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Findings and Recommendations In a health care system undergoing rapid and complex change, the challenges for health services researchers are imposing. The pace of change, the multiplicity of involved parties, and the limited availability of crucial data make it difficult to describe what is happening, much less explain it or track the consequences. In the policy arena, budgetary constraints and, in some cases, skepticism about research may impede investigations that could guide the change or identify its unwanted consequences. Another potential problem is a lack of appropriately educated health services researchers. This chapter presents the committee's findings and recommendations on health services research work force and training issues. These conclusions respond to the request from the Agency for Health Care Policy and Research (AHCPR) for assessments of the current and future work force and for recommendations to inform decisions about federal resources for educating health services researchers. The conclusions and recommendations are also intended to be useful to other government agencies (e.g., the Department of Veterans Affairs), educators, and private organizations, including foundations and employers that support health services research or education. DATA AVAILABILITY AND IMPROVEMENT One of the committee's first findings was that existing data on the size and characteristics of the health services research work force are fragmentary. The committee sought and obtained private Finding to collect additional information 77

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78 / HEALTH SERVICES RESEARCH from a variety of sources, including employers. The resulting database is the most extensive available listing of the health services research work force, but it still lacks important information about the characteristics of those listed. The committee urges the Association for Health Services Research (AHSR) to seek funding to update and extend the database through a more detailed survey of researcher characteristics including, for example, age, gender, ethnicity, and employment status. In addition, the committee encourages the National Science Foundation and the National Research Council (NRC) to consider revising the annual census of those who have received doctorates and the longitudinal sample survey of doctoral recipients to allow better identification of those educated or working in the field of health services research. Such steps would provide information useful for understanding the dynamics of the health services research work force. Finally, as part of a more general government effort to evaluate the results of various research training programs, the committee recommends that the AHCPR and other relevant government agencies investigate the career paths and productivity of trainee and fellowship recipients. These recommendations are consistent with those of a recent report on graduate scientists and engineers (COSEPUP, 19953. That report's main recommendation was that "the National Science Foundation and the National Research Council should continue to improve the coverage, timeliness and analysis of data on the education and employment of scientists and engineers to support better national decision-making about human resources in science and technology" (pp. 5-14~. A more specific recommendation was for an increase in information on nonacademic employment to reflect the increasing importance of employment in this sector. WORK FORCE SIZE AND CHARACTERISTICS The committee identified approximately 5,000 current health services researchers. This estimate undoubtedly omits some health services researchers and includes some individuals who are interested in health services research but not actually engaged in it. Approximately 50 percent of the researchers for whom degree information was available have doctoral degrees, and another 28 percent (mostly physicians) have clinical degrees. The proportion of the work force whose doctorates are specifically in health services research rather than another field or discipline could not be determined. Given the number, size, and age of programs offering degrees in health services research or closely related fields (primarily health policy or health care management), however, the committee believes it likely that only a minority of researchers now have such degrees. The largest segments of the current health services research work force appear to be employed in academic institutions and private research organizations

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FINDINGS AND RECOMMENDATIONS / 79 and consulting groups. Employment in health plans, insurance companies, and similar organizations appears to have been growing fast, albeit from a smaller base. As noted in Chapter 3, a recent study indicates that for graduate scientists and engineers in general, academic jobs are declining while positions in business and industry are growing. Without information on researchers' age, employment history, or percentage of time spent in research, life table models or other work force estimation methods cannot be employed to arrive at reasonable numerical projections of the future supply of health services researchers. On qualitative grounds, however, the committee foresees growth in the health services research work force if public research funding escapes significant reductions and if competitors in the emerging health care market continue to support growth in knowledge about the quality, effectiveness, and cost of clinical services, the behavioral determinants of health status, and similar questions. SUPPLY IN RELATION TO DEMAND Current Supply and Demand The committee was not able to make an empirically based, quantitative statement about the match between current supply and current demand for health services researchers. In particular, it was unable to find systematic data on underemployment and unemployment levels for researchers or on other variables that would support such a statement. However, based on interviews with health services research employers and on the experience of committee members, the committee reached two qualitative conclusions. First, no anecdotal or other evidence suggests that the current supply of health services researchers exceeds current demand. Second, employers appear to be more concerned about the quality than the quantity of prospective researchers. Well-trained researchers with practical experience in health care organizations (e.g., integrated health care systems, insurance companies) and experience in managing research units appear to be in short supply. Recruiting difficulties also appear to exist for those trained in both health services research and selected disciplinary areas including statistics, epidemiology, health economics, and outcomes and health status measurement. In some clinical areas, such as oral health and allied health services, trained health services researchers also appear to be scarce.

