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OCR for page 128
HEALTH SERVICES PES=RCH
In recent years, expenditures for health care have expanded
enormously. Each year has also seen new legislation vitally
affecting the organization and provision of health care
services. At the same time, research appropriations
earmarked for understanding how the health care system works
and how it can be made to function more effectively in the
future have experienced a precipitous decline.
Health services research, unlike research on cancer,
heart disease, or mental illness, does not have a dramatic
purpose that speaks to the direct experience of aillicns of
people. Indeed, the public has often been apathetic toward
the abi, ity of organized services to meet the needs of the
sick and diseased (Shryock, ~ 966, ~ 969} .
Nor does health services research have a large, we, 1-
organized constituency to advocate funding for it;. Health
services research is a hybrid of disciplines that are
unified only by common research goals.
Health services research seeks to examine the
organization and performance of health care delivery systems
and to open health car" policy to research which analyzes
the components of this system (Black, 1974~. At a time when
cor~om~c constraints threaten our ability to bring quality
health programs and personnel to individuals and families
throughout our nation, it is health services research that
seeks to devise more sensible allocations of our collective
and finite health resources {White, 1975; White and
Henderson, 19761. Through the application of quantitative
and systematic research methods, health services research is
concerned ultimately with the organization, utilizaticn, and
outcomes of health care.
Even wel1-informed people, both in government and in the
scientific professions, have insufficient know, edge as to
what heal th services research is, how it is performed, or
the range of disciple ines involved in it. Because of this
~ ack of awareness, they are unfamiliar with the special
prob lems of hea Ith se rvice s res earch and the ta rents and
resources that are necessary.
At the s ame ~ ime there ha s been both a legis lative and
an administrative demand for improvements in the delivery of
health care. Improving a system that is as complicated,
diffuse, and poorly understood as the U. S. health care
system cannot be done ef fectively and safely without a much
128
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more subs tantia l information and knowledge bases and
analyses of the dynamics of the present system.
Prior to a discussion of research training needs in this
area, the committee examines what health services research
is and what role it can have in providing medical and other
health-care services to the population.
ORIGINS OF FEDERAL SUPPORT
Health care delivery systems are shaped by the historical
contexts in which they develop. Such factors as economic
organization, ideological forces, available technologies and
pre-existing professional organization affect access to
medical care, distribution of services, and ultimately the
quality of health care (Mechanic, 1975). Indeed, in our own
nation, health care policy and delivery systems development
are determined today by administrative decisions that must
balance "the perceived medical needs of the people, the
scientific realities of today and the available money in a
political climate which insists on distributional equity"
(White, 1977~.
Health is the nation's third largest industry today
(Altman and Eichenholz, 1976). It is estimated that public
and private expenditures for health services and supplies in
the U.S. grew from $12 billion, or 4.6 percent of the gross
national product (GNP) in 1950, to $139 billion' or 8.6
percent of the GNP, in 1976. At the same time there has
been a growth in the proportion of total health outlays
borne by the federal government. In FY 1976, for example,
the federal government provided support for more than 60
percent of all medical research costs, 45 percent of the
costs to construct and maintain health facilities, 40
percent of medical education costs, and 30 percent of the
costs for health services. This represents a growth of the
federal share of total spending from 12 percent in 1950 to
28 percent in 1976 (office of Management and Budget, Special
Budget Analyses, 1977).
Implementation of large-scale federal health programs
calls for a knowledge of the unique health needs of a region
or pcpulation and requires an accurate estimation of the
need for new health care services, facilities, and
personnel. The federal government has found it necessary to
provide for R and D activities useful in guiding this policy
and planning process (President's science Advisory
committee, 1972~. Indeed, it was in the face of critical
health care needs the' the federal government launched the
first ma jor program of health services R and ~ in 1955 when
Congress appropriated sufficient funds to improve the
organization and design of hospitals and related health
services. 2
129
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In the absence of specialists to conduct health services
research, the government has had to rely on scientists and
health professionals from a variety of fields to redirect
their activities and interests to the problems of health
services development {Eichhorn and Bice,1973~. As a result,
a body of knowledge has accumulated over the years, and
research techniques have been developed to the point that
health services research is now considered a distinct area
of scientific inquiry.
With the development of its theories and methods, health
services research has been established ~ n academic
institutions through a I' mined number of programs of
training. It is at these institutions and research canters
that indiv~ duals can gain expert) se at both the predoctoral
and postdoct oral levels in the problems and methods of
health services research. Hence, for the first time it has
been possible to foster the development of a cadre of
Investigators trained to address the complex questions of
health care delivery.
Because of.th" absence of a supportive constituency,
federal support for these programs of training has been
diffuse and sporadic. 3 it is the hope of the Committee that
a description of the current climate of federal support for
this research endeavor, coupled with a discussion of the
role this research and training can have in addressing the
urgent health care questions today, will lead to a
continuity of commitment by the federal government to the
development of health services research in the future.
NATIONAL CENTER FOR HEALTH
SERVICES RESEARCH
The Congress iona 1 appropriations of 19 55, which Permitted
the implementa-~on of the demonstration provisions of the
Hi [l-Burton Act, launched health services research by the
federal government. By the late 1950's, the NIH also
supported a number of noncategorical health services
research projects under the general research authority of
the Public Health service Act (PHS Act), and by 1963 the
Bureau of State Services began the first organized
extramural research program in community health services
(Sanazarro, 1973~.
The proliferation of these federal programs led the
White House Conference on Health in 1965 to recommend the
establishment of a single entity to coordinate these
activities (PSAC, 19651. Consolidation was achieved in 1967
when Congress directed the Secretary to establish a center
for health services research, demonstration and development
programs, and the training of research personnel in this
area. 4 This was carried out by an order of the Secretary in
130
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~g68 that est abashed the National center for Health
Services Research and Development (NCHSED} . s
The NCHS~D was formed initially by a transfer of
existing programs from the Divi signs of Community Health
service, Medical Care Administration, Hospital and Medi cal
Faci ~ ities, and from other units of the Department of
Health, Education and Welfare tHEW) . The diverse ty and
complexity of tasks that resulted from this consolidation is
ref. ected in this statement of goals:
Thi s new program of health services
res earch and deve 1 opment of fers a vehicle
through which al ternative means for
maintaining and increasing the
ava i labi lily of good health care can be
achieved; the productivity of health
manpower can be increa sea; better
hospitals and nursing homes can be
designed, and a ful ~ range of
alternatives to' costly ins' itutional care
can be developed. (U. S . Congress, ~ 9 67)
The basi c charge to the center, however, was threef old:
to improve access to health care, to guarantee quality, and
to moderate rising costs on a national scar e (Sanazarro,
~ 973~ . As a first step in meeting these goals the Center
laid out a program of R and D, with a heavy emphasis on
development, to identify ma jor health care problems and to
a s su rue coop erat i on f rom the pubI i c and pri vat e s ec to' s .
Largely through demonstration activities, the Center
supported projects to train and deploy physician extenders,
to test such new cost containment and f inancing methods as
all- incl usive rate reimbursement, to examine the potential
of computer technology on health care del ivery, and to
standardize the health services data systems withi n state s
and nationwide. ~
In ~ 974, Congress clarified the role of the Center
through the Health Services Research, Health Stati sties and
Medical Libraries Act (PL 93- 353) (Fox, ~ 976} . Today its
intramural and extramural research is directed toward the
following areas: quality of care; inf ration, productivity,
and costs; health care and the disadvantaged; health
manpower; health insurance; planning and regulation;
ambulatory care and emergency medical services; and long-
term care (NCHSR, ~ 9 76) ~
As Figure 6. ~ indicates, budget constraints severely
limit the work of the center, making di f ficult the tasks of
providing a stable program of re search and of demonstrating
the contributions of health services research to health care
policy.
131
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70r
60
z 50
o
J - 4o
30
,^
20
-
-
-
10 _
o .. 1 1 1 1 1 1 1
1 970 1 971 1972 1973 1 974 1975 1976 1 977PB
FISCAL YEAR
FIGURE 6.1 NCHSR research funds by fiscal year. PB refers to Me level of funding recommended by the Administration
(President's Budget). From PHS (1976a)`
HEALTH SERVICES RES=RCH
IN ADAMHA
Federal programs to provide mental health care Services to
the nation r epre s ent a drama tic departure f ram tradi t iota
service delivery models and generate for health services
research a different set of challenges and research
problems.
In its ~ 961 report, the Joint Commission on Mental
IN Iness and Health called for one fully-staffed full-time
mental health clinic for each 50, 000 of the population
(Report of the Commission on Mental Iliness and Health,
1 961~ . With the enactment of the Mental Retardation
Faci lities and Community Mental Hea Ith Center Construction
Act in 1963 {PL B8-1 64}, the federal government became
committed for the first time to provide opportunities to
treat emotionally and mentally disturbed persons, who might
otherwi se require hospitalization, in a community setting .
Community Mental Health centers (CMHC' s} were also
envi stoned by some a s " socia ~ change agent s " instrumental in
lowering the incidence of mental disorder (Caplan, 1964;
Arnhoff, 1975; Robin and Wagenfeld, 1977} . Over 600 CMHC's
are in place today.
Mental health services research personnel are challenged
today to provide information on the social, economic, and
behavioral factors that render mental health care delivery
ef fective . In the f ace of serious economic conditions, such
132
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information will assist the health planner to devi se a
coherent federal policy for mental health that will permit
the optimum allocation of limited federal resources (PHS,
1976a) .
Since 1972, there has also been an ~ ncreasing cornrritment
to provide federally funded programs to threat alcoholism and
drug addiction in a variety of settings (ADAMHA, ~ 976) . The
challenges that face health services research personnel are
largely simi lar to those that face individuals studying
me no al health ca re de livery. However, the abs en ce of a
know 1 ed ge ba s e re ga r d ing the ba s ~ s f or the se a d dic tive
behaviors increas es the complexity--and importance--of the
tasks facing these research personnel.
ADAMHA's interest to improve these programs of care is
reflect ed not only in the areas of research and evaluation
supported at this time, but also is evident in the current
expa nsi on o f re s earch ~ ra ining in thi s area within the
f.ramewo ok of the NRSA Act .
HEALTH SERVICES RESEARCH
TN THE NIH
Health information systems can assist individuals operating
a variety of heal' h services to gain access to information
relevant -o the performance of the health services
(Alderson, ~ 974) . While it is clear that it is not the goal
of the National LO brary of Medicine (NLM} to enhance the
efficiency of health services as such, the work cuff the ELM
to develop computer technology for dis seminating medica 1 and
other inf ormation serves as an important resource for the
development of health care programs throughout the nation.
The committee notes that the HEM has provided a limited
program of training in the area of computer technology and
information science under the auspices of the Medical
Libraries Assistance Act in recent years.
CURRENT TRENDS IN HEALTH SERVICES RESEARCH
The public perceives a variety of serious problems in
medical care today. These include the inability to get
personal medical care, the rising costs of hospital care,
the lack of good medical care for common problems despite
the proliferation of advanced technologies to prolong life,
evidence of difficulties with Medicare, and many others.
Health services research seeks to address these and a wide
variety of other problems.
In the wake of the social programs of the 1960's for
example, health services research has begun to investigate
the access to and use of health services by the aged, the
133
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economically disadvantaged, minorities, and geographically
isolated populate ens. One recent investigation (Haggerty et
al. , ~ 975} has shown that neighborhood health centers
increase the access and use of health services by the poor,
with a consequent reduction in use of hospital admissions
and emergency-room use.
In the quality assurance field, a recent study
demonstrated that education is not as effective as financial
incentives in change ng the behavior of doctors (Brook and
WE lliams, 1977} . A group of physicians was found to be
administering intramuscular inj ections routinely to' Medicaid
pa ~ tents, despi ~ ~ the fact What peer physicians had
determined these injections to be unnecessary. It was not
until the Medicaid program der.~ ed payment of reimbursement
claims that a reduction wa s noticed in the number of
in jections reported.
An increasing emphasis has been placed on the problems
of health costs in recent years. Economists have
demonstrated that higher -` nf ration has meant that low-income
f ami ~ i e s and the eld er ly-- f or whom hea Ith care bud get s have
a i ~ ed to ke ep pa ce wi th servi ce s c o st s - - a re devoting a
erg er share of thei r limite ~ incomes to hea lth co st s
(Davis, ~1976 ~ . Evidence has also accrued that suggests that
certificate-of-need laws have successfully cursed hospital
bed expan si o n, but have a Is o motivated hospi ta ~ s to
accelerate investment in costly services, facilities, and
equipment (Sa ~ Wearer and Bice, ~ 976) . Research on these and
related quest ions may lead to a better understanding of ways
to abate soaring health-care! costs.
A' though ' arge-scale investment in sophisticated new
techno~ ogles has contributed to rising health-care costs in
general, the apple iced ion of computer technology to hospital
information systems may actuate y be a cost-effective way to
facilitate the f low of information within the hospital while
reducing the time and e f fort spent to store and retrieve
such informant on. Recent studies have demonstrated, for
example, the uti lity of medical information systems in
ambulatory care settings (Barrett, ~1976} '.
JUSt as clinical research seeks to test the ef ficacy of
a new form of treatment on patients manifesting a particular
di sorder, health servic ~ s re search seeks "co improve the
ef fecti~renes s of applying the treatment to those who can
benefit from it. A recent health services research study
has shown, for example, ~ hat the U. S. population has yet to
benefit from the use of drugs and treatments for essential
hypertension, despite the demonstrated efficacy of the
treatment (Weinstein and Stason, ~ 976} . Such research
assists the specification of policies and priorities for
continued federal investment in health care.
