Health Services Research: Trying to Fix a Broken System

Despite the private and public funding of health services research, and the brainpower focused on aligning health policy decisions, provider behavior, budgets, and information technology, there are substantial obstacles to system change. While HSR proponents want to be in the vanguard of either bolstering or killing proposals about system change, they face stiff opposition to a more structured health care system. Some of the challenges that the HSR change masters are up against are multiple competing bureaucracies, provider support for the status quo, greater rewards for specialist over primary care, inadequate IT, duplicate and costly regulatory oversight, and too much provider autonomy at the expense of accountability.

Nevertheless, for the foreseeable future, count on policy wonks to pursue system change, using HSR as a major tool. Although they may succeed in the long term, in the short term expect more disruption, fragmentation, documentation, and duplication in negotiating the system that often seems at odds with providing excellent patient care.

The Robert Wood Johnson Clinical Scholars Program

The Robert Wood Johnson Clinical Scholars Program (http://rwjcsp.stanford.edu ) has fostered the development of physicians interested in health systems research in academic medicine, public health and other venues. In existence for more than 30 years, the program-which offers two years of graduate level study at one of four universities: the University of California at Los Angeles, University of Pennsylvania, Yale University, and the University of Michigan-has produced more than 1000 physicians who are leaders in health services research.

Iris Litt, MD, Program Director of the RWJ Clinical Scholars Program, says that the program encourages physicians to conduct research that will improve health care. They are change agents and visible role models who help us identify what needs to be changed, and how can it be changed to make things better.

Physician scholars learn how to conduct innovative research and to work with communities, organizations, practitioners, and policy makers on issues that affect the US health care system. Each year the RWJF selects up to 29 clinical scholars; 20 are funded by RWJF, eight by the Veterans Administration, and one by the American College of Surgeons.

The vast majority of RWJF Clinical Scholars are primary care physicians-with internal medicine, pediatrics and family medicine well represented. A handful of otolaryngologists/head and neck surgeons have been through the program:

• Kenley Chin, Otolaryngologist, Los Altos, CA
• Louise Davies, Chief, VA Outcomes Group, White River Junction, VT
• Jay Piccirillo, Director of Clinical Outcomes Research, Washington University, St. Louis, MO
• Edward Weaver, Otolaryngology/Head and Neck Surgery, Puget Sound Health Care System, Seattle, WA
• Bevan Yueh, Otolaryngology/Head and Neck Surgery, VA Puget Sound Health Care System, Seattle, WA

The Commonwealth Fund’s Health Services Research Commission

In July 2005 the Commonwealth Fund formed an 18-member commission to chart an HSR-driven course for US health care that would significantly expand access to care, improve quality, and squeeze waste from the system, leading to a high performance health care system. The commission includes heavyweights such as Maureen Bisogno (CEO, Institute for Healthcare Improvement), Christine Cassell (CEO, American Board of Internal Medicine), Michael Chernew (Harvard Medical School), and George Halvorson (Kaiser Foundation Health Plan). In August 2006 it released its manifesto for change. Its high points are: