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1
:Introduction anti Background
When faced with the same symptoms, why do some people seek medical care
and others avoid contact with health care providers?
*
How do different instruments for measuring patient health status compare
in their ability to adjust data on health plan costs, services, or health
outcomes to controlfor differences in the health status of plan members?
*
How do capitated, per case, or other methods for paying health care
institutions and practitioners affect the provision of appropriate and
inappropriate medical services and the outcomes of care?
*
What kinds of preventive, therapeutic, or other services can be safely and
effectively provided by health professionals such as physical therapists,
dental hygienists, and other allied health providers?
*
What are the strengths and weaknesses of current federal approaches to the
regulation of pharmaceuticals and devices in making beneficial products
available to patients?
*
Is the growth of managed care affecting clinical research and technological
innovation?
13
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14 / HEALTH SERVICES SEARCH
Health services researchers investigate questions such as these. The answers
that researchers provide can guide critical decisions by government officials,
corporate leaders, clinicians, health plan managers, and ordinary people
experiencing health problems ranging from minor to life threatening.
Unfortunately, many important decisions closely connected to these and similar
questions must now be made in the absence of adequate knowledge of the likely
consequences of different choices. The challenge for health services research is
to reduce this knowledge gap.
This report focuses on one part of the health services research enterprise its
work force and its programs for educating and training that work force. The rest
of this chapter reviews the origins of the study, describes the study strategy, and
defines key terms. Chapter 2 discusses the evolution of health services research,
presents major themes and questions addressed by current research, and considers
how emphases may shift in the future. Chapter 3 examines the size and
characteristics of the current health services research work force, the match
between supply and demand for this work force, and issues in estimating work
force requirements for the future. Chapter 4 focuses on health services research
education and training programs. In Chapter 5, the committee presents its
findings and recommendations. The Institute of Medicine (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.
ORIGINS OF THE STUDY
This study originated in a request from the Agency for Health Care Policy
and Research (AHCPR), a unit of the U.S. Department of Health and Human
Services. AHCPR 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~. The legislation
reflected policymakers' interest in acquiring a better knowledge base for guiding
public and private decisions about health and health care. AHCPR is the largest
single funder of health services research and health services research education
in this country, although the various institutes of the National Institutes of
Health, taken together, spend more. Other government agencies, private
foundations, insurers, managed care plans, and additional organizations also
sponsor research and, to a lesser extent, research education and training.
AHCPR asked the IOM to investigate work force issues in health services
research and prepare a report with recommendations to inform decisions about
federal resources for educating and training health services researchers. Among
the questions posed were: What levels and types of trained health services
research personnel are available now? What personnel may be needed in the
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INTROD UCTIOA AND BA CKGRO UND / 1 5
next decade? What changes in programs and resources may be necessary to meet
future demand for health services researchers?
When the study was first discussed, many policymakers anticipated that
health reform legislation would be enacted at the federal level and that such
reform would generate more questions for health services research and more
resources (including education and training funds) for investigation. That reform
did not materialize, and significant federal action appears unlikely for the
immediate future. Research resources may actually be cut as part of initiatives
to reduce the budget deficit or cut federal taxes.
Federal inaction notwithstanding, a restructuring of the health care delivery
system driven primarily by cost concerns and by the independent actions of a
great many private organizations is proceeding with surprising speed. Although
economic considerations have been the immediate determinants of change, past
research on the organization, financing, use, and outcomes of health care has
influenced the direction of these changes in some measure, particularly in areas
involving financial incentives, data reporting and analysis, and evaluation of
treatment options and patterns. Regardless of its antecedents, health care
restructuring raises significant questions and presents information-gathering
challenges for the field of health services research and its supporting education
and training programs.
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 (see
Appendix D).
The committee met in July 1994, January 1995, and March 1995. It
undertook a number of information collection activities. Because health services
research lacks licensure or certification processes to aid in the identification and
enumeration of health services researchers, the committee used a "building block"
strategy that combined several components to develop a database of health
services researchers in the United States (see Chapter 3 and Appendix A). In
addition, IOM staff surveyed directors of health services research training
programs in the United States and Canada about various matters, including recent
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16 /HEALTH SERVICES RESEARCH
applications for admission, acceptance rates, students' academic and work
experience, financial aid, curriculum, and employment of program graduates (see
Chapter 4 and Appendix By.
