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4 Educational Programs, Resources, and Issues Today's health service researchers have developed their careers through quite diverse pathways.) They often did not initially seek a career in health services research but migrated to the field from other areas. Such migration has sometimes but not always been accompanied by formal education in health services research. Researchers with doctorates from programs specifically in health services research remain relatively less common than those with discipline- based degrees, which may or may not include concentrations in health. This chapter describes the major types of health services research educational programs and key issues or concerns about the nature and funding of education for health services research. The latter discussion pursues themes raised in Chapters 2 and 3. point. 'The educational paths of this committee's members (see Appendix D) illustrate this 55

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56 / HEALTH SERVICES RESEARCH EDUCATIONAL PROGRAMS Information Sources The most comprehensive listing of formal programs in health services research is provided by the Directory of Training Programs in Health Services Research compiled by the Foundation for Health Services Research (FHSR, 19923. The self-described mission of these programs is to prepare individuals to conduct health services research. If a program's primary mission is to prepare individuals for careers in management, clinical practice, or disciplinary research, it could qualify for inclusion if it provided a specific, well-defined track that prepared students to undertake health services research. The 1991-1992 directory (the most recent) listed 121 programs in the United States and Canada, some of which offer more than one degree (e.g., both Ph.D. and M.S.~. The directory includes 45 master's programs, 66 doctoral programs, and 26 fellowship programs. For each program, information is provided about its focus, structure, degree offered, size of student body and faculty, fees, and application procedures. In early 1995, 22 programs had health services research training grants from the Agency for Health Care Policy and Research (AHCPR) under the National Research Service Award (NRSA) program (see Table 4.1~. Four of these programs three of which offered only postdoctoral work for clinicians-were not among those listed in the FHSR directory. To better understand the current structure and capacity of health services research training programs, the committee (with funding from the Robert Wood Johnson Foundation and the Baxter Foundation) canvassed all the training programs listed in the FHSR directory. Questions dealt with such issues as program structure, focus, curriculum, student body, capacity, financial aid, and the posttraining careers of graduates. Of the 121 listed programs, 63 responded to the canvass for an overall response rate of 46 percent. (Appendix B provides more detailed information on the canvass and its limitations.) Types of Programs Given the number of disciplines involved in the field of health services research, counting and categorizing the programs that train health services researchers are not straightforward tasks. The diversity of the programs listed in the FHSR directory illustrates the point. Some institutions offer a formal degree in health services research. Others offer a more broadly labeled multidisciplinary degree (e.g., programs in health services management and policy). Some are clinically or professionally oriented (e.g., Ph.D. programs in

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EDUCATIONAL PROGRAMS, RESOURCES, AND ISSUES / 57 nursing or social work). Other emphases within the broader field of health services research are found in M.S. and Ph.D. programs in clinical evaluative sciences and in a Ph.D. program in risk management and insurance. Many health services research programs have their organizational home in schools of public health. Several programs, particularly postdoctoral programs for clinicians, are housed in schools of medicine. As might be expected, the 22 training programs supported by AHCPR in fiscal year (FY) 1994 (see Table 4.1) are less diverse than the 121 programs that chose to be listed in the FHSR directory. Thirteen of the AHCPR-supported programs provide both pre- and postdoctoral training in health services research; one university separately sponsors and funds both a predoctoral and a postdoctoral program. Of the seven programs offering only postdoctoral training, five limit the program to clinicians (primarily physicians). Educational programs in health services research are differentiated by their level, focus, and depth. These characteristics relate to the degree offered, if any (e.g., M.P.H., Ph.D.), the organizational structure and disciplinary base (e.g., academic department, multidisciplinary nondepartmental program), and the amount and type of required educational work (e.g., cognate or practicum requirements, number of course hours in research methods and statistics). Student backgrounds may also differentiate programs, especially postdoctoral programs. Some programs are designed specifically for clinicians, others for Ph.D.-trained health services researchers; still others will accept additional backgrounds. (Appendix B includes a rough categorization of the FHSR-listed programs by discipline, level, and institution or program.) Master's Degree Programs Although "terminal" master's degree programs are common for applied fields such as health care management and public health, the basic health services research degree is clearly a doctorate. Nonetheless, graduates of general master's degree programs in health services research, health policy, public health, or related fields are an important component of the health services research work force as described in Chapters 1 and 3. Some students come to these programs with nursing, pharmacy, or other clinical degrees. Many schools offer physicians or dentists the opportunity to pursue a master's degree jointly with their clinical doctorates. For the most part, master's programs in health services research prepare graduates to participate in research teams under the direction of more extensively

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58 / [IEALTH SERVICES RESEARCH TABLE 4.1 Institutions Receiving National Research Service Awards from the Agency for Health Care Policy and Research (AHCPR), FY 1994 Program Predoctoral Postdoctoral Brandeis University Brown University Case Western Reserve University Children's Hospitala Cornell Universitya Dartmouth College Harvard University (Health Policy Program) Harvard University (School of Public Health) Johns Hopkins University New England Medical Centera Oregon Health Sciences University/ Kaiser Permanente Center for Health Researcha Stanford University X X X University of California, Los Angeles/RAND Corp. X University of California, San Francisco University of Medicine and Dentistry of New Jersey University of Michigan University of Minnesota University of North Carolina University of Pennsylvania University of Rochester University of Washington Yale University X X X X X X X X X X X X X X X X X X X X X X X X X X aNot listed in the 1991-1992 Foundation for Health Services Research directory of training programs. SOURCE: Data provided to the committee by AHCPR, Division of Education, Evaluation, and Demonstrations, January 1995.

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EDUCATIONAL PROGRAMS, RESOURCES, AND ISSUES / 59 prepared investigators or to undertake applied analytic work under the direction of operational managers. Some graduates go on to doctoral work. A few become qualified principal investigators or research managers based on extensive, well-directed experience and perhaps some specialized nondoctoral training. Doctoral Programs Multidisciplinary programs. The committee identified a number of multidisciplinary graduate programs in health services research, although it could not determine the extent to which they were interdisciplinary (as that term is defined in Chapter 1~. It is the committee's sense that the most focused, comprehensive, and intensive health services research educational programs offer a doctoral degree in health services research itself and that they use a multidisciplinary faculty, many or most of whom identify themselves as health services researchers. Doctoral programs in related areas such as public health, health management, or health policy appear to be more variable in the emphasis placed on training health services researchers as opposed to managers or policy analysts. Schools of public health often distinguish between a research-oriented Ph.D. curriculum and a D.P.H. (Doctor of Public Health) curriculum intended to develop leaders for public health services. Disciplinary doctoralprograms. Some doctoral programs in disciplines such as economics or sociology provide health-related subfields or concentrations. These disciplinary programs characteristically emphasize educational requirements in the discipline and maintain relatively few requirements within the subfield. The health services research component of a disciplinary degree may sometimes come primarily through dissertation or other research experience. Disciplinary programs often rely on schools of public health or other health- related programs located elsewhere in their parent university to provide coursework and faculty supervision for their health services research subfield. Courses in health economics, medical sociology, or health policy may also be taught in economics, sociology, or political science departments. Postdoctoral Programs Programs for clinicians. Some postdoctoral programs are designed specifically to provide clinicians (those who already have M.D.s or other clinical degrees) with training in health services research methods. For example, one track in Dartmouth's program in evaluative clinical sciences "is focused on individuals who will combine clinical residencies with education and research in

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60 / HEALTH SERVICES RESEARCH . . . an integrated program that adds one year to the residency and results in a tMaster of Science degree!'' (FHSR, 1992, p. 12~. (Dartmouth also has a Ph.D. program targeted at physicians.) There is at least one postdoctoral fellowship in health services research specifically for dentists, and several universities and Department of Veterans Affairs (VA) medical centers offer master's degrees or postdoctoral health services research programs for physicians. Such programs attract many young clinicians, but they also provide a significant opportunity for midcareer change. Other postdoctoral programs. Other postdoctoral programs provide an opportunity for those with recent doctorates in health services research and related fields to concentrate on specific research interests and to develop experience that will increase their likelihood of securing research funding. These postdoctoral experiences generally do not lead to an additional degree. In addition to university sites, postdoctoral programs may be offered by nonacademic organizations such as hospitals and managed care organizations. The latter may offer academically oriented researchers an opportunity to move into more applied kinds of research and research management. On-the-Job Training and Continuing Education A variety of programs and activities aim to extend the knowledge and skills of those already in the health work force. Many individuals who are already educated in one or another basic discipline receive training and education in health services research through structured short courses or seminars that provide instruction in specific topics, such as outcomes measurement and the use of analytic software packages. On-thejob education may take the form of mentoring, which can guide the development and maturation of newly graduated health services researchers. More generally, work itself is a critical educational experience. In addition, reflecting a recent trend, many health services research education programs are reconsidering the traditional, full-time, residential format and offering options that better accommodate students who want to continue to work or enroll on a part-time basis. Classes are now being offered during evenings and weekends and through distance learning arrangements (e.g., mail, video). Several programs are specifically designed for business and government executives or midcareer professionals who want training in health services research. To meet the need for lifelong learning and career flexibility, university programs, professional groups, and other organizations also offer training through a variety of means, including short courses and summer institutes. . ~

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EDUCATIONAL PROGRAMS, ~SOURCES, AND ISSUES / 61 Current Program Enrollments As described in Chapter 3's discussion of the research work force pipeline, the committee estimated that the health services research programs enroll at least 1,015 students in master's programs, 51 1 in doctoral programs, and another 197 in postdoctoral fellowship programs. (Appendix B notes why limitations in enrollment data make it likely that this estimate is low.) As was true for the health services research work force in general, the committee was not able to categorize participants in health services research training programs by gender or ethnicity. Based on its experience but no directly relevant data, the committee thought the problem of underrepresentation in educational programs was more of a concern for minorities than for women (although the latter may be underrepresented in various segments of the work force). The committee sees no reason to expect that African-American, Hispanic, and other minorities who are generally underrepresented in advanced education would be found in health services research programs in numbers proportional to their share of the population. Health services research programs probably compete with medical, dental, and other professional schools for the relatively limited pool of minority college graduates, a problem noted in other reports on advanced education in the health professions and in science and engineering (NRC, 1994, IOM, 1994a). These reports have argued that efforts to increase minority representation must focus on broadening the educational pipeline at the precollegiate level (see, for example, University of California, 1993; IOM, 1994a, 1995~. Strategies for achieving this objective generally call for cooperation among educational institutions, governments, corporations, and private foundations in developing college and career information resources, curriculum guidance and support programs for schools, mentoring programs for individual students, and similar activities. At the undergraduate and graduate levels, affordable tuition and financial assistance are important, as is a supportive learning environment. Curricula and Preparation for the "Real World" Core Courses No accrediting or other standard-setting organization provides curriculum guidelines for health services research programs, and federal awards for training programs do not have explicit curriculum prescriptions. Moreover, because educational programs in health services research vary in level, focus, and objectives, their curricula necessarily vary. Doctoral programs, for instance, will generally provide more coursework in research methods and statistics than

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62 / HEALTH SERVICES RESEARCH master's programs. Programs in disciplines such as economics typically emphasize discipline-specific courses over health-related topics. Certain courses, however, tend to be viewed as the core of a health services research curriculum. Although the only course cited by a majority of survey respondents for all program levels (master's, doctoral, and fellowship) was research methods, majorities or near-majorities also cited statistics or biostatistics (see Table B.4 in Appendix B). Health economics was another quantitatively oriented course cited by more than one-third of respondents in each program area. Given the committee's own judgments as well as what it learned about the demand for researcher capabilities, it agreed that these areas should generally be part of the core curriculum. The committee noted with some concern that health care organization was mentioned as a core course by less than one-third of respondents in each of the program areas, although larger proportions mentioned health policy, a subject that may have considerable overlap with health care organization. Whatever the label, the committee viewed a solid understanding of the health care system as an essential part of education in health services research. Preparation for the "Real World'' In addition to standard coursework, it is valuable for students to be involved in ongoing health services research under the supervision of a mentor. Ideally, students should be exposed to all phases of research-from initial development of the project to final dissemination of the findings. Practical experience in proposal writing and fund raising is also valuable. Students who plan a career in academia should, in particular, be encouraged to write articles for scholarly journals and to present academic papers at professional conferences. Students who want to be prepared for careers in government or the private sector should be directed to internships or similar experiences that will expose them to the particular demands and stresses of research and policy analyses in these settings. Stresses include the need for quick turnaround of analyses, writing styles that are less academic, rapid shifts in target issues, and sensitivity to client needs and demands. In government, researchers may find that seriously incomplete or flawed analyses (e.g., unadjusted studies of hospital mortality data) are made public prematurely, whereas researchers in managed care or insurance organizations may chafe under proprietary restrictions on publication of their analyses. Another part of the real world of health services research that most students will face is participating in studies as a member of a research or project team. Given the multidisciplinary nature of the field and the variety of educational paths that lead there, researchers will often find themselves working with individuals from varied disciplinary or clinical backgrounds and different levels

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EDUCATIONAL PROGRAMS, ~SOURCES, AND ISSUES / 63 of training and experience. As this study proceeded, the committee became concerned that those in doctoral programs are not routinely educated to value the contributions of master's level researchers, to understand what may reasonably be expected from other researchers and from clinicians, 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. For work in many industry settings, effective participation in project teams may also require skills in understanding client needs and crafting analyses that are both methodologically sound and acceptable, persuasive, and even attractive to clients. In the governmental world, a similar appreciation is needed for the expectations of policymakers in tire administrative and legislative branches. Students will vary in the degree to which they are temperamentally suited for academic, industry, governmental, or other settings, and schooling cannot substitute for the learning that occurs in a real job in industry or government. Educational programs can, nonetheless, help students to understand and cultivate the intellectual and personal qualities needed to succeed in a variety of environments. Given recent trends in employment, it is the general sense of the committee that health services research programs will benefit their students by providing broader rather than narrower educational opportunities. These include opportunities for coursework in several disciplines and methodological techniques, practical experience in research and policy analysis, development of skills in teamwork and communication, and exposure to differences in expectations for researchers held by academic, government, and industry employers. Health services researchers have versatile and marketable skills in such areas as conducting oral interviews and focus groups, locating information sources, interpreting published reports and data, and synthesizing information. For those considering a career shift, for example, from academic to industry employment, special continuing education programs may be useful in building or refreshing the knowledge or skill base needed for such a shift. FUNDING FOR EDI;JCATION IN HEALTH SERVICES RESEARCH Support for training in health services research comes in several forms and from a variety of sources. The federal government and other organizations provide some grants to students directly but also provide grants to institutional programs, which, in turn, support students. Students themselves contribute through tuition payments, and state taxpayers help support programs in public institutions. Research grants that include research assistantships serve the joint purpose of supporting research and training. Teaching assistantships likewise

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64 / HEALTH SERVICES RESEARCH serve a dual purpose. Foundations and corporations may provide special-purpose grants or gifts for purposes such as curriculum development or endowed professorships. Federal Programs The federal government provides the majority of dedicated finding for health services research education. A key vehicle for this support is the NRSA program, which provides grants to educational institutions (which make traineeship awards to individual pro- and postdoctoral students) and to individuals directly in the form of fellowships. Other, more indirect mechanisms support some training, including federal research grants that fund research assistantships for students and awards for dissertation research. Historical Context As described in Chapter 2, the federal government funded some health services research before the 1960s.2 The first formal support specifically for training in the field, however, awaited the 1967 decision establishing the National Center for Health Services Research and Development (NCHSR). NCHSR's Health Services Training Grants program provided awards to qualified public or private institutions for education programs to educate "competent investigators in the methods and techniques of conducting health services research including analysis, development and demonstration projects" (USDHEW, 1970, p. 19. Institutions could focus on the organization, delivery, quality, financing, utilization, and evaluation of health services delivery systems. Program grants included funds for institutional expenses as well as stipends for trainees. In 1970, stipends ranged from $3,000 to $4,700 ($11,575 to $18,134 in 1994 dollars), depending on an individual's work and educational experience, arid other trainee expenses including tuition might also be covered. The program accounted for about 8 percent of NCHSR's appropriations for the years 1968 to 1973 (undated, unpublished document from DHHS files, about 1983~. In 1972, the report Improving Health Care through Research and Development noted "constant pressure ton NCHSR] to curtail research training 2Congress first granted the Public Health Service authority to train health researchers in 1930 in the Ransdell Act (P.L. 71-251), which created the National Institutes of Health (NIH) and provided for research fellowships at the NIH and other medical or research centers. When the National Cancer Institute was created in 1937, it had legislative instructions to create what became a formal fellowship program (NRC, 1975a, 1994~. As subsequent institutes were created, the training authority was expanded.

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EDUCATIONAL PROGRAMS, RESOURCES, AND ISSUES / 65 programs" (PSAC, 1972, p. 3). Shortly afterwards, the Nixon administration recommended phasing out most of the health training programs for biomedical, clinical, and other health researchers on the grounds that the programs were unnecessary and were inefficient in generating researchers (NRC, 1979~. Following considerable debate, Congress responded in 1974 with the National Research Service Award Act (P.L. 93-348~. The legislation consolidated and restructured programs in the various institutes of the NIH. It also called for continuing study of training needs and asked the National Academy of Sciences to undertake this activity and malice recommendations for "serious legislative consideration." The National Research Council (NRC) issued its first report on personnel needs and training for biomedical and behavioral research in 1975 and its most recent report in 1994. (See NRC, 1994, for a historical review.) The 1974 legislation did not affect clinical training, nor did it affect "authority available elsewhere in the Public Health Service Act under which the Secretary may enter into contracts with public and private entities and individuals for health services research and health statistics training" (NRC, 1975b, p. 1~. For FY 1974, however, the Office of Management and Budget (OMB) refused to allow NCHSR to use any appropriated funds for training programs after existing trainees and fellows completed their terms (NRC, 1976~. All NCHSR support ceased in FY 1976, although the Alcohol, Drug Abuse, and Mental Health Administration (ADAMHA) continued NRSA awards in health services research. In 1980, ADAMHA reclassified its awards so that the disciplines or fields (e.g., public health, economics, and psychology) covered by the health services research category were reclassified as either behavioral or clinical sciences awards (NRC, 19819. During the 1970s and 1980s, various NRC and Institute of Medicine (IOM) committees repeatedly recommended reestablishment of the health services research training program. The 1979 report, for example, stated that health services research was a national need, and it emphasized the importance of federal support for health services research training (NRC, 1979~. The reports also continued to include recommendations for numbers of health services research training awards. Nonetheless, OMB continued to refuse departmental requests to support health services research training, even after the Health Services Research, Health Statistics, and Medical Technology Act of 1978 (P.L. 95-623) explicitly authorized the extension of NRSA to cover health services research training. Through the early 1980s, NCHSR provided only minor and somewhat indirect training support that covered a few research fellows in the agency's intramural research program (which were equivalent to postdoctoral fellowships for new or established researchers), an unknown number of research assistants (as part of project grants), and several dissertation research awards. Table 4.2 presents the number of trainee positions funded and fellowships awarded in health services research by the NCHSR and the AHCPR from 1967

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66 / HEALTH SERVICES RESEARCH to 1994.3 Table 4.3 presents the recommendations for health services research traineeships and fellowships made by the NRC or the IOM from 1976 to 1994. The actual and recommended numbers of awards have consistently been far apart, most notably, of course, during the years when no awards were made. In 1986, MESA awards in health services research were finally reinstituted. At that time, NIH allocated 0.5 percent of its total MESA budget (or approximately $1.1 million) for health services research. The awards were administered by NCHSR and later by AHCPR after it was created In 1989 (replacing NCHSR). AHCPR decided to supplement the MESA allocation it received Dom NIH; Mom FY 1990 through 1992, more than ones rd of total health services research NRSA Finds came Dom AHCPR ~ntemal fiends. The NIH Revitalization Act of 1993 Increased the NIH allotment for health services research to 1 percent of the total MESA budget (about $3.5 million in FY 1993~. Despite this increase ~ doing, AHCPR has continued to supplement the NIH allocation. Table 4.4 and Figure 4.1 summarize Finding for the NRSA health services research awards since FY 1986. Current NRSA Program Today, NRSA awards (institutional pre- and postdoctoral traineeships and individual postdoctoral fellowships) provide one of the most important resources to individuals wishing to pursue predoctoral or postdoctoral training in health services research. Although AHCPR makes most of these awards, the National Institute of Mental Health supports training in mental health services research.4 Given the multidisciplinary, and hence nondepartmental, nature of health services research, NRSA institutional awards provide important support to institutions working to develop such broad-based programs. 3 NRSA awards from some NIH institutes, including the National Institute of Alcohol Abuse and Alcoholism, the National Institute on Drug Abuse, and the National Institute of Mental Health, also support the training of health services researchers as well as clinical and basic science researchers. However, because the institutes do not classify their awards as health services research, the number of awardees receiving training in health services research through these agencies cannot be determined. 4As noted in Chapter 2, the National Institute of Nursing Research does not have health services research as part of its explicit research and training mandate, but many of its NRSA awards support students training in health services research as defined in this report.

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EDUCA TIONAL PROGRAMS, ~SOURCES, AND ISSUES / 67 TABLE 4.2 Awards for Health Services Research Training, 1967-1994 . Fiscal Year Institutional Number of of Award Grants Traineeships Number of Fellowships Total 1967 15 85 22 107 1968 16 105 31 136 1969 21 152 32 184 1970 50 267 61 328 1971 51 330 82 412 1972 49 347 90 437 1973 44 327 50 377 1974 40 348 35 383 1975 36 212 11 223 1976 (est.) 20 110 4 114 No Awards Were Granted 1977-1985 1986 7 33 7 40 1987 8 39 7 46 1988 8 40 6 46 1989 10 36 7 43 1990 10 73 14 87 1991 11 65 12 77 1992 13 92 12 104 1993 16 95 17 112 1994 22 114 19 133 NOTE: Awards given during the period FY 1969-1989 were from the National Center for Health Services Research; those for FY 1990-1994 were from the Agency for Health Care Policy and Research (AHCPR). No new fellowships were awarded after FY 1973 and no training grants after FY 1974; the numbers shown for 1975 and 1976 represent continuing commitments. SOURCE: Compiled from NRC, 1976, 1979, 1981, and 1994, and from data provided to the committee by AHCPR, Division of Education, Evaluation, and Demonstration, July 1995.

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68 / HEALTH SERVICES SEARCH TABLE 4.3 Recommendations for National Research Service Awards for Health Services Research by Committees of the National Research Council (NRC) or the Institute of Medicine (IOM), 1976-1994 Years Covered by Report Recommendations Year 1 Year 2 Year 3 1976 NRCa 1976, 1977, 1978 185 185 185 1977 NRCb 1979, 1980, 1981 250 275 300 300 440 440 1978 NRCa 1981, 1982, 1983 275 300 330 1979 NRCa (explicitly reiterated 1978 recommendations) 1981 NRCa 1982, 1983, 1984 330 330 330 1983 IOMC 1985, 1986, 1987 330 330 330 1985 IOMC 1988, 1989, 1990 330 330 330 1989 NRCC (reiterated 1985 recommendations) 1994 NRCd 1994, 1995, 1996 - 1999 115 240 360e a This recommendation is for Alcohol, Drug Abuse, and Mental Health Administration (ADAMHA) slots only. b The committee made specific recommendations for both ADAMHA (top number) and National Center for Health Services Research (NCHSR) (bottom number) slots. c This recommendation is for both ADAMHA and NCHSR slots; no allocation between the two agencies was given. This recommendation is for AHCPR slots only. e The committee also recommended 360 awards each year for 1996-1999. SOURCES: NRC, 1976, 1977, 1978, 1979, 1981, 1989, 1994; IOM, 1983, 1985.

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EDUCATIONAL PROGRAMS, ~SOURCES, AND ISSUES / 69 TABLE 4.4 Funding of National Research Service Awards (NRSA) for Health Services Research, FY 1986-1994 Fiscal Year Total NRSA Expenditure 1986 1987 1988 1989 1990 1991 1992 1993 1994 $1,146,379 1,274,000 1,308,136 1,322,975 2,588,749 2,500,832 3,141,342 3,645,090 4,3 1 0,662 NOTE: From FY 1986 through FY 1992, the Agency for Health Care Policy and Research (AHCPR) received 0.5 percent of the total NRSA assessment appropriated to the National Institutes of Health (NIH). Beginning FY 1993, AHCPR's assessment from NIH increased from 0.5 percent to 1 percent of the total NIH NRSA appropriation. aTotals for these years included supplementary fiends from AHCPR (See Figure 4.13. SOURCE: Data provided to the committee by AHCPR, Division of Education, Evaluation, and Demonstrations, January 1995. Table 4.5 describes some of the key features of both the institutional and individual NRSA grants. Essentially, both types of awards provide for student stipends and a limited amount of money to defray some expenses of training and to cover trainee's expenses for medical insurance and some travel to scientific meetings. Although NRSA stipends are not considered salaries and are not subject to any costs normally associated with employee benefits (such as deductions for FICA, workers' compensation, or unemployment taxes), the stipend is counted and taxed as part of the student's gross income. Postdoctoral (but not predoctoral) trainees and fellows are required to pay back their awards. They may do so by making a cash payment or by performing health services research or teaching on the basis of roughly one month of service for every month of the

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70 / HEALTH SERVICES RESEARCH 5 4 cn = 0 3 C) o an 0 2 - . _ . _ o $2,588.749 $2 500,832 $1,274,000 $1,308,136 $1,322,975 $1,1 46,370 ? , ////// $4,31 0,662 $3,645,090 $3,14 1 ,342 '//////, //////, _ ~ . //////, 1987 1988 1989 1990 1991 1992 1993 1994 Year ~ NIH Assessment OAHCPR Supplement Figure 4.1 Funding for National Research Service Awards in health service research, FY 1986 through 1994. SOURCE: Data provided to the committee by the Agency for Health Care Policy and Research (AHCPR), Division of Education, Evaluation, and Demonstrations, January 1995. first 12 months of postdoctoral NRSA support they receive. Because the fellows can count their second year of NRSA-supported activity towards their payback requirement, those who have completed a two-year fellowship are considered to have fulfilled their payback obligations. Institutional pre- and postdoctoral traineeships. In FY 1994, the AHCPR awarded training grants to 22 institutions to develop or enhance research training opportunities for individuals interested in health services research. These awards assist health services research programs to develop multi- and interdisciplinary curricula, faculty, and research activities. As described earlier, the programs may provide both pre- and postdoctoral training or both. Some programs are targeted solely to preparing clinicians in health services research. In addition to university-based programs, awards may go to other institutions (e.g., Children's Hospital in Boston).

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EDUCATIONAL PROGRAMS, ~SOURCES, AND ISSUES / 71 TABLE 4.5 Key Features of National Research Service Awards Traineeships and Fellowships Feature Traineeships Fellowships Stipend Predoctoral $10,008 NA Postdoctoral (Same schedule used for both trainees and fellows) Years of Postdoctoral Experience Less than 1 2 3 4 5 6 7 or more Stipend ($) 19,608 20,700 25,600 26,900 28,200 29,500 30,800 32,300 Indirect costs Equal to 8% of the institution's total None allowable direct costs or the institution's actual indirect cost rate, whichever is less. Trainee tuition, Can be reimbursed NA fees, travel, and health insurance Other training costs $ 1,500 per predoctoral trainee $2,500 per postdoctoral trainee $3,000 per fellow (Fellows at for profit institutions receive only $2,000.) NA = not applicable. SOURCES: AHCPR, 1994a, b.

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72 / HEALTH SERVICES RESEARCH NRSA grants to institutions from AHCPR totaled more than $3.7 million in FY 1994. The grants ranged from $69,272 to $289,999 and funded between 2 and 10 trainees at each institution. In total, 114 individuals received support through the program. The committee heard suggestions that current institutional awards cover a smaller proportion of institutional costs than in the early 1970s. For example, awards in the earlier period included significant salary support for program directors. Detailed information was not, however, readily available to allow specific comparisons between current and past awards. Predoctoral trainees at all levels of experience received an annual stipend of $1O,008. (Stipends for postdoctoral trainees follow the same schedule as postdoctoral fellowships, which are described in the next section.) In 1994, the NRC recommended that predoctoral stipends be increased to approximately $12,000 for FY 1996. As mentioned earlier, the $3,000 to $4,700 stipends of the early 1970s would be worth $ 11,575 to $ 18,134 when adjusted for inflation. The early stipends were not taxed, but current awards are subject to income taxes. Thus, current stipends are demonstrably less generous than in previous years. Individual postdoctoralfellowships. Unlike the institutional grants, NRSA postdoctoral fellowships are awarded directly to individuals. Applications are accepted three times a year: December, April, and August. Those fellowships may be particularly helpful to women or other students who might not have as much flexibility to relocate to enroll at a NRSA-designated institution. Nineteen individuals received postdoctoral fellowships from AHCPR in FY 1994. Their stipends were based on the same scale as is used for the institutional traineeships. The fellows' stipends for the first year of support were determined by the number of full years of relevant postdoctoral experience at the time of the appointment. Stipends ranged from $19,608 for those with less than one year of postdoctoral experience to $32,300 for those with seven or more years of relevant experience. Institutions may (and frequently do) supplement these stipends. Institutions offering postdoctoral fellowship positions typically receive no NRSA payments and must cover all their costs through research grants or other sources, which creates some problems. In basic science research, postdoctoral fellows tend to fit readily into their mentors' laboratories and can begin immediately to carry out part of their mentors' basic programs of research. In health services research, although the fellows may become a part of their mentors' overall research teams, mentors may find it more difficult to segment parts of complex health services research projects in ways that allow fellows to produce short- and intermediate-term payoffs. Moreover, because fellows are not usually enrolled students, they do not pay tuition, nor are they routinely considered part of a department or a faculty member's teaching load. Without these kinds of institutional support from ACHPR or the university, department

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EDUCATIONAL PROGRAMS, RESOURCES, AND ISSUES / 73 or faculty members may incur substantial costs for their mentoring activities. Some of the best investigators may, as a result, be reluctant to accept additional postdoctoral students. Other Federal Programs The federal government also supports health services research educational programs by awarding grants in support of dissertation research. AHCPR has awarded such grants since 1975. In FY 1994, 23 students received grants of up to $20,000 to support their dissertation research in health services. Students apply for the grants in January and awards are announced in the summer. The Health Care Financing Administration also provides health services research dissertation grants, although their grants are applied for in October and awarded by December. The VA, through its Academic Affairs and Health Services Research and Development offices, conducts and supports pre- and postdoctoral training programs at 13 VA medical centers. Since 1983, the program has trained 1 13 predoctoral students and 38 postdoctoral students in health services research. An additional 78 physicians received technical assistance or training in health services research during their VA-supported postdoctoral fellowships in such fields as ambulatory care, geropsychology, and women's health. The stipends given to these students and fellows are somewhat higher than NRSA awards. Predoctoral students receive between $15,700 and $17,000 a year, postdoctoral students receive $34,000 a year, and physicians' stipends are indexed to match their salaries at an affiliated school of medicine. Nonfederal Programs A significant source of support for health services research training comes from the educational programs themselves. Many universities award scholarships, waive tuition and fees, and provide teaching assistantships and other employment opportunities to their students. Even if a program receives federal funds (NRSA or other), those funds often must be supplemented with internal monies in order to provide the competitive stipend and benefit package that will attract top students. Several state governments directly and indirectly support health services research education by subsidizing the programs offered through their state universities and by providing some grants for research and, less commonly, training. Some foundations and private companies also offer training support to health services researchers, although support more often comes indirectly through grants for research. Formal training support from private industry has typically been

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74 / HEALTH SERVICES RESEARCH given to students in specific areas, such as pharmacoeconomics or managed care administration, rather than to students in more general health services research programs. Some private organizations sponsor students on semester or year-long internships to expose them to how health services research is carried out in the for-profit environment. For example, U.S. Quality Algorithms (a subsidiary of U.S. Healthcare) is sponsoring a one-year managed care fellowship at the medical college of Thomas Jefferson University in Philadelphia. Another way for industry to support health services research educational programs is through the endowment of faculty chairs; Blue Cross of California recently did this by endowing a chair in health care financing at the University of Southern California. The Pew Charitable Trusts has long sponsored innovative educational programs in health services research through its Health Policy Program. The Pew program enables current and future leaders in health care to pursue doctorate and postdoctorate training in health policy at three sites: Brandeis University, the University of Michigan, and the University of California, San Francisco (UCSF). Each of the three programs has developed a unique educational model. Brandeis University offers a two-year accelerated, interdisciplinary program leading to a Ph.D. in health policy. The University of Michigan runs a three- year intensive, nonresidential program designed so that students can remain employed full time while obtaining a doctorate in public health. The UCSF program provides one- or two-year postdoctoral fellowships to social scientists, physicians, and other health professionals. The Robert Wood Johnson Foundation also supports education in health services research through its Scholars in Health Policy Research Program, which offers two-year postdoctoral training to recent graduates in economics, political science, and sociology to advance their involvement in health policy research. The foundation also sponsors the Clinical Scholars Program, which provides postdoctoral fellowships specifically for young physicians to help them develop research skills in nonbiological disciplines that are relevant to medical care. CONCLUSION Formal education or training in health services research takes many different forms that draw students from different programs and prepare them for varied roles and careers. Programs range from the master's to the postdoctoral level. Short courses, summer institutes, and other opportunities add further diversity. Health services research may be the principal focus of a multidisciplinary educational program or a secondary emphasis in a disciplinary or professional program. Although the committee stressed the importance of doctoral programs devoted to health services research, other program models are also valid.

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EDUCATIONAL PROGRAMS, RESOURCES, AND ISSUES / 75 The committee noted that funding for education in health services research has been unstable and generally limited. Although funding has increased in recent years, it is still below levels achieved in the early 1970s. The next chapter summarizes the committee's findings and presents its recommendations.

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