[HF3212, Health services research: a historical perspective, 2000, Length: 00:48:16, Color, Sound. This Beta SP was duplicated from a VHS tape by Bono Film & Video, Inc., for the National Library of Medicine, February 2011.]
[Narrator]: Every so often, circumstances converge to help launch a new field. One such field is Health Services Research, which emerged in the early 1960s, at a time of great ferment and imminent change in the American health care system.
[Music]
[Health Services Research: A Historical Perspective]
[Presented by: National Information Center on Health Services Research & Health Care Technology, National Library of Medicine]
[Doris McMillon]: I'm Doris McMillon. Health Services Research received its name in a 1960 reorganization of several study sections within the National Institutes of Health, or NIH, of the United States Public Health Service. [Doris McMillon, Narrator]
By 1963, it seemed to have a clear leader, Kerr White, who had served on the health services research study section and then became its chair.
Dr. White had a vision of what the new field should be. He saw it as an amalgam of the perspectives of public health and clinical medicine and of the methods of economics, social survey research, epidemiology, biostatistics, and systems analysis.
It was a distinct field of scientific enquiry that examined the impact of the organization, financing, and management of health care services on access, delivery, cost, outcomes, and quality of service.
Health Services Research was not created by a single individual or in a vacuum. Its roots can be traced back to Sir William Petty and John Graunt in seventeenth-century England. Their work included a comparison of the mortality rates in the hospitals of London and Paris that showed that the London hospitals were considerably better, in terms of mortality rates, than those in Paris.
Petty and Graunt weren't the only ones to systematically investigate medical practice. In the nineteenth century, another Englishman, William Farr, challenged his medical colleagues to evaluate "the medical contributions of the country on a liberal scientific basis".
He impressed Florence Nightingale, who proposed to work with Farr on a uniform reporting system for London hospitals. Based on her experiences in the Crimean War, Florence Nightingale wrote a number of essays on hospital statistics.
She introduced the first hospital discharge-abstract system--a brief minimum data set--to find out what was going on in hospitals. Health Services Research continued to develop in the early twentieth century, both in Europe and in the United States.
In 1914, Ernest Codman called for a method of hospital reporting to assess the outcome of treatment at the Massachusetts General and other Hospitals. In 1925, Edgar Sydenstricker studied the incidence of illness in the general population of Hagerstown, Maryland.
In the late 20s and early 30s, the Committee on the Costs of Medical Care, or the CCMC, recognized the uneven distribution of sickness and health expenditures in a national cross-section of families and other studies aimed at trying to gain an overall understanding of the American health system, along with its gaps and deficiencies.
One outstanding contributor to the CCMC's work was Isadora Falk, who later became a leader in Franklin Roosevelt's Social Security Administration.
[Dorothy P. Rice]: Isadora Falk is lovingly known in our world as the father, I think, of Health Services Research, and came to the Social Security Administration after he completed his work with the Committee on the Costs of Medical Care, and he became the Director of Research and Statistics. [Dorothy P. Rice, ScD (Hon), Professor Emeritus, UCSF]
And, subsequently, many years later, I became the Deputy Assistant Commissioner for Research and Statistics. So he had a very, very important role in the development of objective data that was really subsequently used for policy purposes.
[Doris McMillon]: In 1938, English researcher James A. Glover documented a wide variation in tonsillectomy rates in children living in otherwise similar locations. Kerr White encountered this and other sophisticated British studies during a 1959 to 1960 sabbatical year spent in England when he was on leave from the University of North Carolina.
Using Hill-Burton program research and construction funds that had recently been allocated, White energetically pursued investigations into the quality of medical care, with his colleagues at Chapel Hill, when he returned from his sabbatical.
[Kerr White]: We called our group in Chapel Hill "Medical Care Research Group". In terms of the concepts, perhaps the most important figure was Jerry Morris, Professor J. N. Morris, of the Social Medicine Research Unit in the London Hospital in London, [Kerr White, MD, Director Emeritus, Kerr L. White Institute]
who published a volume, "Uses of Epidemiology", which is a small, succinct volume, and also an article in the British Medical Journal about 1958, I would think it would be, probably, in which he showed the application of these methods to looking at health services in various ways--or medical care--in various ways.
[Doris McMillon]: By 1963, NIH officials were clear that they saw potential in the field. By then, White was at Johns Hopkins, where he joined forces with Charles Flagle.
They were both members of the Health Services Research Study Section, which provided the spark for the next important developments. The study section actively tried to shape the new field.
One major initiative was the commissioning of a set of papers by carefully selected authors as a means of defining the scope, methods, and standards of the field. These papers were published in 1966 by special arrangement with the Milbank Memorial Fund Quarterly.
Another initiative was support for the launching of a new journal, "Health Services Research", which began in 1966. Charles Flagle was a member of the original editorial board of the new journal.
[Charles D. Flagle]: I think the concept that promoted this interdisciplinary activity was the concept of General Systems Theory. Dr. Daniel Howland at Ohio State University introduced what he called the Doctor-Nurse-Patient Triad. [Charles D. Flagle, D. Eng, Professor Emeritus, School of Hygiene and Public Health, Johns Hopkins University]
And that model was one of a cybernetic system in which the patient was being observed. The patient was providing information for doctors and nurses who were making decisions about care. And there was this continuous activity centered around the patient in which the patient was a part.
The patient was a signal-giver, not just in terms of what the patient said or consciously communicated, but in terms of vital signs--other signs and symptoms. [Universal Newsreel -- Milions of Americans Receive "Ticket to Medicare" -- Voice: Ed Herlihy]
[Ed Herlihy]: The new bill expands the thirty-year old social security program to provide hospital care, nursing home care, home nursing service, and outpatient treatment for those over 65.
[Doris McMillon]: The enactment of Medicare and Medicaid by Congress in 1965, and concurrent development of the Regional Medical Programs, were other formative influences on the emerging field.
[Charles D. Flagle]: About that time, in the middle sixties, another law was passed--the Comprehensive Health Planning Act--which established community planning within state health departments, and at the federal level, also. So here was another activity that enriched what began under the banner of Health Services Research.
[Doris McMillon]: One of the most important initiatives of the Health Services Research Study Section in the sixties was providing funding for efforts already underway in research centers associated with some of the pioneering health maintenance organizations.
One of these early research centers was directed by Mitch Greenlick as part of the Kaiser Permanente organization in Portland, Oregon. This ongoing center was further supported by the study section.
[Mitch Greenlick]: When I came to Kaiser Permanente in 1964, I was brought there by Ernie Saward, who was the Medical Director, to create a research center that would use Kaiser Permanente as a laboratory for doing health services research in the public domain. [Merwyn (Mitch) R. Greenlick, PhD, Dept. of Public Health and Preventative Medicine, Oregon Health Sciences University]
He believed, as did Morrie Collen in the Northern California region of Kaiser, who had started a research center two years before that, that Kaiser Permanente was a social experiment. And as a social experiment, it needed to make itself available for Health Services Research.
So, he brought in researchers, he provided funding for us to do Health Services Research, he provided access to the population, and he made the system available to us for demonstrations.
[Doris McMillon]: Morris Collen's work at Northern California Kaiser Permanente was also innovative in its bringing science and technology together in the delivery of care. He applied computers to medicine in a new system of "multiphasic screening."
[Morris Collen]: Our multiphasic health testing program was established because we had to provide health check-ups, and in competition with other plans that did not, we had to develop new methods. [Morris F. Collen, MD, Consultant and Director Emeritus, Division of Research, Kaiser Permanente]
So, as a result, the department was then called Medical Methods Research, we are now actually called Divisional Research, and a sub-division is Health Services Research.
But the Department of Medical Methods Research exploited technology, automated equipment, and computers so that every member joining would go through a whole battery of tests within a couple hours, in which an automated history was taken, blood was drawn, chemistry tests were performed, chest X-ray, electrocardiograms, and it was all customized to age and gender of each individual member.
[Doris McMillon]: At an informal meeting at Chicago's Palmer House Hotel in 1966, another landmark in the evolving field was reached. An idea germinated about creating a national center for Health Services Research and Development. Kerr White...
[Kerr White]: There was Evelyn Flook, who I mentioned earlier, I think, and Tom McCarthy, and one Gil Barnhart, who was in charge of... I forget what his exact title was, but he and Evelyn Flook sort of controlled the basic money and then dispensed it on the recommendations that we made from the study section.
And I said, "Well what we need to have is the equivalent of NIH for Health Services Research and we need to have a center set up." So I drew a picture of it on the back of a napkin of what was needed and how it might be developed as a National Center for Health Services Research.
Then we rushed back that weekend to Washington, where the AAMC, the Association of American Medical Colleges was having their annual get-together.
And we printed up a brochure, which described this entity and what would happen, and all of the good things it would do and so forth. And we printed up...I forget how many copies, but we passed these out at this meeting and I gave a little speech about it and so on, to which no one paid much attention whatsoever.
Then I proceeded to lobby Phil Lee and George Silver--Phil Lee was then the Assistant Secretary of Health; that was his earlier incarnation--that we needed this thing. And then I lobbied Ted Kennedy's staff--I got to know some of them.
And eventually, Phil Lee set up a sort of investigation, got Paul Elwood to write a report on whether this was a good idea, what could be done about it, and so on. And eventually it came about in 1968.
[Doris McMillon]: An executive order created the National Center for Health Services Research and Development. Its mission was considerably broader than that of the NIH HSR Study Section. Its agenda included the support of demonstration and development projects, in addition to research and evaluation.
And it ambitiously defined seven major program areas: health care organization and delivery, health care institutions, social analysis and evaluation, health economic analysis, health manpower utilization, health care technology, and health care data.
The center also created several Health Services Research Centers through grant and contract arrangements with outside university-based, and other organizations in various parts of the country.
Three of the early centers were the center at the University of California, San Francisco, run by Phil Lee; the center at the University of Missouri, run by Donald Lindberg; and the center at the University of North Carolina, Chapel Hill, run by Cecil Sheps.
But the sailing was not always smooth for the new National Center for Health Services Research and Development. Some thought that the center was burdened with exaggerated and unrealistic expectations.
Others thought that the center blundered by trying to grow too quickly. Edward Hinman, an official with the U. S. Public Health Service at that time, believed that the center suffered from not having a solid political base and a home within the Public Health Service that everyone was comfortable with.
[Edward Hinman]: The initial Director for the center was Dr. Paul Sanazaro, who had been part of HEW for a period of time, and was running the Regional Medical Programs and moved over to run the National Center. [Edward J. Hinman, MD, Assistant Surgeon General, USPHS, Ret.]
He had an academic background, was a distinguished researcher, and stayed with the center for several years. When he left, he was succeeded by Dr. Robert Van Hoek, who was a career administrator in the Public Health Service, not a full-time academic background.
He was Acting Director for several years while some of the controversy over the direction of the center, its administrative location, continued. He was replaced by Dr. Gerald Rosenthal, who was an economist with an academic background, which changed some of the direction of the center's activities.
Part of the tension that existed in the center was related to mission considerations as well as to external political considerations. The mission issues related to whether the function of the center was to fund applied research or to fund policy analyses.
Part of the issue there would be, how much each of the funds should go to the economists' and psychologists' side of the equation, and how much should go to people doing work in quality of care measurement...things of that nature.
Adding to the center's woes was close scrutiny from the Nixon administration, which was skeptical about an agency created at the end of the Johnson presidency and seemingly connected with many of the Great Society health care initiatives.
The Regional Medical Programs suffered the same fate, for quite similar reasons, in these years. In 1972, the President's Science Advisory Committee issued a critical report on the center, and in 1973 this was followed by an Institute of Medicine study and a congressional hearing.
Disputes also erupted between proponents of different styles of Health Services Research and between those who remained optimistic and those who grew pessimistic about the policy relevance of their work. Norman Weissman was Extramural Program Director of the National Center for Health Services Research from 1973 to 1989.
[Norman Weissman]: In 1973, legislation created the National Center for Health Services Research and they dropped the "development" from the name and that was presumably because Congress thought "development" implied the need for more resources and more money. [Norman W. Weissman, PhD, Department of Medicine, University of Alabama at Birmingham]
And they didn't want us developing anything. It was okay to research it, kind of...was the implication.
[Doris McMillon]: The center's annual budget fell steadily, while training grants were suspended entirely in 1976.
Compensating, to some extent, for the decline of the National Center was the growth of Health Services Research in the Executive and Legislative Branches of government, and in old and new federal agencies such as the Social Security Administration, the National Center for Health Statistics, and the Health Care Financing Administration, which was created to oversee the Medicare and Medicaid programs.
But these agencies bickered with one another over the control of the rapidly expanding store of federal health data. Health Services Research continued to develop in non-government research centers and universities, and sometimes had a big impact in shaping national policy.
The late Sam Shapiro ran the Center for Health Services Research at the Johns Hopkins University School of Public Health from 1973 to 1982. His comments...
[Sam Shapiro]: We did a number of studies, we broadened our range of interest and began to do studies wherever we saw the opportunity to do a study. One of the major studies we were attempting to determine the effectiveness of coordination of health services for primary care. It was a national study, it involved us with many areas of the country.
[Doris McMillon]: Karen Davis, who would join the Hopkins faculty in the 1980s, had worked in President Jimmy Carter’s administration.
[Karen Davis]: I was at the U. S. Department of Health, Education, and Welfare as the Deputy Assistant Secretary for Health Policy, responsible for the design of President Carter's National Health Insurance Proposal. [Karen Davis, PhD, President, The Commonwealth Fund]
At the time that legislation was being considered, a group of researchers at the University of Chicago, very fine Health Services Researchers, Lu Ann Aday, Ron Andersen, and Gretchen Fleming, did a book on access to care where they found that, unlike the situation in the 1960'sand early 1970's, that the poor went to physicians more often than the non-poor.
The Office of Management and Budget thought this was great news and decided that there was no need for a Carter National Health Insurance Plan or even funding for community health centers and other programs that helped the poor obtain care, based on the Aday, Anderson, Fleming research.
We commissioned, within the department, other analyses of data on this issue and we found it's important to disaggregate and it's important to adjust for health status. Low-income people tend to be sicker than high-income people.
Once you adjust for health status, low-income people in fact see physicians less often than high-income people. Also, if you split the low-income population into those who are on Medicaid and those who are uninsured, we found that those who are uninsured had a third less utilization of health care services than did those low-income people with Medicaid.
So, with this evidence, we were able to convince the President that he should stay committed to his National Health Insurance Proposal, and certainly that funding should continue for programs targeted on low-income populations.
[Doris McMillon]: A major contribution to the ferment in Health Services Research in the 70s and early 80s, was the rise to special prominence of health economists. A national sense of crisis over runaway health care costs and great anxiety about the economy in general set the context for this important development.
[Karen Davis]: And then the interest really shifted to issues such as insurance coverage and what was called "cost-push versus demand-pull" sources of increases in health care costs. Was it Medicare that caused health care costs to skyrocket? Was it labor costs or increasing wages?
Nurses had always been underpaid in hospitals, and as they began to catch up, was it what was called a "cost-push” behind the growth in cost or was it a “demand-pull" from improved insurance coverage?
And the research that I did at that point really tried to sort out how much of it is technology, how much of it is wage catch-up or better wages for hospital workers, and how much of it is improved health insurance coverage.
Then the literature really began to switch to, can we find solutions to rising health care costs? And in particular, can we design better ways of paying hospitals than cost-reimbursement?
[Doris McMillon]: Economists promised to provide rigorous, cost-effectiveness analysis in non-normative ways, leaving decisions about policy options to managers and policy-makers. In addition, one of the great social experiments of that period gave health economists a prominent platform on which to demonstrate the power of their approach.
This was the Rand Health Insurance Experiment, or HIE, the centerpiece of which was a field trial of alternative health insurance plans. It was directed by economist Joseph Newhouse.
[Joseph Newhouse]: Essentially, the Rand Health Insurance Experiment was a controlled trial of cost-sharing, or how much people had to pay for medical care when they went to the doctor. [Joseph P. Newhouse, PhD, Dept. of Health Policy and Management, Harvard University]
The experiment replaced the insurance the people had with a very broad coverage that varied the amount they had to pay from nothing, meaning they got everything for free, to a large deductible, about $2,500 in today's dollars. It took place in six different sites around the country.
It ran from about 1974 to 1982 and the families participated for either three years or five years--they were randomized to those periods of time. And it collected a large amount of data on both their health care use and their health care outcomes.
We collected diagnoses from claims data; we interviewed people on their functioning; we gave them a physical examination to determine such things as cholesterol and blood pressure.
[Doris McMillon]: Kathleen Lohr was a key staffer on the project at Rand.
[Kathleen Lohr]: Our basic findings were that the imposition of cost-sharing reduces the use of health care services across the board. [Kathleen N. Lohr, PhD, Dir., Program in Health Services and Policy, Research Triangle Institute]
We went through a fairly elaborate exercise of trying to specify the sets of appropriate and effective services for managing patients with this or that diagnosis or problem, as well as the ineffective and unnecessary services. And we concluded that cost-sharing is, in fact, a very blunt instrument for trying to reduce the use of health care in this country.
We found that it reduces the use of services that are both needed as well as unneeded and that it has a particularly strong effect on certain population groups...The most important possibly being low-income children, where we found a catastrophic drop in the use of clearly needed, as well as unneeded, services.
[Doris McMillon]: These findings had an enormous impact. They challenged the Rand investigators to find indicators of "appropriate" and "inappropriate" procedures as well as "outcome" measures of the actual efficacy or inefficacy of these interventions. Joseph Newhouse...
[Joseph Newhouse]: Many of the measures of health status and quality of life that we use today are derived from the Rand Health Insurance Experiment. Bob Brook, John Ware, Kathy Lohr, and others developed what were, then, the finest set of measures of those concepts that were available.
And they showed that people that used additional services because care was free didn't have their health improved, unless they were both sick and poor. People who were hypertensive and poor had their blood pressure better controlled on the free plan, and people with correctable vision problems had those better corrected on the free plan.
[Doris McMillon]: Despite these important methodological and empirical advances, the Rand Experiment did not produce quite the results originally intended.
[Joseph Newhouse]: When we started, we were in the Nixon administration, which was proposing a national health insurance plan. And the idea was that our results would inform whatever plan was adopted, at least downstream.
When we finished, we were in the early years of the Reagan Administration and there was no interest in the Executive Branch in national health insurance. The private sector, however, did pick up on our results and the use of cost-sharing, especially deductibles in private health insurance plans, increased markedly in the 1980s.
[Doris McMillon]: In fact, Health Services Research provided the foundation for one of the major health policy initiatives of the Reagan Administration. The Diagnosis-Related Group, or DRG, funding mechanism for the prospective payment of hospital care for Medicare beneficiaries, which grew out of detailed studies on "case mix". Judith Lave...
[Judith Lave]: I would argue that much of the case mix work was motivated by interests in costs. Because of the impact of having to understand case mix in order to understand costs. And certainly all of the work on case mix has had a major impact on policy, in particular, how we pay institutional providers. [Judith R. Lave, Ph.D., Professor, Health Economics, University of Pittsburgh]
[Doris McMillon]: Nevertheless, and despite clear signs of progress in certain quarters, many of the Health Services Research community feared that the field was being kept alive primarily by the interest of a few federal agencies and private foundations, while the Reagan Administration and Congress remained generally hostile or indifferent. A few foundations were particularly important.
[Judith Lave]: Some of the foundations have been extraordinarily supportive. The Commonwealth Fund, the Robert Wood Johnson foundation, Kellogg, and Kaiser.
[Doris McMillon]: Established professional organizations had begun to acknowledge Health Services Research as a legitimate discipline, but sometimes only in limited ways.
[Kathleen Lohr]: The American Public Health Association, or APHA, had a section called Medical Care, which was probably the closest thing to a society for health services researchers at the time.
There was also a Rump group called the Committee on Health Services Research that organized discussion groups on important health care services, topics, and methodologies. And those sessions took place on the days before the beginning of the APHA annual meetings each year.
[Doris McMillon]: Several leaders of the field felt that it was crucial to establish a new, independent organization. In April 1981, a group of academically-based Health Services researchers organized the Association for Health Services Research. Gordon DeFriese was one of that group.
[Gordon DeFriese]: There were ten of us, ten or twelve of us, who got together at that APHA meeting and decided that an association could be formed, and that now was the time to do it, then was the time to do it. And Clif Gaus was asked to be the first president, and then the second president was Stuart Altman. And then I was asked to be the third president, and then it went on from there.
[Doris McMillon]: Inspired by the energetic efforts of the late Alice Hersh--the association’s first full-time staff member and then executive director--the AHSR actively and successfully promoted and advanced the field. Striving to be inclusive in order best to survive and flourish, the association has promoted all types and styles of health services research.
AHSR's influence was evident in the 1989 campaign to establish the Agency for Health Care Policy and Research as a replacement for the National Center for Health Services Research.
[Joseph Newhouse]: The National Center for Health Services Research had developed a reputation for being a backwater agency, and it was very far below the Secretary of Health and Human Services in terms of its input.
So the intent of the 1989 Act was to bring the agency up in the hierarchy of the department, put it on a footing with its sister agencies of NIH and FDA and CDC, although, of course, its budget was much smaller than those agencies'.
[Doris McMillon]: Key to the Association for Health Services Research's political success was its strategic alliance with John Wennberg of Dartmouth and Robert Brooke of Rand, both of whom had gained considerable respect and political recognition in the 80's for their research on variations in medical practice, and the frequent inappropriateness of medical procedures.
[John Wennberg]: This all started when I came up to Vermont to head up the Regional Medical Program. Fresh out of MPH, no experience, that was the Vietnam War time and it was easy to get a job. [John E. Wennberg, MD, MPH, Dartmouth Medical School]
But it was a very interesting opportunity because I'd been trained in epidemiology as well as in clinical medicine and I knew that if we were going to try to plan for a region, we needed to have information.
And in the process of doing this, we developed this strategy called "Small Area Analysis", which was essentially set out to define how much resources were inputted--or how much resources were allocated--to a population living in each of the communities of Vermont.
How many doctors did they have? How many hospital beds did they have? How much money did they spend on health care? And the second level of question was, given the level of resource inputs, what did they do with it?
You know, what kind of services did they provide? And that's where we began to see this extraordinary variation in the utilization of care. One community, for example, was doing tonsillectomies at a rate such that 73 percent of kids were having their tonsils out by the time they were fifteen.
Another community just ten miles down the road was doing it at about a level of 15 percent. And it was pretty clear from the casual observations that I would make of my own kids, who were living close to these areas, that it was very unlikely to be that the patients were different -- the kids were different.
It had to be something to do with the supply side. So that's when we first began to get into this whole question of, is the classic model of how the health care system works really correct?
[Doris McMillon]: Wennberg realized that, if such research could be further developed, a great deal of unnecessary health care expenditure could be avoided and the Medicare program, for example, might be saved from imminent bankruptcy.
Congressional leaders like William Proxmire and Henry Waxman also saw the "variations" and "outcomes” approach as a way to produce considerable savings in the health care system.
The Health Services Research field embraced the new directions in research and, by doing so, gained political support and resources that had long been denied.
Many of these resources were invested in ambitious research initiatives such as "Patient Outcomes Research Team", or PORT studies, conducted around the country as large, multi-disciplinary projects. Paul Cleary…
[Paul Cleary]: PORT studies were motivated by some of the findings from Jack Wennberg. Jack had found that, for a lot of medical procedures, there are tremendous variations in the rate at which they're done in different parts of the country, and for no obvious reason. [Paul D. Cleary, PhD, Professor of Health Care Policy, Harvard Medical School]
In other words, it wasn't because patients were sicker in one part than another. So the agency funded the PORTs, which were very large multidisciplinary efforts to try and understand why practice patterns were higher in certain parts of the country than others, and what kinds of procedures or patterns of practice were associated with the best outcomes.
I think there were maybe sixteen PORTS around the country. We had, for example, a PORT on heart attack treatment, so we examined the rates at which heart attack patients are treated with surgery in different parts of the country, in different types of procedures--and more importantly, what kinds of procedures are associated with the best outcomes.
[Doris McMillon]: "Guidelines" research was anther closely related AHCPR initiative. The Institute of Medicine played an important role, and efforts were made to enlist leading professional organizations in support of these projects.
Nevertheless, conflicts sometimes erupted and caused temporary, though intense, political difficulties for the agency. Norman Weissman…
[Norman Weissman]: And so, the idea of guidelines is for practitioners who know that stuff best, to try and communicate it to other people who might be able to use it. And that's what the notion of guidelines is about. And I don't know how anybody could be against that.