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80 / HEALTH SERVICES SEARCH Future Supply and Demand The committee identified several factors that may affect the future supply of and demand for health services researchers, although economic, technological, political, and other uncertainties make specific predictions risky. On the need or potential demand side, this report has identified many major questions for health services research, and it has underscored the importance of understanding the nature and effects of rapid changes in the health care system. For the foreseeable future, the committee expects that demand for health services researchers with particular degrees or skills will reflect the increased emphasis that public and private decisionmakers are placing on market forces (and therefore informed consumer choice of health plans and care options) in the health care sector. That is, demand will continue for researchers prepared to build knowledge about health outcomes, health status measurement, quality assessment, patient and consumer decisionmaking, informatics, and related areas. The prospects for some employment sectors are uncertain, particularly those dependent on government funding. For academic institutions, where most researchers are now employed, relative or absolute contractions in funding for education and research from federal and state governments are anticipated by many policy analysts and educators. In a financially stressed university environment, the multidisciplinary character of programs in health services research (and research education) may leave such programs more vulnerable to reduction or elimination than longer-established and more easily defined programs in specific disciplines. This vulnerability may be offset, to some degree, if health services research programs can document growth in the applicant pool, employer demand for graduates, and financial support for students from actual or potential employers through mechanisms such as tuition reimbursements and research funding. In addition, most academic health centers are facing declines in patient care revenues as health care plans bypass these centers in favor of institutions that are less specialized, less comprehensive, less involved in health-related training and research of any kind, and thereby less costly. Overall, the demand and economic rewards for most categories of specialty and subspecialty clinicians appear likely to decline, and surpluses are anticipated. As a result, some additional physicians, nurses, and other clinicians may seek education and employment in health services research. TRAINING PROGRAMS The committee encourages continued evolution of formal educational programs in health services research. These programs play a special role by providing (1) an organizing focus for the field, (2) an environment supportive of

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FINDINGS AND RECOMMENDATIONS / 81 creative research and methodology development, and (3) an important source of personnel prepared to increase the knowledge base for responding to issues of cost, quality, and access facing the nation. The committee believes that they encourage systematic, multidisciplinary investigation and understanding of health services, behaviors, and outcomes and, further, that they promote the formulation of research frameworks and strategies that integrate the theories, concepts, and tools of different disciplines. They are, therefore, a valuable national resource. Still, a single educational path is neither practical nor desirable. Health services research will continue to attract and benefit from people with a variety of disciplinary and clinical degrees who are prepared to make important theoretical, conceptual, and empirical contributions to the field. To take full advantage of this variety, the field needs to provide a range of training opportunities for those who are pursuing or have completed graduate degrees in other areas. It is, however, desirable and important for these researchers also to have explicit training in health services research through either a disciplinary or, ideally, a multidisciplinary program. To the extent that recruiting problems exist in some discipline or skill areas, employers may resort to on-thejob training and short-term programs. The committee believes that such limited training is not, in general, sufficient preparation for those who are expected to design and conduct high-quality health services research. Some formal academic training is important. Academic training is only a partial answer for the experience-related areas of apparent shortage, particularly in areas such as managed care or research management where on-thejob training and seasoning yield essential background. Worksite-based internships and fellowships may also help to bridge the gap between the university and the workplace. These findings led the committee to recommend some shifts in the focus of publicly supported training in health services research. In particular, the committee recommended that AHCPR consider greater emphasis for some predoctoral and postdoctoral awards on training in areas such as outcomes and health status measurement, biostatistics, epidemiology, health economics, and health policy in which recruiting difficulties have been reported; more explicitly consider in evaluating institutional training program awards how an applicant's training approach, faculty, research opportunities, and training slots relate to personnel shortage areas; and set aside a substantial percentage of institutional awards for innovative programs in health services research, which might be completely new programs or significant modifications of existing programs (see below). .

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82 / HEALTH SERVICES RESEARCH The committee offered no ranked prescription for the program innovations to be encouraged. By way of example, however, innovative programs might be designed to . explore new models and methods for truly multidisciplinary and interdisciplinary education and investigation; . test creative educational opportunities and technologies for midcareer professionals with varied levels and kinds of educational backgrounds and work experiences; extend student and faculty research experiences in nonacademic settings through mechanisms such as internships and faculty sabbaticals; develop strategies to involve more community-based practitioners in outcomes and related research originated and managed by faculty investigators; or cultivate partnerships with public or private organizations to encourage collaborative research training, joint methodology development, or other cooperative ventures. Several of these examples point toward educational programs that are more community and customer oriented, that is, that prepare students better for employment in government and industry as well as academic settings. Such innovative steps may be somewhat more costly than current programs. AHCPR should consider providing some additional funds to cover better the institutional costs of developing innovative educational experiences. The committee also felt that greater flexibility in the timing of dissertation grant awards was desirable to better accommodate students' schedules. It therefore recommends that the agencies awarding such grants, including AHCPR and the Health Care Financing Administration, offer multiple award cycles throughout the year instead of the current once-a-year cycle. The committee also noted the problems of nontraditional students, including single parents and others with significant family responsibilities. Most predoctoral programs require people to be in residence for one to two years, although a few provide on-thejob or on-campus options that provide greater flexibility. Flexibility in postdoctoral programs also warrants consideration. The committee endorsed the recommendations for health services research training awards that were issued in 1994 by the NRC Committee on National Needs for Biomedical and Behavioral Research Personnel. The recommendations called for 360 National Research Service Awards (NRSA) yearly for fiscal years 1996 through 1999. This recommendation was up slightly from the 330 NRSA awards recommended in several reports during the 1970s and 1980s. It would still leave the number of awards at a slightly lower level than prevailed for health services research in the early 1970s but would more than double the actual 1994 numbers.

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FINDINGS AND RECOMMENDATIONS / 83 The committee also supported three other NRC recommendations for the NRSA program that focused on stipends and on women and underrepresented minorities. The recommendations called for the program to 1. "raise the real value of stipends to more competitive levels by fiscal 1996: approximately $12,000 per year for predoctoral awardees and approximately $25,000 for postdoctoral awardees with less than 2 years of research experience tand] maintain the real value of these stipends (i.e., the nominal value adjusted for inflation) through annual increases of 3 percent per year (the assumed annual rate of inflation)" (NRC, 1994, p. 2~; 2. "examine research training opportunities for women through the NRSA program and strengthen the role of postdoctoral support to assist women in establishing themselves in productive careers as research scientists" (NRC, 1994, p. 8~; and 3. "hold Minority Access to Research Careers (MARC) awards constant at fiscal 1993 levels, or approximately 680 awards, pending the outcome of . . . [a not-yet-published] NIH evaluation study" (NRC, 1994, p. 8~. CONCLUSION As this report was being drafted, events were unfolding that promised to be quite significant for the health services research work force and related educational programs. Specifically, a quite dramatic market-driven restructuring ofthe health care system was well under way, one that could significantly disrupt established patterns of patient care and relationships between clinicians and patients and affect the cost, availability, and quality of health care. Restructuring is likely to bring both positive and negative effects and to distribute benefits and burdens unequally across different income, age, and other population groups. The committee believes it critical that the nation sustain the research capacity including funding, personnel, and educational programs to document and understand these changes and their consequences. Recently, however, some in Congress were calling for the elimination of AHCPR as a cost-cutting measure (Brown, 1995~. In the context of market- oriented strategies for containing health care costs, abolition or near elimination of AHCPR and its focused health services research and training agenda could undermine the development of knowledge important for effectively functioning and accountable markets and for assessing the impact of health care restructuring on the public's health and, especially, on the availability and quality of care for the nation's most vulnerable children and adults. Although an array of private organizations can be expected to continue and probably increase their investment in outcomes research and similar activities, these efforts taken as a whole are unlikely to substitute for more than a portion

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~ /~ ~ of govemment-suppoded research Id twining in magnitude, coherence, scope, or concern far long-tc~ consequences. Like other kinds of heakh-rel~ed research Id training in the biomedical Id clinical sciences, hearth services research Id research twining ~e, in considerable measure, public goods Frothy of support by society as s Bold