Finally, In the area of alcoholism and drug abuse,
health services research has led to the establishment of
occupational alcoholism services in the industrial setting
and to the creak ion of pilot programs to demonstrate methods
134
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to return recovered drug addicts to products ve employment
(ADAMHA, ~ 97 5 ~ .
THE NATURE OF HEALTH SERVICES RESEARCH TRAINING
Health services research training can be offered to a wide
range of individuals, including those who hold
baccalaureates, masters degrees, academic doctorates,
professional doctorates, and ether health professicnals.
Trai ning may consti ~ up ~ work towards a ma ster s degree, a
research doctorate, or postdoctoral training in (~) the
behavioral sciences (including sociology, anthropology,
psychology, and population studies]; (2) the biomedical
sciences tincturing biostatistics, bioengineering, and
epidemiology); (3) the social sciences (primarily economics
and political sciences}; {4) public health (including
environmental health and maternal and child healths ; and (~)
in other research fields (such as operations research,
heal th adminis:+ratio~., and health education) .
The aspect of health services research training that
d~ stinguishes it from other types of research training is
the nature of the primary research problem. The health
services investigator apple ies research methods from the
di scipl~ne of training to on" or more of the health services
problem area s li s ted be low:
Problem Areas in 7
Health Services Research
health facilities
health manpower
adulatory care
dental health services
emergency health services
health services for the
di sadvantaged
long- term care
nursing health services
pharmacy-related health
services
economics ~ including health
insurance), inflation, cost
containment and production
legal aspects of health care,
including regulatory studies
quality as surance of health
services
health services organ) cation,
planning and adminis tration
utilization of health services
135
health services evaluation
health statistics develop-
ment
health status, including
indicators development
health systems analysis
health care technology and
technology assessment
medical data systems
community studies related to
health care
sociobehavioral aspects of
health care, including
compliance.
OCR for page 136
Heal th s ervices research training as it is cif ered
through such health agencies as ADAMHA dif fers only in that
the primary research problem is modified further by the
delivery system being analyzed, named y the mental health
services system (including substance abuse programs}.
Regardless of the source of research training support,
however, it i s the research problem that clearly
chase erizes the heal th services researcher.
CURRENT MARKET STTUATION FOR TRAINED
HEALTH SERVICES RE SEARCH PERSONNEL
The NCHSP has provided research training support at both the
predoc~ora~ and the postdoctoral level for over a decade.
Sims lard y, ADAMHA has provided important training in
evaluation research since the latter part of the ~ 960' s,
when evaluate ion of the programs of mental health care gained
momentum. 9 Because these programs of research training
represen the first ma jor effort by the federal government
to provide funds for formal training in areas relevant to
the enhancement of ~ he health care system, the Committee
sought to assess the current employment situation of a
selected sample of these individuals following their
training in thi s area of research.
Over 5 0 0 indiv idua ~ s were i dent i f ~ ed a s having re ce ived
predoctoral or postdoctoral research support through the
programs of the NCHSR or ADAMHA. of these, 396 received
support through the NCHSR since FY 1 97 0 3 a, and ~1 0 through
the evaluation training programs of ADAMHA since FY ~ 975.
A survey instrument wa s bevel oped that inc luded both the
questionnaire on training and employment in the biomedical
-anti behavioral sciences (Chapters 3 and 4, and Supplement
6}, and an additional one-page form to acquire information
Perth nent to the individuals specialization in health
services research (see Supplement 6). Over 65 percent of
the trainees surveyed responded to this questionnaire.
Onl y 1.2 percent of the trainees were
seeking employment at this time
(Appendix H11.
Over 6 5 percent were employed in
educationa ~ institutions, with another
~ 5. 5 percent employed in f ederal,
state, or local government (Appendix
H2) .
· About ~ 0 per cent report ed that the y
were engaged in health services
research (Appendix Had.
136
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.
Individuals engaged In health services
research were rather evenly
distributed among the eight broad
categories of health services research
specialization developed by the
Committee {Appendix Hid.
The programs of training supported by the NCHSR and --
ADAMHA may be expected to differ with respect JO the areas
of specialization emphasis, due to the fact that the systems
of health care differ for each supporting agency. Hence, it
is not surprising to find that a substantial proportion of
individuals who received support from ADAMHA specialize in
the sociobehavioral aspects of health services research
(Table 6.~), while a number of individuals who received
support from the NCHSR wick on problems dealing primarily
with the legal aspects of health care, quality assurance, or
services organization, planning, and administration (Table
6.2~. Beyond these major categories of emphasis, these
individuals tend to be rather well distributed among other
areas of research specialization.