The resistance that comes against that, typically, that I've heard, has been, well you know, the people in Washington can’t tell me how to practice medicine here in Alabama, or something like that.
So it's not really the government trying to tell a local practitioner, but for some reason, there's that perception.
[Doris McMillon]: While these battles were under way, another more muted and subtle one was also taking place over the direction and emphasis of the Health Services Research field as a whole.
Some Health Services researchers felt that, by focusing on clinical practice and "outcomes" studies--even as joint efforts of clinicians, economists, and other social scientists -- the field had allowed its scope to become too narrow and restricted.
Thus, the 90s also saw the reappearance and advocacy of wider agendas for health services research. When Clif Gaus became administrator of AHCPR, he endorsed outcomes and guidelines research, but also devoted his attention to other questions still, in his view, on the agency's agenda.
Will managed care work for the disabled and chronically ill? Will states find ways to cover previously uninsured populations? And will changes in the marketplace affect providers’ willingness to offer uncompensated care?
These same readjustments of agenda were also apparent in a book on the field commissioned by the Association for Health Services Research and published in 1991 under the title "Health Services Research: Key to Health Policy", edited by Eli Ginsberg, a forty-year veteran of the field.
The book begins with a broad and inclusive history of Health Services Research and contains chapters by, among others, Karen Davis.
[Karen Davis]: Well, I think from my own point of view, there are three major issues that health services research needs to continue to address as we enter the twenty-first century. The first and the one that's been of foremost concern to me is the issue of access to care.
Particularly for the uninsured, but increasingly for the underinsured. So understanding the erosion in employment-based coverage; what is going to happen to the numbers of uninsured; what's going to happen to the care that the uninsured receive; what's going to happen as managed care attracts away the profitable patients, what will happen to public hospitals, community health centers, and other safety net providers and their ability to really see that those who need care get it.
The second issue that I think requires a very intense Health Services Research effort is the whole issue of managed care. That's looking at issues of quality; it's looking at issues of continuity of care. The third set of issues, I think, relates to the aging of the population. The "baby-boom” generation will begin to retire about the year 2010. We're going to become an older society.
[Doris McMillon]: Another major issue, in the 90s, was the issue of race. Marsha Lillie-Blanton…
[Marsha Lillie-Blanton]: Race is one of those omnipresent factors in the healthcare system that no one wants to talk about. And yet, everyone would agree that it very much influences whether you get care, where you get care and, to some extent, the quality of the care that you get. [Marsha Lillie-Blanton, Dr. P.H., Vice President in Health Policy, The Henry J. Kaiser Family Foundation]
We now have considerable research that provides support for race's influence in, access to, and use of health services. The challenge Health Services researchers have faced is how to define and measure a construct, which is essentially a social construct, in a field of research that very much assigns biologic meanings to factors.
And so, it just makes it much more difficult to measure and interpret. I think the other main challenge we face is how we tease out the effects of race from economic conditions--something that is...two factors that are very much intertwined in this country.
And those are challenges, I would say, that Health Services researchers are getting much better at, but we still have a distance to go.
[Doris McMillon]: Where does American Health Services Research stand now? No matter how Health Services Research is defined, it's clear that the field has made significant contributions, which are now being increasingly recognized.
One indicator is the dramatic increase in the budget for AHCPR, now renamed the Agency for Healthcare Research and Quality, or AHRQ. Another important indicator is the expanded role of the Health Care Financing Administration, as well as the Department of Veterans' Affairs, where a Health Services Research and Development office is mandated to use Health Services Research as a management tool to improve care for veterans.
In addition, many institutes of the NIH support Health Services Research, and several set aside 15 percent of their budgets for work in this area. Medical journals and individual clinicians are more receptive now than they have ever been in the past.
A good part of the reason for the expanded role of Health Services Research is the way the field has changed with the times, focusing increasing attention on measurable clinical outcomes and the economic bottom line. Judith Lave…
[Judith Lave]: But I would like to say something about the differences in research in the 1970s and research in the 1990s, maybe in looking at the kinds of research proposals that have come through the study sections.
