeably, as is common in the health professions. Conceptually, however, education may be viewed as transmitting broad knowledge relevant to a field and developing critical thinking abilities that are widely viewed as essential to the creation and evaluation of new knowledge. Training may be more narrowly defined as providing the skills (e.g., facility in statistics and survey design) that are necessary for specific research activities (e.g., preparing surveys, analyzing data). FINDINGS AND RECOMMENDATIONS Work Force Data . ~. . One of the committee's first findings was that existing data on the size and characteristics of the health services research work force are fragmentary and incomplete. The committee urges
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SUMMARY / 5 · the Association for Health Services Research (AHSR) to seek funding to update and extend the database created for this study through a more detailed survey of researcher characteristics including, for example, age, sex, ethnicity, and employment status; · the NRC to consider revising the annual census of those who have received doctorates and the longitudinal sample survey of doctoral recipients to allow better identification of those educated or working in the field of health services research; · the AHCPR and other relevant government agencies as part of a more general effort to evaluate the results of various research training programs to investigate the career paths and productivity of those who receive trainee grants or fellowship awards. These recommendations are consistent with those of the 1995 NRC report Reshaping the Graduate Education of Scientists and Engineers. That report urged the National Science Foundation and the NRC to continue to improve the coverage, timeliness, and analysis of education and employment data to support more informed decisions about the country's science and technology work force. A more specific recommendation was that additional information on nonacademic employment be gathered, given the growing importance of this sector. Work Force Supply and Demand The work force engaged in health services research has three broad components: (1) researchers who originate, design, supervise, and report basic and applied health services research; (2) individuals who assist in health services research under the direction of others; and (3) individuals who analyze health services information and apply certain tools of health services research in management and policy settings. The boundaries of the health services research work force (and its individual components) are, however, highly permeable. People come to the field by many paths, some through formal education and others through relevant work experience. Similarly, those trained in health services research may migrate to work that uses their skills but is quite different from traditional academic or think tank employment. This permeability adds to the problems in counting the research work force. These problems are accentuated to the extent that some researchers choose to identify themselves with their primary discipline (e.g., economics or medicine) rather than with health services research. Using its multiple databases, the committee identified approximately 5,000 current health services researchers. As an estimate of the size of the work force, this number omits some health services researchers and includes some individuals
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6 / IIEALTH SERVICES RESEARCH who are interested in health services research but not actually engaged in it. Approximately half of the researchers for whom degree information was available have doctoral degrees, but the specific field or discipline could not be determined, and another 28 percent (mostly physicians) have clinical degrees. The largest segments of the current health services research work force appear to be employed in academic institutions, private research organizations, and consulting groups. Employment in health plans, insurance companies, and similar organizations appears to be growing fast, albeit from a smaller base. The picture for states, which generally contract out for research rather than maintain research staff, suggests severe financial pressure on research projects except for those related to costly programs such as Medicaid. For graduate scientists and engineers in general, academic jobs are declining while positions in business and industry are growing. Without information on researchers' age, employment history, or percentage of time spent in research, life table models or other work force estimation methods cannot be employed to arrive at reasonable numerical projections of the future supply of health services researchers. On qualitative grounds, however, the committee foresees expansion in the health services research work force if public research funding escapes significant reductions and if organizations competing in the emerging health care market continue to support growth in knowledge about the quality, effectiveness, and cost of clinical services, the behavioral determinants of health status, and similar questions. The committee also was not able to make an empirically based, quantitative statement about the match between current supply and current demand for health services researchers. Based on limited information from health services research employers and on the experience of committee members, the committee concluded that well-trained researchers with practical experience in health care organizations (e.g., integrated health care systems, insurance companies) and in managing research units appear to be in short supply. In addition, recruiting difficulties were reported for those trained in both health services research and selected areas, including outcomes and health status measurement, epidemiology, health economics, statistics, epidemiology, and health policy. In some clinical areas, such as oral health and allied health services, trained health services researchers also appear to be scarce. Overall, the committee reached two qualitative conclusions. First, no anecdotal or other evidence indicates that the current supply of health services researchers exceeds current demand. Second, employers are more concerned about the quality than the quantity of prospective researchers.
