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CHAPTER 3 THE: FIELD OF HEALTH SERVICES RESEARCH The field of health services research includes the persons and resources employed to produce and disseminate knowledge about personal health services. Although the field has certain features of an academic discipline, it is not generally regarded as a distinct scientific discipline with its own characteristic theories and methods. Rather, the field gains its coherence by concentrating on questions and problems pertaining to a particular set of activities, namely, the provision of personal health services. In this sense, health services research is an applied field; its priorities are established by societal questions and problems about personal health services. This chapter describes features of the field of health services research, distinguishing them from characteristics of academic disciplines, and sketches the history of the problems and circumstances that have shaped the field's priorities and development. Field as Distinct from Discipline The body of knowledge known as health services research encompasses findings from studies conducted from a variety of perspectives and applying a variety of methods, many of which combine approaches of several academic disciplines.* In this sense, the field is multidis- clipinary. It does not, however, have a distinct theoretical framework or set of characteristic concepts and methods ordinarily associated *Health services research employs concepts, theoretical frameworks, data, and methods from the field of medicine and other health profes- sions (nursing, dentistry, pharmacy, etc.), the social and behavioral sciences, the applied social sciences (social work, business and hospital administration, etc.), industrial engineering, law, biostatistics, demography, and geography. 33

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34 with academic disciplines. These and other differences between fields and disciplines account for differences in their internal organization and research priorities. The major differences between research in academic disciplines and that in applied fields are in their conceptual content, the purposes for which research is done, and the sources of questions for research. Research in academic disciplines is identified by its relationships to particular conceptual frameworks. Economics, political science, and sociology, for example, all focus on exchanges among individuals. However, research in each of these disciplines usually concentrates on selected features of exchanges that are relevant to its own conceptual framework. An economist studying physician-patient exchanges, for instance, might examine effects of prices on the volume and types of services consumed or produced; a sociologist would be more inclined to study the effects of organizational characteristics on interpersonal behavior. Research is done to produce knowledge to be incorporated into the theories of academic disciplines from which further questions for research are derived. Findings are usually directed toward other scientists within the disciplines working on related questions. By definition, applied fields are problem-oriented. Their research questions are drawn from the work of practical affairs, and their theoretical and methodological approaches are more diverse than any of the individual disciplines that contribute to the field. Research on why people use different types of health services, for instance, may draw upon concepts and methods of economics, psychology, and sociology, using administrative or clinical definitions to categorize "types of health services." As the questions that occasion research are practical problems in the area being investigated, findings are addressed to and used by persons who must deal with the problems as well as by those who are interested in their implications for knowl- edge in their scientific disciplines.tl] While the purposes and content of research may differ between that done by a person studying a health services problem frog the perspec- tive of an academic discipline and another who identifies himself as a '"health services researcher," knowledge in the field of health services research encompasses the products of both. The crucial features of studies that make them health services research are those defined in Chapter 2, rather than the motives of researchers or the perspectives and methods they employ in their research. An economist studying the capital expenditures of hospitals to test theories of the behaviors of nonprofit firms, for instance, produces health services research regardless of his intentions and interests. Hence, the analogy with biomedical research and development, which distinguishes between basic and applied research is not entirely applicable to health services. While many of the studies that contribute to health services research

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35 are done in response to practical problems, many others are done to develop basic knowledge in the participating academic disciplines. Because the field of health services research is identified by the content of the research questions and findings, there is considerable variation among the perspectives and interests of persons who contribute to it. Lacking commitment to theoretical frameworks and methods that ~ unify academic disciplines, the field is divided into several groups on the basis of several dimensions. First, because more persons who con- tribute to the field identify themselves primarily with their disciplines, the field is partitioned along disciplinary lines (e.g., health economists, medical sociologists). Second, within disciplines, researchers subdivide into groups sharing interests in particular features of health services. For instance, among medical sociologists, some are interested in the structure and dynamics of health care organizations and others concentrate primarily on the illness behavior of individuals. Third, groups divide among and within disciplines along particular substantive interests (e.g., mental health services, rehabilitation services). Finally, because many issues in health services research are value-laden, researchers are often divided by political and value orientations. Although these circumstances are not unique to the field of health services research, they point out the potential problems of characterizing the entire field of health services research in terms of its purposes, interests, and perspectives. Because the research priorities and agendas of applied fields are set largely by societal definitions of problems and issues, research emphases and perspectives change with changing circa stances. Origins and Development of the Field The types of systematic inquiry and the organizational structure that characterize the contemporary field of health services research have developed only within the past 20 years. During this period, research in personal health services became recognized subspecialties within several academic disciplines, and professional groups, training programs and specialized journals in health services research were established. These developments, along with the enlarged and relatively regular sources of federal support for studies in this area, have provided the institu- tional structure by which the field of health services research is identified. Although health services research has only recently come to be recog- nized as a distinct field of inquiry, it builds upon traditions of research on health services that began in the opening decades of

