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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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