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SUMMARY / 7 Training Programs Funding for education in health services research comes from a variety of public and private sources. With funds provided by the National Institutes of Health under general authority of the National Research Service Award (NRSA) Act, AHCPR administers the major federal funding program for pre- and postdoctoral education in health services research. The program, which AHCPR has also supplemented through its own budget, provides awards both to institutions and to individuals. Health services research education and training are provided under many different organizational auspices, for example, as part of doctoral programs in health policy and administration, public health, nursing, social work, biostatistics, and economics. The committee noted, however, that formal programs in health services research play a special role by providing an organizing focus for the field and an environment supportive of creative research and methodology development. They stimulate systematic, multidisciplinary investigation and understanding of health services, behaviors, and outcomes, and they promote the formulation of research frameworks and strategies that integrate the theories, concepts, and tools of different disciplines. These programs are also an important source of personnel prepared to increase the knowledge base for responding to issues of cost, quality, and access that face the nation. They are, therefore, a valuable national resource. A single educational path is, however, neither practical nor desirable. Health services research will continue to attract and benefit from people with a variety of disciplinary and clinical degrees who are prepared to make important theoretical, conceptual, and empirical contributions to the field. To take full advantage of this variety, the field needs to offer a range of training opportunities so that those who are pursuing or have completed graduate degrees in other areas can obtain explicit training in health services research through either a disciplinary or, ideally, a multidisciplinary program. As this study proceeded, the committee became concerned that those in doctoral programs were not being adequately prepared for the "real world" (or worlds) of health services research. Given the nature of the field, researchers will often find themselves working as part of a research team with individuals from varied disciplinary or clinical backgrounds and different levels of training and experience. The committee was concerned that students are not routinely educated to understand what may reasonably be expected from other researchers or clinicians, to value the contributions of master' e-level researchers, or to develop the qualities needed to lead or participate effectively in a research team. Such qualities include communication skills, facility in group decisionmaking processes, and knowledge of conflict resolution strategies. Given recent trends in employment, it is the general sense of the committee that health services research programs will benefit their students by providing broad educational
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8 / HEALTH SERVICES RESEARCH opportunities that make them more versatile, flexible, and attractive to corporate and governmental as well as academic employers. These opportunities include course work in several disciplines and methodological techniques, practical experience in research and policy analysis, and exposure to differences in expectations for researchers among academic, government, and industry employers. Academic programs cannot substitute for on-thejob education, but they can make entry to a new work setting somewhat easier. Based on changing sources and types of demand for health services researchers, some shifts in the focus of publicly supported training in health services research are advisable. In particular, the committee recommended that AHCPR consider greater emphasis for some predoctoral and postdoctoral awards for training in areas such as outcomes/health status measurement, biostatistics, epidemiology, health economics, and health policy in which recruiting difficulties have been reported; · more explicitly consider in evaluating institutional training program awards-how institutions' approaches to training, faculty composition, research opportunities, and training slots relate to high-demand areas; and set aside a substantial percentage of institutional awards for innovative programs in health services research, which could be completely new programs or significant modifications of existing programs (see below). The committee offered no ranked prescription for the program innovations to be encouraged. By way of example, however, innovative programs might be designed to · explore new models and methods for truly multidisciplinary education and investigation; test creative educational opportunities and technologies for mid career professionals who have varied levels and kinds of educational backgrounds and work experiences; · extend student and faculty research experiences in nonacademic settings through mechanisms such as internships and faculty sabbaticals; . develop strategies to involve more community-based practitioners in faculty research on clinical practice and its outcomes; or cultivate partnerships with public or private organizations to encourage collaborative research training, joint methodology development, and other cooperative ventures.
