Health Services Research: Trying to Fix a Broken System

Few could argue credibly that America, which outspends all other countries on health care, has the world’s best-trained physicians, the best-equipped hospitals and incomparable technical innovation, should not have the world’s best health care system. Yet politicians, health care policy analysts, consumers, and most providers are keenly aware that that is not necessarily the case. There are yawning and persistent gaps in access, quality, and coordination of care; a devastating number of medical errors made every year; and huge inefficiencies in a badly uncoordinated health care system.

These deficiencies have led to unceasing calls for universal health insurance or a single-payer system to provide a more uniform approach to care. But more discerning eyes see that pouring even more resources into a bloated and inefficient system might make things worse, not to mention inviting a colossal incursion on the public treasury. The alternative is trying to unravel medicine’s multifaceted troubles and realigning service delivery and reimbursement more sensibly. The discipline that is charged with doing just that is health services research.

What Is HSR?

A working definition of health services research (HSR) is the study of access to health care, its costs, and its outcomes for the purpose of identifying the most effective ways to organize, manage, finance, and deliver the highest quality care equitably to the most people. Researchers at the National Institutes of Health (NIH) coined the term health services research in 1959 in anticipation of lawmakers creating two massive new entitlements, Medicare and Medicaid, and their accompanying bureaucracies. NIH built in HSR to study the nonclinical aspects of health care such as economics and quality, and to monitor and shape the new programs. NIH administrators realized that by funding health care in a big way they would need to collect data on program performance, eventually creating the Agency for Health Care Policy and Research to do so. As the bureaucracies and their budgets grew more cumbersome, the new agency couldn’t handle all the number crunching, so in 1981 the government funded the Association for Health Services Research (AHSR) to massage the data. Later AHSR morphed into AcademyHealth, which is still responsible for the government’s HSR data collection and dissemination (www.academyhealth.org ).

In the past four decades HSR has pinpointed emergent issues, identified many of the system’s flaws, and precipitated change based on its analysis of what has gone wrong and what could be improved. Luminaries such as David Nash, MD, PhD, Chair of Jefferson University’s Medical School’s Department of Health Policy, have lent weight to finding strategies to reduce health care expenditures through the improvement of health and quality of care. Dr. Nash’s focus has been value-based purchasing, where he and his colleagues tease out return on investment with various disease management interventions. It’s an uphill climb in a health care system in which identifying reference and intervention populations, quantitative methods and data quality, and confounding and bias all work against work against developing clear strategies that would allow payers to reward or penalize providers through the use of incentives or disincentives. Nevertheless, Dr. Nash and others keep trying.