The Committee has concluded that there is evidence of
ow unemploymer ~ among i ndivi due l s who have received federal
support for training in health services research and that a
large ma Gorily of these individuals have found employment
that permits them to engage in health services research.
The Committee believes that these federal ly supported
Frog rams 0 f t ra i ni ng have be e n s uc ces s f u ~ in provi ~ ing to
these individuals research skills that may be used in a
variety of employment settings and on a range af probe ems of
interest to health planners today. In summary, the
Committee has concluded that current employment conditions
for these trained health services research personnel are
good .
ASSES SMENT OF THE LABOR FORCE
In addition to those individuals who have received federal
support f or training in heal th service s research, the
present supply of available personnel ~ ncludes a cadre of
inve Litigators who have Proved into heal th servi ces research
either by virtue of their employment experiences (e. g.,
selecting a -opic for study ~ hat contributes to the
enhancement of the hea Ith care sys ~ em) or through some f orm
of nonfederally supported tray ning (e. g. , selecting a thesis
opi c con sidered appropr Ian e to studie s of the h ea Ith care
system). Because no data base exists that can be used to
estimate the magnitude of the health services research labor
force, the committee undertook a second survey directed to
acquire ~ his inf orma~ion.
137
OCR for page 138
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OCR for page 140
More than 2, COO individuals were identified for the
purposes of this survey, either because they had received
re search grant or contract support from NCHSR sometime since
FY ~ 9 6 0, ~ ~ o r ~ e cans e they had pubIi shed thei r re s ear ch
findings in journals relevant to this area after 1967. 12
The same survey instrument described in the previous
section was used to gather training and employment data from
this sample e of personnel. More than 5 00 individua Is could
no ~ be contacted bec ause of i Inadequate addres s e s . Of the
remaining 1, 50 0, more than 7 0 0 responded. Because the
Committee hopes to complete this study in the coming year,
only preliminary data are reported below.
Of the 7 00 He spondents, over 25 percent hold doctorates
in health care professions, but reported no formal research
training . The reman ning respondents repre sensed a varied
di st ribut ion among type s and leve ~ s of acaderni c tr airing,
with some individuals ho 1ding baccalaureates only, some
holding masters degrees, and some possessing acetic
doctorates .
Appendix H5 provides some information regarding the year
in which formal training had been completed by the se
respondents. It is interesting to note that professional
doc torate s a nd i ndividua Is wi th bac ca ~ aureate trai ning a lone
comp, eyed their education larger y before ~ 960, whereas most
o f t ho se with ac ademic doctoral e s rece ived the ir degree
a f ter that yea r f or the most part .
Because these indict duals completed their academic or
pro f ess tonal training prior to the development of formal
programs of training in health service s research tHaggerty,
1973) , it is ur.1ikely that these individuals have had the
opportunity to refine their research skills in light of
current theories and methods. ~ ~
The Committee is aware that grave problems arise in any
attempt to estimate the current available supply of health
se rvice s re s earc h pe rs once ~ . However, data f ram thi s survey
suggest that it will be possible eventually to make some
statement regarding the current employment situation of
inaividua Is who once worked in th i s area . The Committee
views ~ hese data as a first important step in understanding
the dynamo cs of the system.
OUTLOOK FOR THE LABOR MARKET
Th ere i s a s igni f ice nt awaken ing o f awarene s s among
government aiming strators today of the need to improve
national programs of physical and mental health care in the
face of inf ration and the high costs of medical care.
New approaches to health care are being developed within
a very short time frame. Plans are under way to implement
as scan as possible the far-reaching network of Health
systems Agencies (HSA' s), which provide an opportunity for
140
OCR for page 141
cc~mprehersiv" health planning at a ~ ocal level; for Health
Maintenance Organizations (~MO's) for free-market
competition ~ n health benefit plans; and for Professional
S' andards Review Organizations {PSRO's) to assure quality
care at a low cost to the taxpayer for Medicare and Medical
patients.
There is an important need for personnel to conduct
research associated with the imps ementation of these and
rela ~ ed programs ~ o enhance health care. However, federal
interest in providing research support must be tempered by
the knowledge that the bulk of avail able health services
research personnel have not had the benefit of fcr~ral
training in the ~ heories and methods that have been
discussed earlier in this chapter. As a result, programs of
research support may ultimately lack the availability of
personnel whose expertise is of sufficient calibre to tackle
sophisticated research problems relating to health care
planning.
The Committee recommends the support of programs for
research training to increase the number and quality of
health services research personnel. The importance of
quality in heal th services research cannot be overemphasized
as the demand for improved health care is heard from al
sectors of our society. This challenge can best be met
through the continued devel opment of a pool of personnel
whose research skills can assure the advancement of heal th
care.