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36 the Twentieth Century. As Odin Anderson has observed, systematic research on health care emerged in the 1920s in response to concerns about equity of access to health services, and its emphases have historically reflected prevailing societal definitions of issues surrounding the organization, financing, and quality of health services.~2] As these emphases changed and evolved, participation in the field and the varieties of settings in which research is done broadened, and, increasingly, the federal government became its princi- pal source of financial support. The predominant policy issues of various periods in the history of health services in the United States define four general stages of health services research: its origins from 1900 to the 1930s, during which the principal features of the nation's health services industry took shape; the 1930s through the early 1950s, during which voluntary health insurance emerged as the principal mode of financing hospital services; the mid-1950s through the mid-1960s, which witnessed the the extension of federal subsidies for training, hospital construction and planning, and repeated changes in hospital reimbursement by Blue Cross; and from the late 1960s to the present, during which costs, reimbursment, quality of health care, and planning and regulation became ma jar issues . ~3 ] Origins: Pre-1930s During the opening decades of the Twentieth Century, the nation's personal health services industry consolidated in the private sector. Medical care was purchased by the patient from physicians working in solo practices and charging fees for each service and from independent, voluntary hospitals. Care for indigent and medically indigent persons was provided free or partially free by physicians applying a sliding scale of fees, voluntary hospitals in receipt of philanthropic funds, and public hospitals and clinics financed with local or state tax funds. These patterns had been established without conscious planning or public intervention and, with the exception of the efforts of organized labor in the early 1900s to establish worlmen's compensation schemes and later compulsory national health insurance, they raised few public policy issues. Research during this period was sporadic and largely descriptive in nature. Sponsored by philanthrophic foundations, private associations, and a few federal agencies, studies focused on prevalences of illness in general populations and on the activities of local health departments. Concern about the health and health care of the poor gave impetus in the 1920s to studies by the Public Health Service examining relationships between income and morbidity, to investigations of infant mortality by the Children's Bureau, and to a series of studies by the American Public Health Association of the organization, expenditures, and accomplishments of municipal health departments.

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37 The most ambitious effort of this period was the series of studies undertaken by the Committee on the Costs of Medical Care (CCMC). Composed of more than 40 eminent physicians, public health professionals, represen- tatives of health care organizations, insurance companies, the general public, and economists and statisticians, and sponsored jointly by eight private foundations, the Committee undertook several studies from 1928 through 1932 that culminated in more than 70 reports and papers and a far- reaching set of recommendations for the reform of health services financing and organization. Among the more than 20 field studies undertaken by the staff or under the C~mmittee's sponsorship were the first major population surveys of use of personal health services, which revealed substantial variations among income groups; projects that laid the groundwork for estimating populations' needs for personal health services; and the pioneering work on the potential benefits of the group practice form of medical care organization. 1930s - 1950 Although the CCMC's recommendations in favor of group practice and the use of ancillary medical personnel, prepayment for personal health services, and community-wide planning for health care did not result in immediate changes in the nation's health services industry, its findings and insights were a major source of information and ideas in the public debate concerning compulsory health insurance that re-emerged during the depressions of the 1930s. In addition, they gave impetus to a variety of more systematic and detailed studies of the organization of medical practice and of the supply and distribution of health services. In 1935-36 the Public Health Service undertook the first official National Health Survey involving interviews of more than 700,000 households in 21 states, studies of activities of public health agencies in 94 communities, and, in cooperation with the Department of Commerce, studies of the financial situation of hospitals. Data frog the population survey with those from the earlier CCMC study were to comprise the nation's information base on the use of personal health services until the early 1950s. Data from the survey of hospitals were extensively analyzed by staff of the Public Health Service's Office of Public Health Methods, leading to the first attempts to define health service areas for hospitals. With the enactment of the Social Security Act of 1935, the Office of Research and Statistics was created in the Social Security Administra- tion. Staff in this office worked on estimating aggregate expenditures for health services, making actuarial projections of alternative national health insurance plans, and conducting surveys of the coverage of developing prepayment plans. These efforts were joined in the mid-1930s by several books and reports analyzing the cases for and against govern- ment sponsored and voluntary health insurance.

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38 By the early 1940s, concern about the availability of personal health services had given impetus to research on the geographic distribution of medical personnel and facilities. The Public Health Service produced a series of studies on the location of physicians in the United States that culminated in the first estimates of optimal physician-population ratios. In 1944, the Commission on Hospital Care of the American Hospital Association, with the financial support of private foundations, issued a report showing that hospital beds were unevenly distributed and that their distribution was unrelated to needs for inpatient care. Following enactment of the Hospital Survey and Construction Act of 1946, data from the Committee's studies were employed to establish standards to guide the allocation of subsidies for construction of hospitals. Before the 1940s, most research on health services was done in the United States largely by statisticians, economists, and physicians employed by government agencies and private associations or by the staff of commissions financed by private foundations. During the late 1940s, programs for research on health services developed in universities, and other disciplines began to become involved. Multidisciplinary teaching and research programs in public health administration developed in schools of public health, and, encouraged by the Agricultural Extension Service of the Department of Agriculture, sociologists, social anthro- pologists, and social psychologists were attracted to research on the health care of rural populations. 1950s - 1965 The fifteen years between 1950 and the mid-1960s marked a great expansion of research on health services and the beginnings of organizations and associations devoted to furtherance of the field. Debate over national health insurance having subsided, attention turned in the early 1950s to questions of the extent and effectiveness of voluntary health insurance coverage. The first truly national study of health insurance coverage and use of and expenditures for personal health services was undertaken in 1953 by the newly established Health Information Foundation and repeated periodically over the following decade. These studies, with the periodic National Health Surveys initiated in 1956 by the Public Health Service, provided systematic descriptive information that revealed continuing differences in volumes of personal health services consumed by the poor and the uninsured as compared to higher income and insured segments of the nation's population. By the early 1960s, research on use of personal health services had become a major area of study for social psychologists and sociologists interested in relationships between social and psychological determinants of utili- zation and for economists interested in the demand for various types of

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39 services under different insurance schemes. As attention shifted to questions pertaining to the effects of modes of health services organi- zation on utilization, comparative studies of rates of hospitalization under solo practice, fee-for-service arrangements versus prepaid group practices were done, showing the now familiar pattern of lower use of inpatient services by populations enrolled in prepaid group practices. Research on hospitals was stimulated by amendments in 1950 to the Hospital Survey and Facilities Construction Act of 1946 authorizing funds for studies in hospital administration. The Division of Hospitals and Medical Facilities of the Public Health Service conducted intramural research and sponsored contracted studies of patient groupings, hospital classifications, and a variety of other questions-of interest to economists and operations researchers. When the first explicit appro- priations for support of extramural research were made in 1955, the Public Health Service established the Hospital Facilities Study Section, which in 1959 was broadened to become the Health Services Research Study Section. Research on health services during the 1950s produced several landmark studies that incorporated innovative conceptual and methodological approaches. In 1956, the Commission on Chronic Illness published its three-volume report of its five-year study of chronic illness, two of which reported findings from extensive field surveys and clinical evaluations. The Commission on Financing of Hospital Care released its three-volume set including essays on hospital costs and financing. Evaluations of medical care were reported, based on comparative analyses of stays in hospitals following surgery, review of charts, and observation of physicians in office settings. Economists began applying concepts of cost-benefit to particular illnesses, and engineers introduced and tested the computer as an aid in medical diagnosis and patient screening and monitoring. By the early 1960s, the organizational base of the field of health services research had begun to form. Programs in hospital a~ministra- tion were underway in several universities, and, in the early 1960s, multidisciplinary departments of community medicine began to appear in medical schools. Subspecialties in health economics and medical sociology had developed and were producing their first generations of researchers with concentrations on aspects of personal health services. New associations and groups within existing ones were created to serve as forums for the dissemination of research ideas and findings, and journals specializing in health services research appeared (e.g., Health Services Research, Inquiry, Journal of Health and Social Behavior, Medical Care).