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SUMMARY / 9 Several of these examples point toward programs that are more community and customer oriented; that is, programs that better prepare students for employment in government, business, and academic settings. Such innovative steps may be somewhat more costly than current programs and may require additional public and private support. The committee also reviewed and endorsed the recommendations for health services research training awards that were issued in the 1994 NRC report Meeting the Nation's Needs on Biomedical and Behavioral Scientists. The recommendations called for . · funding 360 NRSA yearly for fiscal years 1996 through 1999; raising stipends to more competitive levels by fiscal year 1996 and maintaining the real value of these stipends by adjusting for inflation; examining research training opportunities for women through the NRSA program and strengthening the role of postdoctoral support to assist women in establishing themselves in productive research careers; and holding Minority Access to Research Careers awards constant at fiscal 1993 levels, or approximately 680 awards, pending the outcome of further analyses. HEALTH SERVICES RESEARCH: TODAY AND TOMORROW Health service researchers face no shortage of important, contentious questions and methodologic challenges. Among the critical areas for continued attention are the following: Organization andfinancing of health services. Health services research can inform the debate over incremental reforms in health insurance and market-based strategies to control health care costs. It can, for example, clarify the complexities of maintaining and overseeing health insurance markets, in particular, the peculiar dilemmas presented by adverse risk selection and the difficulties of devising methods for paying health plans and providers and monitoring their performance so that they are discouraged from avoiding sicker people or skimping on the quality of care. Access to health care. Research continues to document how access-the timely receipt of appropriate care is affected by insurance coverage, levels of payment to providers of care, race, culture, and other factors and how, in turn, lack of access affects health. Continued work in these areas is important for informed policy choices.
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10 /HEALTH SERVICES RESEARCH Practitioner, patient, and consumer behavior. Although researchers have identified many factors affecting health behavior, much remains to be learned about ways of encouraging desired behaviors, such as cost-effective use of medical care and compliance with preventive or treatment protocols. Quality of care. Health services research has played and will continue to play a critical role in developing and improving mechanisms for identifying quality of care problems and measuring the performance of health plans and clinicians in a competitive market. One priority (a corollary of the point above about adverse selection) is the development of better methods of adjusting comparative data so that the performance of those who treat sicker patients is fairly rated. Clinical evaluation and outcomes research. A major recent emphasis in health services research has been clinical evaluative studies and outcomes research on the benefits and harms of alternative strategies for preventing, diagnosing, or treating illness. Work to date only scratches the surface of ignorance about what works and does not work in health care. Informatics and clinical decisionmaking Health services researchers have found serious deficits in the ways in which knowledge is packaged and disseminated to inform decisionmakers. A major goal of information systems technologies is to help patients, clinicians, purchasers, and policymakers make better decisions about health care. Health professions work force. As this committee confirmed, efforts to forecast, plan, and manage the supply of health personnel and services have proved difficult. Methodologists and researchers are working to improve data systems and tools for estimating work force supply and demand. In each of these areas, health services researchers investigate important and fascinating issues that profoundly affect the health and well-being of individuals and populations. They develop and apply methodologies and analytic frameworks to understand the structure, processes, and effects of health care services and provide a more informed basis for decisions by public officials, clinicians, patients, health plan managers, and others. This report has examined a critical component of the health services research enterprise its work force and its programs for educating and training that work force. The conclusions reflect the committee's judgment that this work force plays an important role in providing information and tools that are necessary for an effectively functioning health care market and an accountable health care system. Its contributions will become even more significant for patients, clinicians, managers, and policymakers as the effects of unprecedented changes
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SUMMARY/11 in health care delivery and financing are more widely experienced. These contributions are unlikely to be sustained by private efforts if public funding is significantly reduced. Like research and education in the biomedical and clinical sciences, generally, health services research and research training are public goods worthy of support by society as a whole.
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Representative terms from entire chapter: