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OCR for page 55
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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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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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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Representative terms from entire chapter:
services researchers
