Compilation of Snapshots
Paul B. Ginsburg, Nancy J. Fasciano
he Community Snapshots Study was conducted January - December 1995 captured the process of change in local health systems and the impact of that change on community residents. The site visits to 15 selected communities included interviews with leaders of organizations in each sector of the health care market and analysis of secondary data. Changes over the past two years, current organizational relationships, and strategic planning for future changes were considered. In addition, consumers in each of the communities were surveyed about changes they are experiencing and their expectations for the future.
The major challenges of the study were its breadth and the tight time frame in which it was conducted. Rarely do site visits address as many components of the health system as these did. In each site, the researchers interviewed representatives of major employers or business coalitions, health plans, hospitals, academic medical centers, community health centers, physician organizations, local health departments, and consumer groups. Major topics covered included developments in managed care, organizational change, state and local policy, and activities of purchasers. Cognizant of the pace of change, the researchers quickly prepared site reports and then promptly proceeded to develop cross-cutting reports on a series of topics.
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Funded by The Robert Wood Johnson Foundation and directed by the Center for Studying Health System Change (HSC), the Community Snapshots study had two distinct components: a series of site visits that involved analysts from three research organizations (the Alpha Center; the Institute for Health Policy Studies at the University of California at San Francisco; and the Health Policy Analysis Program at the University of Washington) and a survey of consumers, conducted by Louis Harris, Inc. Between January and December 1995, the three research teams helped HSC select the 15 snapshot communities, developed interview protocols, conducted site visits, and produced a series of reports detailing their findings.
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A key goal of the Community Snapshots study was to gain an understanding of how the process of health system change differs among communities of varying sizes and at varying stages of health care market development. Accordingly, the sites represent a range in terms of both population size and stage of market development. Geographic diversity was also an important consideration. The 15 communities are distributed across 14 states and seven of the nine Census divisions. The market areas generally span multiple counties; three (St. Louis, Portland, Ore./Vancouver, Wash., and Fargo, N.D./West Central Minnesota) cross state lines. Thirteen of the snapshot communities are in urban areas; in most cases, the market area is defined by the boundaries of the metropolitan statistical area (MSA). Small cities, with populations of less than one-half million, and major metropolitan areas, with populations of several million, are represented. In Des Moines, one of the 13 urban-area sites, the rural areas surrounding the city were also included in the market analysis. Two snapshots focus exclusively on markets in rural areas: west central Minnesota and north central Florida. To facilitate comparisons of urban and rural health systems within a common state policy environment and economize on the collection of data on public policy, we selected rural sites in states where we had also selected an urban market.
The snapshot sites represent varying stages of market development. To categorize communities by market stage, we drew on a theory of health care market development that defines market maturation in terms of increased purchaser power, capitation of managed care organizations and provider organizations, integration and consolidation of delivery systems, and increased use of information technology. Because the data collection and analysis required to develop a formal typology based on this conceptual framework were beyond the scope of this study, we relied on the limited data available in published reports to rank communities in terms of HMO market penetration, financial consolidation of providers and insurers, and concentration of purchaser power. We interpreted the absence of reports in the trade press as an indication that a community was in the early stages of market development. The communities selected represent a range of circumstances along this continuum of market development. In the interest of gaining a better understanding of health system change in highly active markets, we deliberately over sampled communities with markets that appeared to be more advanced.
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Site visits were conducted between May and July 1995. Typically, a four- or five-person research team visited a community and conducted interviews over a one-week period. In some cases, teams made follow-up visits or telephone calls to gather more information. In each community, the researchers met with representatives of five key stakeholder groups: public policymakers, purchasers, insurers/health plans, providers, and consumers. Depending on the complexity of the market, the number of individual and group interviews ranged from 20 to 30.
Local consultants played a key role in helping the teams prepare for and organize the site visits. Selected for their understanding of their health care market, consultants helped gather the market-level and organization-specific information the researchers needed to prepare for interviews, identified interviewees, provided perspective on information gathered during the site visits, and reviewed reports.
Given the relatively small number of interviews that could be conducted within the tight time frame of the study, the research teams attempted to choose interviewees in each market sector who were able to represent the views of their organization, provide a broad perspective on the market, and assess the impact of changes on other actors in the health care system. The research teams also conducted focus groups with representatives of consumer advocacy groups, including labor unions, legal service agencies, senior citizen groups, childrens advocacy organizations, and disability rights groups.
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The interview protocols were designed to gain a broad understanding of the dynamics of the local health care market, not to gather detailed information about individual organizations. In the interest of allowing interviewees to define the key issues in their community, the researchers posed open-ended questions.
Interview guides were tailored to specific groups of interviewees. Because the research teams were able to interview only selected representatives of organizations in each market sector, interviewees were asked not only about their own organizations involvement in the changes unfolding in the health care market, but about the involvement of their competitors and others in their sector. Another set of questions focused on the big picture: the changing dynamics of the local health care market, the forces driving those changes, and their impact on various sectors of the market By asking many actors in the health care market the same questions and comparing accounts, the research teams were generally able to develop a consistent picture of the process and the impact of change in various sectors of the health system.
Interviewees were frequently asked about the competitive actions of their organizations. Given the sensitive nature of the information sought, the researchers were careful to guarantee as much anonymity as possible to individuals and organizations.
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Findings from the site visits are presented in 15 site reports and 10 cross-cutting papers. Results were also discussed at dissemination conference in December 1995. Each of the site reports examines the health care market from a range of perspectives. Depending on the size and complexity of the market and the pace of change over the past two or three years, the site reports range in length from 6,000 to 11,000 words. Five of the ten cross-cutting reports focus on stakeholder groups whose representatives were interviewed during the site visits and explore how individuals and organizations in these five groups, public policymakers, purchasers, insurers/health plans, physicians and hospitals, are leading or responding to health system change in the 15 snapshot communities. One crosscutting paper presents results from the Louis Harris survey of consumers. The remaining four papers explore key themes: the varying nature of competition in health care markets, the different ways in which health care financing and delivery are becoming more integrated, the impact of health system change on the safety net, and the role of change agents and catalysts in health system change. The cross cutting papers will be published in Health Affairs in spring 1996.
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