To investigate the interests of private industry arid state government in health
services research, committee members arid staff conducted telephone interviews
with more than two dozen key individuals in managed care organizations,
hospital systems, consulting firms, state agencies, and other organizations. In
addition, a panel of executives arid researchers from these organizations met with
the committee during its March 1995 meeting to discuss the focus of public and
private sector research, policies on peer review arid dissemination, and
implications for health services research education and training.
The committee found the literature on educational and work force policies
n the field of health services research to be sparse. Much of it appears in a
series of reports on personnel needs and training for biomedical and behavioral
research prepared by the National Research Council (NRC) arid the IOM (NRC,
1975a, b, 1976, 1977, 1978, 1981, 1994; IOM, 1983, 1985~. The most recent
report (from the NRC's Office of Scientific and Engineering Personnel), Meeting
the Nation's Needs for Biomedical and Behavioral Scientists, reviewed models
for estimating supply and need for these personnel and made recommendations
in several areas, including health services research (NRC, 1994~. In addition, the
committee consulted Reshaping the Graduate Education of Scientists and
Engineers, a report of the Academy's Commission on Science, Engineering, and
Public Policy (COSEPUP, 1995~. The current IOM committee also reviewed the
1979 IOM report Health Services Research but determined that it did not
investigate work force and training issues in any depth.
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 (IOM, 1 994a). Responses to that statement
contributed to the development of the committee's final report, which was
reviewed under the procedures of the NRC.
11
'Because government policies limit contractors' use of certain information collection
strategies, the training program survey, the creation of the researcher database, and a
series oftelephone interviews with state and private officials were made possible by grants
from the Robert Wood Johnson Foundation and the Baxter Foundation and by support
from the Pew Health Policy Program at the IOM.
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INTROD UCTION AND BA CKGRO UND / 1 7
DEFINITIONS AND CONCEPTS
Health Services Research
The 1979 IOM report on health services research defined the field as
"inquiry to produce knowledge about the structure, processes, or effects of
personal health services" (p. 14~. A study would be classified as health services
research if it satisfied two criteria: (1) "it deals with some features of the
structure, processes, or effects of personal health services" and (2) "at least one
of the features is related to a conceptual framework other than that of
contemporary applied biomedical science" (p. 14~. It is implicit that such
research could investigate the effects of personal health services on the health of
populations but its primary focus would not be public health interventions (e.g.,
community-wide water fluoridation or education programs) as such.
A 1991 IOM report on information services for health services research,
which was prepared for the National Library of Medicine, catalogued various
definitions of health services research dating back 20 years (IOM, 1991~. That
study committee did not formally adopt the 1979 definition or develop a
definition of its own but noted common features of many definitions, including
a focus on populations as well as individuals.
The current committee also consulted other definitions and descriptions (e.g.,
Flook and Sanazaro, 1973; Steinwachs, 1991~. Building on these earlier
statements, 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.
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.2
Its boundaries are imprecise, particularly as they relate to policy and management
2Although it recognized that the terms are often used interchangeably and are not
clearly differentiated by dictionaries, the committee concluded that a distinction between
multidisciplinary and interdisciplinary would be useful. It suggests that the first term
generally be used to describe work that involves multiple disciplines and that the second
term be reserved for work that attempts to integrate disciplines in ways that forge new
frameworks and strategies for investigation.
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18 / HEALTH SERVICES RESEARCH
studies and certain kinds of clinical research.3 Specific instances of research
may exemplify the multidisciplinary aspect of the field to varying degrees. For
example, an epidemiologist studying the effects of a particular vaccination
program on the incidence of a particular disease might or might not consider
social, economic, organizational, or similar factors affecting (or affected by) the
rate or distribution of vaccinations. Absent such consideration, the research
would not fit the definition of health services research offered here (unless,
perhaps, it were undertaken in conjunction with a broader project).
