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.
Explore This IssueMarch 2007
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.
A major HSR success has been the sequelae to the Institute of Medicine’s 1999 report that avoidable medical errors result in 98,000 patient deaths annually. That research led many hospitals to adopt one or more key recommendations to care quality improvement via system change: computerized physician order entry, intensivists staffing ICUs, and published data on frequencies and outcomes of common procedures.
Without question, HSR has a noble agenda. Proponents want to chart a public policy course that cuts waste and inefficiencies from the system, gives more people greater access to health care, uses information technology (IT) effectively, reduces medical errors, and eliminates regional variations in care. At HSR’s heart is putting the primary care physician in charge of coordinating and streamlining services. The Commonwealth Fund’s Framework for a High Performance Health Systems for the United States (see sidebar, page 13) advocates a more organized delivery system that emphasizes primary and preventive care that is patient-centered.
What Does It Mean for You?
What will this mean for subspecialty care at medicine’s cutting edge with patient lives at stake? Mark Persky, MD, Chairman of the Otolaryngology/Head and Neck Surgery Department at New York’s Beth Israel Medical Center, expresses little confidence in bureaucratic systems that do little to help him provide and coordinate care for his patients with devastating and aggressive head and neck cancers. The thought of even more bureaucracy doesn’t appeal to him. A patient who has had a jawbone removed needs complicated and intense therapy from a large multidisciplinary team because such surgery affects their appearance and ability to communicate and eat. We need specialized physicians, nurses, radiologists, dentists, speech therapists, and so on to rehabilitate these patients, he says-all that in a tangle of reimbursement systems, mostly Medicare and private insurers that put obstacles in the way of getting patients what they need. Citing the example of the patient whose cancerous jawbone has been removed, Dr. Persky knows that the patient needs a prosthesis with teeth, which Medicare won’t cover because they call it an unreimbursable dental procedure.
Dr. Persky doubts that HSR will have an impact on the morass of bureaucracy where everyone is competing for dollars and patients have to tolerate limited access to the care they need. The big picture is that the government and society have to make important decisions about who gets what kind of care, he says. As for one-payer systems improving things, Dr. Persky currently sees patients coming from Canada and other socialized health care systems to Beth Israel because they can’t wait months for an MRI or PET scan needed to accurately assess their conditions. As Americans, we cannot tolerate limited access to oncology care for complicated and aggressive head and neck cancers that such systems engender. He has other doubts: A primary care physician should not be chosen as the person to coordinate this care. At Beth Israel a well-oiled multidisciplinary team makes decisions, as it should.
Making Sense of It All
When Louise Davies, MD, MS, Assistant Professor at Dartmouth Medical School and Chief of the VA Outcomes Group in White River Junction, VT, sees two patients, one with a T2 and the other with a T4 esophageal cancer, she thinks not only of the clinical picture but of what kind of insurance coverage each one has. Often the T2 patient has wonderful insurance and the T4 patient has none. While many other otolaryngologists and head and neck surgeons might also wonder if the T4 patient is uninsured or underinsured, Dr. Davies, a former Robert Wood Johnson Clinical Scholar, has the tools to see poor clinical outcomes resulting from a broken health care system. The Robert Wood Johnson scholarship allowed her to get a close view of how patients move through the health care system, how they make choices, and how specialists dealing with oncology patients can make that an informed journey (see sidebar).
Supported by her RWJ scholarship, Dr. Davies collaborated with a medical anthropologist and a pediatrician, following 25 oncology-head and neck surgery patients in-depth, trying to determine how they made decisions about their care. I found that there wasn’t a lot of decision-making going on, she notes. Most patients decide to have something done, then they move in a linear process through the system. I didn’t see much informed consent. The exception was an extreme prognosis, either very good or very bad, leading doctors and patients to make more definitive decisions.
The implications of Dr. Davies’ research are profound for all specialists dealing with oncology patients. Physicians need time to talk to these patients, and they need to be reimbursed for counseling them through truly informed consent. Practically, that would mean changes in CPT coding, a closer look at RVUs, more clinical trials to get a fix on cost and outcomes, and even reevaluating screening for some conditions such as thyroid cancer, which leads to a lot of false positives and consumption of precious resources-patient and physician time and money. Paradoxically, Dr. Davies says that HSR’s broad-brush approach to policy ultimately will improve the stuff we deal with every day. It will help us with obstacles to access, payment and care coordination. Eventually, it will lead to uniformity in care, pay for performance, and getting rid of everything that makes it hard for us to be the good doctors we were trained to be, she concludes.
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:
- Commit to a clear national strategy to devise and implement high performance health care.
- Emphasize coordination and integration of care through primary care providers.
- Establish and track metrics for health outcomes, care quality, access to care, and population-based disparities.
- Ensure that patients get the right care (not too much, not too little).
- Ensure access to care for all Americans-affordable, established benefits, equitably accessed.
- Balance provider autonomy with accountability.
The Commission hopes to put an end to the nation’s complex web of private/public health care financing, delivery, and quality assurance structures that produce vast inefficiencies in the provision of care-including waste due to duplication, poor processes, the provision of care that is know to be ineffective, and unacceptable variation in quality and safety.
©2007 The Triological Society