• Studies of the impact on cost and quality of different kinds of delivery systems, including health maintenance organizations, preferred provider organizations, and other forms of managed care within the United States and internationally.

  • Medical effectiveness and cost-effectiveness studies, which have led to expanded health insurance for new services (e.g., alcohol treatment and long-term care) and have documented the oral health benefits of fluoridating drinking water.

  • Refinement of concepts and methods of risk adjustment for use in studies to: predict the use of services by a population with certain demographic and health characteristics; estimate appropriate reimbursements for patients with certain characteristics; and compare providers or systems of care on outcomes while controlling for patient differences.

CHALLENGES FOR HEALTH SERVICES RESEARCH IN THE FUTURE

Current efforts to reform and restructure the U.S. health care system create new demands for health services research. The committee notes that difficulties already exist in recruiting well-prepared health services researchers to work on the many health care questions faced by consumers, health care providers, purchasers, employers, health administrators, local and state governments, and the federal government. Profound changes in health care policy and in the organization, delivery, and financing of health care already are taking place even without federal health care reform legislation. These changes are occurring rapidly and in a relatively uncoordinated manner in response to market, political, social, and public health forces.

The evolving health care environment is prompting many parties to try new organizational structures, financing methods, policies, and regulations. It also is generating numerous efforts to evaluate these new programs, policies, and organizations. Health services researchers are thus called upon to examine a wide array of complex topics.



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Health Services Research: Opportunities for an Expanding Field of Inquiry: An Interim Statement Studies of the impact on cost and quality of different kinds of delivery systems, including health maintenance organizations, preferred provider organizations, and other forms of managed care within the United States and internationally. Medical effectiveness and cost-effectiveness studies, which have led to expanded health insurance for new services (e.g., alcohol treatment and long-term care) and have documented the oral health benefits of fluoridating drinking water. Refinement of concepts and methods of risk adjustment for use in studies to: predict the use of services by a population with certain demographic and health characteristics; estimate appropriate reimbursements for patients with certain characteristics; and compare providers or systems of care on outcomes while controlling for patient differences. CHALLENGES FOR HEALTH SERVICES RESEARCH IN THE FUTURE Current efforts to reform and restructure the U.S. health care system create new demands for health services research. The committee notes that difficulties already exist in recruiting well-prepared health services researchers to work on the many health care questions faced by consumers, health care providers, purchasers, employers, health administrators, local and state governments, and the federal government. Profound changes in health care policy and in the organization, delivery, and financing of health care already are taking place even without federal health care reform legislation. These changes are occurring rapidly and in a relatively uncoordinated manner in response to market, political, social, and public health forces. The evolving health care environment is prompting many parties to try new organizational structures, financing methods, policies, and regulations. It also is generating numerous efforts to evaluate these new programs, policies, and organizations. Health services researchers are thus called upon to examine a wide array of complex topics.

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Health Services Research: Opportunities for an Expanding Field of Inquiry: An Interim Statement At this early point in its deliberations, the committee is inclined to believe that although the passage of national health care legislation would further enhance the need for health services research, it would not significantly shift the basic course of this field. New or different sponsors of research may emerge, depending upon which entities are held accountable for which decisions and outcomes. National health reform is expected to provide unique opportunities to set goals and then to monitor progress toward health and health care objectives —and to point out when changes are necessary. The questions of access, cost, and quality must be addressed, however, with or without national reform. Along with documenting the wide reach of health services research today, the committee concluded it should give some attention to broad directions in which the field might be expected to move and to specific issues that will call on the expertise of health services researchers. This section of the committee's interim statement describes a range of projects and developmental objectives that are challenges for the future. Although the committee's listing is quite selective, it includes areas that illustrate the philosophical, academic, and applied elements of health services research. Organization and Financing of Care As the nation has debated health care reform during the past 2 years, the public has become increasingly aware of the issues of health care organization and finance that health services researchers have long addressed. For example, researchers: develop Medicaid managed care programs; design integrated hospital systems to maximize population health; study the impact of various state health policy experiments on the health of their citizens; explore the role of public- and private-sector partnerships in achieving the most appropriate balance between public and private hospital beds in a variety of policy scenarios; compare outcomes of dental hygiene treatment in managed-care and fee-for-service settings; investigate

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Health Services Research: Opportunities for an Expanding Field of Inquiry: An Interim Statement the cost-effectiveness of physical therapy interventions in a variety of practice settings; evaluate new care delivery systems within and across states; and study how the balance in horizontal and vertical integration of health services is to be achieved. The structure of the insurance market influences and interacts with the way health care is organized and delivered in the United States. The following topics are cases in point: development of statewide reinsurance pools; effects of including new populations in the insured population within states; use of services when people receive subsidized health insurance, particularly if they were previously uninsured; effects on enrollment of different types of subsidized insurance for low-income people; factors that encourage or discourage insurance plans from participating in subsidized insurance programs; review of the consequences of whether the Health Care Financing Administration in DHHS (which administers the Medicare and Medicaid programs) should pay for home visits by physicians or nurses to older people that chiefly involve delivering health promotion and disease prevention services; and the relationships among costs, charges, insurance, and organization of care. Researchers—along with policymakers, providers, and consumers—must find ways to explore the role of public health services in the context of health care reform. They also will need to continue to supply data, analysis, and insights about the costs and coverage of health reform proposals. Clinical Evaluation and Outcomes Research Clinical evaluation involves such matters as the assessment and improvement of quality of care, the development and implementation of clinical practice guidelines, and the steps involved in technological innovation and assessment. For example, health services research could provide the kind of increased scrutiny required for evaluating technology transfers. New procedures are often put into practice before valid outcome evalua-

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Health Services Research: Opportunities for an Expanding Field of Inquiry: An Interim Statement tions have been done. Unverified claims of efficacy (however unintentional) lie beneath some long-standing practices. What is needed to properly evaluate procedures are theories of clinical science, bench-to-bedside translation, understanding of vital statistics implications of practices, and the modeling of cost-effectiveness, outcomes, and other analytic methods. Much ongoing work relates to identifying and measuring the outcomes of health care services. Examples include evaluating oral health outcomes in countries using various systems of care delivery and approaches to prevention; investigating whether behavioral risk factors can be modified by individual or community interventions and, if they can, when the best time to act is; determining whether treatment for foot ulcers in people with diabetes varies according to the type of doctor seen; and studying the effectiveness of home-based intervention for people caring for a family member with dementia, of an occupational-therapy home intervention for improving quality of life and adaptation to disability, and of point-of-care testing for myocardial infarction. The committee identified health status and functional outcomes as an area needing further theoretical development. A primary effort should be in developing a “production function” for health. Specifically, economists and clinicians will need to collaborate on the design of integrated health systems that will economically produce the health outcomes that are desired by patients and their families. At present we intuit with little or no data or theory the trade-offs between costs and quality. We still count units of care as the product of health care services, mainly because it is methodologically feasible to do so, when our ultimate aim is to involve concepts such as functioning, satisfaction, and absence of pain and distress in the measurements. Monitoring and Accountability Increased clinical and financial accountability is a significant trend in the health care field—this is a set of issues sometimes characterized as “doing the

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Health Services Research: Opportunities for an Expanding Field of Inquiry: An Interim Statement right thing” and “doing it right.” Health services research can improve current methods of maintaining and monitoring accountability, drawing, in part, on elements of industrial quality management, statistics, and operations research. Achieving greater accountability to the public will require increased reporting and dissemination of information about cost, utilization, and quality. Health services research will provide the basis for the creation of “report cards” to help purchasers and consumers choose among health providers. Laying a data-driven foundation for such judgment calls involves applied, theoretical, and philosophical challenges for health services research in both government and private spheres of activity and funding. Providers' own internal quality improvement activities will also play a role in monitoring. Providers can develop systematic ways to examine— and then improve—their own performance. As large medical care organizations, integrated health systems, and accrediting agencies establish health services research units to do these and other analyses, they will open up employment opportunities for health services researchers beyond those currently available in academic centers. As more health services are provided in different types of settings, health services research can monitor the quality, cost, and access to care and determine who are appropriate providers of cost-effective health care. Policymakers and managers may ask, for instance, whether dental hygienists, nurses, occupational therapists, physical therapists, physician assistants, and other health professionals can provide effective services safely and efficiently. The answers to such questions often rest on ill-defined basic assumptions about what is “effective ” care and who bears what portion of its cost. Health services research provides a framework for clarifying the assumptions and thereby grounding the answers more firmly in data and their appropriate interpretation. The regulatory arena is a source of external monitoring and accountability. Pharmacy provides excellent examples of the range of regulatory decisions government agencies face, such as: determining

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Health Services Research: Opportunities for an Expanding Field of Inquiry: An Interim Statement the form and extent of regulations concerning the advertising of pharmaceuticals; exploring the regulatory process and its impact on what medications are reimbursable and at what price; and describing the effects of various regulatory actions on prices, the availability of medications, and the development of new pharmaceutical products. By exploring the consequences of such regulations on physician and patient behavior and on patient outcome, health services researchers can contribute information to better design and carry out regulatory policy. Informatics and Clinical Decisionmaking Health services research will contribute to the development of medical informatics and the use of electronic communications media in the health field. As provider and accrediting organizations continue to make large investments in medical information systems, technical advances will provide health services researchers and managers access to new information sets; these, in turn, offer opportunities to develop new demonstration models and environments and to devise practical and ethical ways to integrate data from long-term-care, inpatient, ambulatory, and other settings for analyses of quality, cost, and access. Furthermore, informatics and an evolving national information infrastructure—involving providers, purchasers, consumers, and payers —could improve decisionmaking processes (for instance, about matters that involve costs, cost-effectiveness, and ethics). Shared decisionmaking—essentially the communication of information about health conditions and interventions between patients and practitioners to allow mutually agreed-upon steps in prevention, diagnosis, and treatment—is an expanding concept and mode of practice. It depends on an adequate sharing of knowledge and information between patients (and their families) and clinicians. Researchers are finding striking relationships between timely access to accurate, balanced information about treatment options and contingent outcomes of care, on the one hand, and patient choices and resulting aggregate

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Health Services Research: Opportunities for an Expanding Field of Inquiry: An Interim Statement demand for medical care, on the other. This emerging domain relies heavily on, among other specialties, the behavioral sciences, economics and statistics, decision theory, and informatics. Thus, given the kinds of disciplines that health services research involves, the field is in a position to lend significant support to both the theory and the application of shared decisionmaking techniques in health care. Populations and Communities Health services research can and must be used to understand community and cultural values better because health care practice is becoming more patient, or client, driven. Fruitful areas of research include defining determinants of health for individuals and populations, measuring behavioral risk factors, and elucidating ethnic and cultural differences that affect the health of populations. As health services researchers look increasingly at populations, as contrasted to individuals presenting for health care services, investigators can define these populations in many different ways. Although such groups are most commonly described in terms of their sociodemographic characteristics or geographic location, health services researchers can use their understanding of health care organization to define new groups. One example is to define a population as all those people covered by a particular service contract from an integrated delivery system, insurer, or provider. With these and other varied tools available, health services researchers can create the valid comparison groups that will be needed to assess quality of care and ensure publicly accountable decisions. Population-based health services—for example, community-wide health education programs and control of communicable disease outbreaks—are a significant but often underappreciated element of health care in the United States. Health services researchers can explore the impact of these programs on the health of a target population over time. Understanding the effects of these public health services,

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Health Services Research: Opportunities for an Expanding Field of Inquiry: An Interim Statement with an associated consideration of their costs, staffing, and relationship to the health services provided, will be increasingly critical as personal health care services are restructured with a focus on cost containment and as hard decisions are made about the investment of both public and private resources. Provider and Consumer Behavior Health services research can describe how providers act and examine why they make the clinical, ethical, and financial decisions they do. The influence of education, training, and underlying socialization processes on these behaviors is only dimly understood. We do not know how providers make decisions or how they work together; neither do we fully grasp how the growing availability of practice guidelines affects clinicians. Similar attention can be paid to exploring how clinicians choose specialties and practice locations. Health services research can explore further the behavior of the four audiences for its products identified by AHCPR: consumers, policymakers, managers, and providers. By investigating the financial implications of behavior and, conversely, the behavioral implications of different financial circumstances among consumers, providers, and payers, health services researchers can learn how financial incentives and organizational structures influence performance and behavior at all levels. While pursuing the supply side of health care (whether measuring its product as health status or as units of service), health services research can also work toward a general theory of demand for health care. Furthermore, in the United States, having health insurance is not sufficient to ensure that an individual will receive timely and appropriate care. Health services research can explore significant demand-related questions about nonfinancial barriers to care, such as what might cause nonusers of health services to seek appropriate preventive or curative services.