And I think there are two different kinds of differences, one of which is in the 1970s we were much more interested in regulation, the impact of regulation in planning, how to do appropriate planning, and how to worry about the supply and distribution of medical resources.
In the 1990s, I would say that the research is more focused on outcomes--what do we know about effective medical practice, and the cost associated with that outcome, and the variation in medical practice.
[Doris McMillan]: The results of Health Services Research are often seen in political, rather than in scientific, terms. And it is this political filter that appears to cause the field prosperous and lean times, depending on what political forces are at play. But it is also fair to say that the field of health services research is still puzzling over persisting questions that just don't seem to go away.
[Judith Lave]: Much of the research is terribly important, but it doesn't have sort of a "breakthrough" characteristic associated with it. And, for that, I would say all the research and access in trying to understand who receives medical care; what are the implications of receiving medical care; what is the effect of health insurance.
We have been looking at those questions since 1970, 1980, 1990, and will continue to look at those particular questions.
[Doris McMillon]: The tension between a clinical and a public health perspective and between an individual and a population perspective also persists in the field, as pointed out in a prostate disease study conducted by John Wennberg. Norman Weissman…
[Norman Weissman]: And because of Wennberg's work showing that it wasn't necessarily the best thing to have a prostatectomy--that people in the communities where they didn't have prostatectomies also did pretty well and also had good outcomes--the question is that it's maybe right for certain patients and not for others.
And so, the attempt then was to develop guidelines, which would say what steps you go through in determining that process. And one of the important things is that patients have a say in that choice.
That's another new evolution from Health Services Research and an effect on the public that is growing, which is that you and I, or any patient and I, could have exactly the same symptoms, and one of us could choose to have surgery, and another of us could choose to live with the symptoms.
[Doris McMillon]: One of the best overviews of Health Services Research is included on the Agency for Healthcare Research and Quality website.
Agency Director John Eisenberg makes this statement: "Whether at the level of an individual patient and clinician confronting discrete care choices, a medical director of a managed-care plan caring for a defined population, a State official addressing the health needs of entire communities, or public and private purchasers seeking value for their health care dollar, health services research answers the enduring central questions:
What works? Under what circumstances? For which condition? At what cost? But getting the word out to the public remains a challenge.
[Kathleen Lohr]: The merger of the Association for Health Services Research and the Alpha Center, a respected health policy organization in Washington, D.C., created the Academy for Health Services Research and Health Policy. The Academy will bring substantially increased visiblility and influence to the field of Health Services Research.
[Doris McMillon]: Advances in computers and the Internet help, and among other organizations, the National Information Center on Health Services Research and Health Care Technology, NICHSR, a division of the National Library of Medicine, is dedicated to exploring the full possibilities of our new technological capacity for supporting research and information dissemination.
[Karen Davis]: I think the other challenge to Health Services researchers will be how to get their message more to audiences that need this information. There's a big gap between even the information that’s available today and the public understanding of that information.
We're going to have to get out of our offices--out of our ivory towers--and really get sophisticated about becoming better communicators, as well as better researchers.
[Health Services Research: A Historical Perspective]
[Presented By: National Information Center on Health Services Research & Health Care Technology, National Library of Medicine]
[Narrator: Doris McMillon] [Writer: Theodore M. Brown] [Producer-Director: Bill Leonard] [Editor: James C. Charuhas] [Production Assistant: Aya Collins] [Consultants: Marjorie A. Cahn, Elizabeth Fee] [Location Camera: Jim Bolton, James C. Charuhas, Dan Crowe, Tony Evans, Scott Payne, Ben Root] [Rostrum Camera: Brian Matthews] [Studio Cameras: Bernie Lindstrom, Leon Segears] [Animation: Bruce Scallion, Julie Naff, EFX Communications]
[Picture and Video Research: Laura Kreiss, Bonnie Rowan] [Additional Photos and Videotape Courtesy: Academy for Health Services Research and Health Policy, Agency for Healthcare Researcand and Quality, American Public Health Association, History of Medicine Division of the National Library of Medicine, Johns Hopkins University, Kaiser-Permanente, Lyndon B. Johnson Presidential Library, National Archives, Library of Congress, Ronald Reagan Presidential Library, U. S. Senate Historical Office]
[National Library of Medicine, Bethesda, Maryland, MM]