Update on HSC
HSC Celebrates Its Five-Year Anniversary
hen the Center for Studying Health System Change was launched five years ago,
health care decision makers were recovering from intense and often bruising battles
that were a part of failed reform efforts writ large. These efforts to reform
the nation's health system took place during a tumultuous time for health care,
with some arguing that the large-scale policy proposals even served to catalyze
more rapid change. Leaders at The Robert Wood Johnson Foundation (RWJF) saw a
need to monitor such changes as they unfolded and, more important, to assess how
they were affecting consumers in different communities. And so, the Foundation
conceived the Center for Studying Health System Change (HSC) and selected Mathematica,
Inc., to create it (see HSC and MPR).
INSIGHTS FOR DECISION MAKERS
ince that time, the country has continued to experience
major organizational changes in the health system with varying effects on consumers.
The most dramatic of these-the wave of hospital consolidations, the backlash
against managed care and physician practice management companies going bankrupt-have
captured headlines. Other changes are more subtle, but important nevertheless,
such as the broadening of provider networks or the loosening of gatekeeper requirements.
HSC is at the core of a comprehensive effort, funded by RWJF and known as Health Tracking, that includes a network of research organizations that are all system-atically examining shifts in the nation's health care system and assessing what they mean for the country and for individuals at the community level. HSC's research-which is based largely on national, biennial surveys and visits to a dozen communities every other year-has focused on how organizational change is affecting cost, quality, access and coverage.
Studies by other collaborating groups that share the HSC research design include an effort to assess clinical quality of care, an examination of how market changes and public policies affect access to substance abuse and mental health services and a study of how physician organizations are managing care. In addition, a study of employment-based health insurance is ongoing (see HSC at the Core of a Research Network).
Given the common framework, HSC staff and researchers from this network of projects will be able to provide insights into what is happening over time to health care delivery and financing in the communities that each of them is studying simultaneously, laying out a rich national picture of our evolving health system and assessing whether quality and access to care is improving or declining, among other issues.
The data from these studies- which are made available to the public-and the analyses that come from them provide context for decision makers contemplating key policy issues, including how to expand insurance coverage, whether managed care patient protections are necessary and how to incorporate the best attributes of private coverage into public programs, among others.
TREND ANALYSES RELEASED
n the last year, HSC released numerous studies using the
first round of data and began releasing trend analyses examining changes between
1997 and 1999 based on findings from the Community Tracking
Study (CTS), HSC's core research effort. This effort involves surveys of
households, physicians and employers across the country, with much of the sample
concentrated in 60 nationally representative communities. HSC researchers also
go on site to interview health care leaders in 12 of these 60 communities, which
are representative of the nation.
Among the analyses published in the last year is a study focusing on who declines to enroll in employer-sponsored coverage, which found that 20 percent of the uninsured had access to such coverage. This information was used by a variety of groups developing proposals to incrementally expand insurance to low-income families. The study was picked up by newspapers and trade publications across the country and cited in a Jane Bryant Quinn Washington Post column that discussed the various coverage proposals being promoted by presidential candidates.
Research published in the New England Journal of Medicine-showing that one in four primary care physicians is concerned about the care he or she is expected to provide to sicker patients without referral to specialists-was of keen interest to medical societies, health plans and the national news media.
Finally, the release of a series of analyses comparing health maintenance organizations (HMOs) to other types of plans on key dimensions drew more than 200 policy makers to a meeting where a panel of experts debated the implications of the research. The panel included Linda Bilheimer, RWJF; Janet Corrigan, Institute of Medicine; Robert Reischauer, Urban Institute; and John Rother, AARP.
Notable trend studies released in the last year include one focusing on changes in children's insurance coverage and another examining the amount of plan choice that families have. HSC's study of children's coverage gave policy makers their first sense of what is happening with low-income children's coverage since the implementation of SCHIP. The study found no net change in low-income children's coverage between 1997 and 1999, but significant shifts in where children obtain such coverage, as well as a decline in coverage for low-income parents. The analysis of plan choice showed a modest increase in choice for families between 1997 and 1999. Details of this study were featured in opposing editorials in USA Today and contributed to patient protection deliberations in Congress.
HSC staff is finalizing the instruments for the third round of surveys, which will be fielded starting this summer. While much will remain the same to allow for tracking, new questions will shed light on current and emerging issues, such as unmet needs for prescription drugs and specialty care, physicians' perceptions of the impact of consumer information on their practices and the use and perceived impact on physician encounters of drug-related direct-to-consumer advertising.
THIRD ROUND OF SITE VISITS BEGINS
he interviews that site researchers conduct in 12 communities
reveal the strategies local organizations are pursuing and their motivations,
how local norms and culture shape decision making and the effects of national
policy on communities, all of which are difficult to discern from survey data.
For example, in the last year, the site visits highlighted five communities-including Lansing, Mich.- that were pursuing managed care programs for the uninsured and examined why they were launched. HSC research published in JAMA, showing that the uninsured in Lansing had considerable difficulty getting access to care, compared with the 11 other HSC communities, in part motivated leaders in Lansing to launch their managed care program for the uninsured.
HSC has been tracking market events that occurred since the last round of site visits and began the third round of site visits this June. HSC's affiliation with Mathematica Policy Research, Inc. (MPR), allows it to draw upon MPR's well-regarded staff to fill out site research teams and to provide additional expertise in qualitative research methods (HSC and MPR).
In addition, Jon B. Christianson, University of Minnesota, and Lawrence D. Brown, Columbia University, will continue their work on the site visit project and will be joined by Lawrence Casalino, University of Chicago, Aaron Katz, University of Washington, and Robert Hurley, Medical College of Virginia.
Among the topics site visit researchers will focus on for this round are the changing nature of health plans, employer responses to premium increases and the ability of the safety net to care for low-income people who lack coverage. As in the last round, shortly after the site visits HSC will issue Community Reports that describe what has changed in each community over the past two years.
HSC STAFF AND COMMITTEES
hile the core staff has not changed, new people have joined
HSC in the last year. In addition to MPR staff who are now playing substantive
roles in terms of both the survey and site visit work, HSC has added Jeffrey
J. Stoddard, a physician researcher; Kelly J. Devers, who specializes
in qualitative and mixed methods research; J. Lee Hargraves, an expert
on patient satisfaction surveys; and a number of research analysts and research
assistants. Jack Hadley, professor of health services research at Georgetown
University's Institute for Health Care Research and Policy, is at HSC as a visiting
scholar for calendar year 2000.
Joy M. Grossman, a researcher who started at HSC shortly after the organization opened its doors, was promoted to associate director and joined the management team, which includes Paul B. Ginsburg, Peter Kemper and Ann C. Greiner. Grossman's new responsibilities include overseeing HSC data collection activities, managing the organization's research agenda-setting process and contributing to the organization's overall leadership.
HSC also added to its public affairs capacity by hiring a public affairs firm and an outside consultant. These additions enable HSC to better bridge the worlds of policy making and research by regularly providing information about key, ongoing policy topics to HSC staff and acting as a conduit for research ideas from public and private decision makers.
Although HSC's work is used by policy makers across the spectrum, the organization does not take policy positions. It is committed to chronicling key trends in the health care system and their effects on consumers, and then drawing out the range of policy implications.
The organization's advisory committees-comprising both users of research and researchers themselves (see HSC Advisory Committees)-assist in making the connection between research and policy by contributing to HSC's research agenda and commenting on HSC publications. Briefings with key groups in advance of the release of analyses have also proved to be a useful way to identify new research topics of policy interest.