RECOMMENDATIONS
Health services research is an applied activity directly
dependent on the availabi~ iffy of federal funds. Because
health services research will play an increasingly more
significant rod e in the federal effort to provide quality
health care at a reasonab' e cost, the Committee believes
that such research training represents an important national
priority.
Extens ion of NRSA Authority
Throughout its effort to conduct an assessment of health
services research personnel, the Committee has had to expand
ts considerations to include important training programs
other than those of the NTH and ADAMHA. In last year' s
report, for example, the Committee called for the
maintenance of the re search training programs in the NCHSR .
The Committee notes that the NCHSR has once again failed to
rece ive funding to continue i ts once-active re search
training effort.
~ 4
OCR for page 142
Because the ccrnmit+-e is concerned by the instability of
federal commitment to the total health services research
effort, and because the programs of health services research
training provided by the NTH and ADAMHA only supplement but
do not supplant the wide range of program areas supported by
the NCHSR, the Committee concludes that an extension of the
NF.SA statutory aut. hority to include the NCHSR is warranted.
The inc fusion of training through the NCHSR under NRSA will
assure the government of the full benefit provided by
investment in the training of these personnel.
Recommendation. In order to assure the provision of
~ __
urgently required training funds, the Committee recommends a
statutory amendment of. the NRSA Act to include all research
training provided by the BRA. Because of the role these
personnel play in conducting research relevant to national
health care concerns, the Committee recommends that
stat utory author) ~ y be provided at the earl Yes opportunity
through pending ~ egislation, such as the Hospital Cost
Containment Act of ~ 977.
Modification of the Payback Provision
With enactment of the National Health E1anning and Resources
Development Act of 1974 (PL 93-641), opportunities for
effective planning through research and evaluation
activities become available nationally. Similarly, other
nonprofit entities require evaluation anti measurement
activities that characterize health services research, such
as PsPo' s (PL 92-603) and HMO' s (PL 93-222) . Because
trained heal th services research personnel contribute to
these research efforts, the Committee considers subsequent
employment in these kinds of organizations appropriate in
meeting the NRSA payback requirement. The Committee
believes that, properly interpreted, the payback provision
requirements specified in the NRSA Act, as amended by the
Health Research and Health Services Amendments of ~ 976 (PL
94-278}, includes employment in such nonprofit organizations
as ~ ong as the employment requires and utilizes the research
ski lis of the trained health services re searchers.
Recommendation. The Committee urges the secretary of
HEW to confirm that the NESA payback provisions permit the
employment of health services research personnel in such
nonprofit entities as Health Systems Agencies tHSA'S}, or to
seek suitable legislative modification to provide for such
142
OCR for page 143
employment should he conclude that this interpretation is
not permitted by the pee sent law.
Predoctora 1/Postdoctoral Training
The Committee concludes that the research training reported
by the NIB and ADA~4HA within the category of health services
research is critical to the mission of each agency and
shou 1d not be reduced or eliminated.
For a number of years the NIMH has provided training for
social scien Lists in the broad area of evaluation research,
focusing an mental heal th and rel a ted services. This
program was broadened by ADAM HA n FY ~ 975 to cover training
for a wider variety of services, inch uding alcohclism and
drug abuse a s we l l a s mend al heal ~ h.
In view of the critical role the ADAMHA programs play in
bringing these needed services to the nation, the Committee
views the training of personnel to conduct research relevant
to mental health services evaluation to require expansion at
this time . The Committee approves the growth of the total
number of awards for research training in FY ~ 976 from the
level reported in FY ~ 975.
The committee recommends that this program of res earch
training, and that of NTH, continue to expand such that the
tote ~ numbe r o f awar ~ s support e ~ r epre se nt s a ~ O pe rc ent per
annum increment from the level reported in FY ~ 976. This
increment shout ~ continue at the same rate through FY ~ 981,
such that the total number of awards f or health services
research training represent 250 in FY 1979 and 300 in EY
19 81 . In this way, the opportunity for skilled personnel to
take up the sophisticated problems of services evaluation In
area s of interest to the NTH and ADAMHA wi ll be as sured.
The committee believes that the ma jor health care
questions today also require the type of health services
research training precariously of fered through the programs of
the NCHSR. The Committee urges, therefore, the complete
restoration of this program of training as soon as possible
to a level that characterize s its peak year of funding (FY
972} at approximately 440 awards.
Because of the difficulty involved in making
recorrunendations that will permit the rapid but realistic
restoration of a former program of training, the Committee
vet ews the numerical recommendations developed this year as
approximations that must undergo review in. the coming year.
