Below are the first 10 and last 10 pages of uncorrected machine-read text (when available) of this chapter, followed by the top 30 algorithmically extracted key phrases from the chapter as a whole.
Intended to provide our own search engines and external engines with highly rich, chapter-representative searchable text on the opening pages of each chapter.
Because it is UNCORRECTED material, please consider the following text as a useful but insufficient proxy for the authoritative book pages.
Do not use for reproduction, copying, pasting, or reading; exclusively for search engines.
OCR for page 1
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.
OCR for page 2
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.
OCR for page 3
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.
OCR for page 4
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
OCR for page 5
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
OCR for page 6
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.
OCR for page 7
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
OCR for page 8
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.
OCR for page 9
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.
OCR for page 10
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
OCR for page 11
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.
OCR for page 12
Representative terms from entire chapter:
services researchers