Second, the definition's reference to basic and applied research underscores
the fact that health service research involves both questions about fundamental
individual, organization, and system behaviors and questions of direct practical
interest to public and private decisionmakers. In general, health services research
falls toward the applied end of the research continuum. Many university-based
health services research arid training programs are located in or described as
health management and policy programs, clearly emphasizing their concern with
applications. Applied research, particularly that involving the effectiveness of
medical interventions and the use (or nonuse) of the resulting information by
patients and practitioners, is the major focus of work funded by AHCPR. With
support from both public and private sources, health services researchers have
devised better measures of health status and the severity of illnesses. They have
also contributed to the development of methods for paying for hospital care and
physician services that reduce financial incentives for the overuse of inpatient
care, medical procedures, arid specialty services. Researchers are now
intensifying their efforts to develop tools to detect underuse of appropriate care
and to adjust provider payments in ways that discourage providers from skimping
on care or avoiding high-risk individuals.
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. For
example, Donabediar~'s influential writings on quality assessment arid assurance
would fall in the latter category (Donabedian, 1966, 1980, 1982, 1985~.
3The ADAMHA Reorganization Act of 1992 (42 USC § 284d) defined health services
research as "research endeavors that study the impact of the organization, financing and
management of health services on the quality, cost, access to and outcomes of care. Such
term does not include research on the efficacy of services to prevent, diagnose, or treat
medical conditions." The committee assumes that the latter exclusion refers to clinical
research, in particular, controlled clinical trials rather than research in real-world settings
(see Brook and Lohr, 1985, for a discussion of the difference between efficacy and
effectiveness). Depending on its design, a clinical trial would not necessarily be excluded
under the committee's definition.
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INTRODUCTION AND BACKGROUND / 19
Finally, compared to the 1979 definition of health services research, the one
offered here 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.
Investigators can define populations in many different ways based on
sociodemographic characteristics, geographic location, or enrollment in different
health insurance plans. Traditionally, population-based health services have been
conceived of in terms of community-wide health education programs,
surveillance activities, communicable disease control methods, and similar
programs. Now, large health care delivery organizations are managing personal
health services for an increasing proportion of the population, and more efforts
are being made to define organizational policies with a view to their effects on
their defined populations rather than given individuals. These developments
present health services researchers with important questions about how
organizational structures and processes affect the health and well-being of subject
populations.
Health Services Research Work Force
Just as delineating the scope of health services research is not a
straightforward task, neither is identifying the health services research work
force. In contrast to the clinical health professions that have licensure and
specific degree requirements as key defining characteristics, one is not required
to have a license or a specific degree to practice health services research or
most other kinds of research, for that matter. Unlike health services researchers,
however, those in biomedical and behavioral research fields generally can be
identified by specific disciplines (e.g., biochemistry, psychology) and counted as
such in periodic surveys of individuals who have earned or are working toward
doctorates (NRC, 1994~.
The committee distinguished three broad components of the health services
research work force. As depicted in Figure 1.1, they include
· investigators who originate, design, supervise, and report basic and applied
health services research;
· researchers who assist in health services research under the direction of
others; and
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20 / HEALTH SERVICES RESEARCH
· individuals who analyze health services information and apply certain
tools of health services research in management and policy settings.
In general, the first category requires preparation at the doctoral level or
equivalent, whereas the latter two categories usually require master' e-level or
other advanced training. Depending on their preparation and role, clinicians may
be found in any of the three categories. As noted earlier, it is difficult to
distinguish the health services research field from the arenas of clinical research,
health care management, and health policymaking.
-
-
Originate' design,
supervise' and report HSR
(Doctora~-~eve~ personnel)
\ HEALTH
SERVICES
RESEARCH
WORK FORCE
\ Analyze and
\app/yHSR
(Master's-leve! personnel,
clinicians. and others)
. ~
-
-
Assist HSR
FIGURE 1.1 U.S. health services research (HSR) work force, by function. Please note
that the boundaries are not precise.
Health Services Research Education and Training
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
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INTROD UCTION AND BA CKGRO UND / 2 1
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,
reporting results).
Education and training for health services research can occur in many
settings ranging from universities to government institutes and private seminars.
Although the committee attempted to learn more about nonuniversity settings, it
emphasized academic programs in part because of data availability and in part
because federal training funds are largely focused on such institutions and their
students.