Hence, the principal goal that the Committee seeks in making
its recommendations this year is the full restoration of
research training of fered through NCHSR, at a rate to be
determined by the administrative officers, but one that will
permit the opportunities for new awards to be made available
in each succeeding f ~ seal year.
143
OCR for page 144
To penny ~ the entrance of individuals whose current
espy oyment experience may be red event to health services
research, the Committee recommends that the bulk of research
awards in thi s area provided by NIH, ADAMHA, and the NCHSP
be made at ~ he po~doc~ora~ level .
Because the magnitude of train ~ ng needs is direct] y
dependent on the availabi~ ity of federal funds to conduct an
active program of health services research, the Committee
recommends yearly review of the number of individuals to be
trained, with subsequent expansion if research trends
indicate such a modificat~ on is warranted.
Recommendations. The Committee recommends that the NIB
ard ADAMHA expand the program of heals h services research
training reported in FY 1976 at a rate of ~ O percent per
annum through FY 1981 ~ n accordance w' th the levels
suggested in Tabl e 6. 3. At the same time, the Comma t' ee
recommends the rapid re storation of the former program of
research ~ raining provided by the NCHSR at a level
represent ing its peak year ~ 4 4 0 awards) . Of the ~ ota ~
number of awards, the Committee reco~runends that up to 55
percent should be made available at the postdoctoral level.
Iraineeships/Fel~ owships
Heal th servi ces research requires the applicat ion of a
variety of methods to the problems of health care and heal th
car" delivery. As a resume t the institutional training
grant, which permits the development of innovative
interdisciplinary research -raining programs, may be viewed
as the preferable e mechanism of support in this emerging
research area. Indeed, in FY ~ 976 the number of
traineeships provided by NIH and ADAMHA for health services
research training surpassed the number of fell owships at a
ratio of almost ~ ~ traineeships for every fellowship {see
Table 1.11.
The program of research training provided by the NCHSR
since FY ~ 96 ~ represents a similar emphasis on traineeships
(NRC, ~ 976a, Table II . ~ ~ ~ . Whi1 e the network of
institutional training sites has been weakened in recent
years by the absence of funds for continuing these programs
of ~raining, it has not been eliminated. In the view of the
Committee, however, there is an urgent need to restore
support for institutional training capability in order to
assure the continuity of support so important to the
maintenance of program stability in this area.
The committee suggests that traineeships be awarded
primarily at the predoctoral level, although it may be
appropriate in some instances for institutions to mix
IDs4
OCR for page 145
TABLE 6.3 Committee Recommendations for NIH and ADAMHA Predoctoral and Postdoctoral
Traineeships and Fellowship Awards in Health Services Research
Agency Awards Fiscal Year
and Committee
Recommendations 1975 1976 1977 1978 1979 1980 1981
Actual awards
Total 183 191
Pre 132 121
Post 51 70
1976 recommendations
Total 185 lamb 185b
Pre 135 135 135
Post 50 50 50
1977 recommendations
Total 550 715 740
Pre 225 415 430
Post 225 300 310
Total NIH/ADAMEA 250 275 300
Pre 160 175 190
Post - 90 100 110
Total HRA (NCHSR) 300 440 440
Pre 165 240 240
Post 135 200 200
Y 1976 awards were reported in 1977 subsequent to the release of the 1976 Report
of the Committee. FY 1976 awards reflect an increment in the nether of training
awards in health services research reported by the NIH.
bIn this year's report the Committee has amended the recommendations it made last
year so that the total neither of fellowships and traineeships recommended in
FY 1977 is 210 and for FY 1978 is 230.
145
OCR for page 146
predoc~oral and postdoctcral research traineeshiFs as
circumstances dictate. However, predoctoral research
that Ding through the institutional training grant works not
only to provide the trainee with important interdiscip~ inary
research expert ence as thesis work is developed, but al so to
advance health service s research through the preparation of
ski, led personnel who may move on to provide innovative
research and research training following the ccmpletion of
t hei r doctora ~ work.
The research tra ining fellowship also plays a role,
although more limited, in hea Ith service s research training .
The talented investigator who has interest in pursuing a
course of health service s re search training is provided the
opportunity ~ o seek such training with a particular leader
in this area or at an. ins ution where a critical mass of
inve stigators may be working on the problems that
characterize health services research. The Commi' ten views
thi s mechani so of support to be suitable primari ly f or
postdoctoral research training. In this way the fellowship
may encourage the individua ~ we Ah some experience in the
area of heal' h care policy to take up advanced training.
