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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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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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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
Representative terms from entire chapter:
services researchers