Education and training opportunities also vary by level or intensity. This
report considers three categories: (1) predoctoral education that leads to a
research doctorate in health services research or a relevant discipline; (2) post-
doctoral education that provides formal, specialized training and research
experience for those with research or clinical doctorates; and (3) master's-level
education that prepares individuals to participate in research. In addition, the
report notes that continuing education is an important resource, both to inform
new or established researchers about advances in knowledge or methods and to
assist people in shifting career paths as employment opportunities contract or
expand in different sectors.
Support for Health Services Research
As is also the case for biomedical and clinical research, the federal
government clearly is the major sponsor of health services research and research
training. Although the lead governmental agency for health services research is
nominally AHCPR, other agencies also fund significant amounts of research (see
Table 1.1~.
Some research areas in particular, technology assessment, quality
assessment including outcomes research, and data systems are also attracting
industry funding, generally for work that will support corporate objectives and
decisionmaking needs. For example, researchers with an understanding of
pharmacoeconomics are in high demand from drug companies attempting to
nfluence or respond to market and regulatory shifts and uncertainties. State
governments also support some health services research, primarily through
contracts with outside organizations. The committee did not find specific
information about the aggregate level and distribution of health services research
funding provided by private foundations, corporations, state governments, and
other sources.
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22 / HEALTH SERVICES RESEARCH
TABLE 1.1 Federal Expenditures for Health Services Research, FY 1994 and
1995 Appropriations (in millions of dollars)
Agencya
FY 1994
FY 1995
AHCPR 1 52 1 60b
NIMH 92 95
NIDA 64 66
NIAAA 28 29
NLM 8 8
HCFA/ORD 43 46
VAIHSR&D 31 32
TOTAL 418 436
NOTE: Other institutes fiend health services research but do not identify it as such. The
National Cancer Institute; the National Heart, Blood, and Lung Institute; and the 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. The
Centers for Disease Control and Prevention also sponsors preventive services research.
a Abbreviations stand for Agency for Health Care Policy and Research, National Institute
of Mental Health, National Institute on Drug Abuse, National Institute on Alcohol Abuse
and Alcoholism, National LibraIy of Medicine, Health Care Financing Administration/
Office of Research and Demonstrations, and Depa~ln~ent of Veterans Affairs/Health
Services Research and Development office, respectively.
h These figures represent AHCPR's total agency budget minus $2 million for "support."
SOURCE: Adapted from briefing materials distributed at the Association for Health
Services Research Board of Directors meeting on February 14, 1995.
Federal support for health services research has been punctuated by periodic
expressions of skepticism about its contributions (PSAC, 1972; Gray, 1992; see
also Chapter 4~. As this report was being drafted, the future of this support was
once again in doubt (Brown, 1995~. Even at current levels, funding for health
services research is a smaller percentage of total health spending today than it
was in 1970 (see Table 1.29.
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INTROD UCTION AND BE CKGRO UND / 23
TABLE 1.2 Federal Expenditures for Health Services Research in Relation to
Total U.S. Health Spending, FY 1970 and FY 1994 (in millions of dollars)
% Change
Type of ExpenditureFY 1970FY 1994afrom 1970
Total U.S. health$67,000$1,000,0001,393
Federal health18,000328,0001,722
Federal biomedical research1,60010,000525
Federal health services research180470161
Federal health services research
expenditures as percentage of
U.S. total health expenditures
0.27 0.05 -81
Not adjusted for inflation
SOURCE: Adapted from presentation by Clifton Gaus, Administrator of the Agency
for Health Care Policy and Research, at the Association for Health Services Research
Board of Directors meeting on February 14, 1995.
CONCLUSION
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 level, integrates their
conceptual frameworks and methodologies to provide new ways of studying and
understanding the health care system. The next chapter sets the context for the
report's discussion of work force and training issues by reviewing the evolution
of health services research as a field. It highlights areas of inquiry related to
current controversies and developments, particularly those associated with
managed care, integrated health systems, and other features of a health care
system that is undergoing substantial restructuring.
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Representative terms from entire chapter:
services researchers