Recommendations. The Committee recommends that
_
trainee ships represent no les s than 75 percent of the total
number of awards for health services research training. Up
to 6 0 percent of the trainee strips should be made available
for predoctoral research training a'_ this time. In
contrast, up to 6 0 percent of the individual fellowships
shout ~ be made available for postdoctoral research training
as specif fed in Table ~ . 3 .
Midcareer Re search [raining
The Commit'_ee notes that heal ~ h services research Ferscnne]
evidence many of the same characteristics of those in other
newl y emerging areas of inquiry. Health services research
personnel today primarily represent individuals who have
been trained in a basic field or profession and who now
occupy positions in health service research by virtue of
their career paths, together with those whose interest in
health services research led them to seek formal research
~raining. Hence, a program of "mid-career" research
training in health services research might provide an
~ Important opportunity for number of individuals with similar
interests in formal training.
Midcareer research training could attract physicians
with experiences as providers in the health care system,
academi c doctorate s whose re search interest s have shi f ted to
questions of head th care, and nondoctorates who desire the
~ 46
OCR for page 147
acqui s it ion of r e sea rch ski ~ ~ s through f ormal
emphasizes advanced techniques and methods in
services research . The Committee recommends that the
establishmen ~ of a midcareer research training program on a
trial basis would provide opportunities for individuals
whose employment experiences qual if ies them f o r advanced
training in health services research.
training that
health
Becommendation. The Committee
_ ~
percent of the fellowship funds be
the training of midcareer ~
health services research at stipend
their level of career development.
recommends that up to 5 0
set aside to provide for
invest~qators in the methods of
level s commensurate with
Priority Fields
Heal th services research personnel are drawn floor a variety
of academic disco plines and professional backgrounds
on
the
f ields
problems of _ _
cony r i lout e s un ique ly to th e
hea lash car" de livery.
to work
Each of these
solution of the complex
quests ons that face the health pi anner today.
The committee has concluded that it would be
inappropriate to single out particular disciplines for
research training at this time. Instead, the Committee
bed ieves that the professional community wit ~ determine the
appropriate mix of disciplines and levels of training as
research training proposals are developed for training In
phi s area .
147
OCR for page 148
Representative terms from entire chapter:
care delivery
FOOl~CIES
l" This def Unction was developed for -the Survey of Health
services Research Personnel and is based in part on the
definition f ounce in the Pres idiot ~ s Science Advisory
Comnittee (PSAC, I97 2) .
2. In 1955 the Congress aE:Fropriatec] funds to ir`Flement the
demonstration authority of the Hospita ~ Survey and
Cons ~ ruc tion Act of ~ ~ 4 6 .
3. For a fuller treatment of the impediments to the conduct
of hea ~ th services research, see P SAC ( 1972) ~
4. See The Part nersnip for Health A~end~rents (PE 90-174)
for ~ snecif ication of this authority.
5. In ~ 974 the National Center for Health Services Besearch
and I3~lopment (~liSRD) was rer:~am£d the Nationa ~ Center f cr
Health services Research (NC USP) . Either acronym wil ~ he
used in the text to correspond with its use historically.
Further, the term '~Center" will be Oslo throughout to refer
to this federal unit.
6. These ~ and D activities store designed to f it together
~ the same community as an t'Fxperimental Health Services;
Delivery Sys tent' ~ ERSES) .
7. This list of problem areas has been developed by the
Panel on Health Services Research as part of its effort to
survey the current empl oyment situation for health services
research per sonne ~ ~ see Supplement 6) .
B. A limited number of research training awards were
provided through programs of research and training
consolidated into the t3CH,S}RD in ~ 968. For purposes of
analysis, the ir:~dividuals in training In EY 19 70 and beyond
were utilized in the survey of heal th services research
pers onne l.
9. The Social Sciences Divisior~ of the LIMB has provided
research training in evaluation methods through such
disciplines as sociology and social psychology. However.
not all research trainees
th is survey if tile y had on ly
to complete thei ~ qualif ying
inco~;pl ete support and failed
doctoral exam ideations.
11. Although the NCHSR was established in EY 1968, programs
of research Support were continued from the various bureaus
and divisions which were comfrey tc ~ corn tale ~CHSR.
12. The aut hc~r inde x Maintained by Dr ~ Gerald
the rosa shi not on 71n ivers ity Schoo ~ o f He di cine,
Missouri, served as the? bilk iographic source icr
sample. Only names with adequate addresses were
this source' a nd from that of the NCHSR.
Per kof f of
st Louis
this
d :rawn f row
13. of course, some of these individuals are
area of healths service s research since it: is their
experience and familiarity with the problems of health care
delivery that estabI ished this area of enquiry.
149
leaders in the