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40 These developments were facilitated in large degree by the availability of funds for extramural research from the federal government. By the early 1960s, several sources had been established, including the authori- zations for research on nursing established in 1955 by the National Institutes of Health, studies of health care facilities sponsored under 1955 amendments to the Hospital Survey and Facilities Construction Act of 1946, and a Community Health Services Research Grants program initiated in 1963 by the Division of Community Health Services of the Bureau of State Services. Mid-1960s to the Present Since the mid-1960s, the emphases of health services research have been influenced by two major trends: the institutionalization of health services research within the nation's universities, and the expansion of the federal government's roles in health care delivery, financing, planning, and regulation. These trends have had the salutary effect of concentrating a portion of the nation's intellectual resources on important health care issues. On the other hand, demands for "targeted studies" and immediate answers to complex questions have forced trade-offs between longer term investigation of fundamental questions and shorter term studies relevant to current policies and programs. As funds became available in the mid-1960s for general-purpose health services research and training, the locus of health services research shifted to the nation's universities. In this setting, research became markedly more theoretically- and analytically-oriented. Research on the use of health services, for instance, began to quantify the social and economic determinants of variations in use of physicians' services,[4] and research on hospitals focused systematically on isolating causes of variations in productivity, efficiency, and costs.~5] As in other areas of research, attempts to apply theoretical models and sophisticated analytic methods to complex questions not only produced new insights but raised additional conceptual and methodological issues for research and led to subspecialization within the field. In the area of hospital costs, for example, the difficulty of defining and measuring outputs of hospitals led economists to develop and test several competing models,[6] and re- search on outcomes of care and health status produced a variety of approaches.~7] The traditions of health services research that developed in the 1960s contributed important knowledge and methods that are being employed to infold and assess contemporary health care policy. Rising costs of health care, for instance, have led the federal and state governments to institute several forms of regulatory programs whose effects are being analyzed by health services research. Studies of the effects of the Economic Stabilization Program on physicians' fees,[8] of prospective

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41 hospital reimbursement on per diem charges,[9] and of certificate-of- need laws on hospital investment[10] build upon previous health services research while raising relatively unexplored conceptual and methodo- logical issues. The current situation of the field of health services research differs from that of previous periods, however. On the one hand, it enjoys the benefits of having learned from the recorded experience of its predeces- sors and of its access to the more powerful conceptual and methodological tools of various cognate disciplines. On the other, it faces issues that are vastly more complex and far-reaching in their consequences than those of earlier periods at a time when expectations of the application of knowledge from research are heightened and resources are scarce. In such circumstances, the field of health services research is subject to contending forces leading in one direction to research aimed at improving concepts and methods and furthering knowledge about fundamental dynamics within a health services system, and in the other to the application of what is known to the development and assessment of health care policies and programs. These problems of the division of intellectual labor are neither new nor unique to the field of health services research, nor can they be settled by edicts. The field of health services ~ ~ ~ to a variety of forums and means of communication nor ~ research currently has access ~ through which such matters can be aired and debated. These should be employed to the fullest extent if those who regard themselves as "health services researchers" are to have a voice in the future development of the field. _

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42 REFERENCES 1 2 3 4 s 6 7 8 Robert L. Eichhorn and Thomas W. Bice, "Academic Disciplines and Health Services Research," in E. Evelyn Flook and Paul T. Sanazaro (eds.) Health Services Research and R & D in Perspective (Ann Arbor: Health Admini- . Stratton Press, 1973), 136-149' and David Mechanic, Prospects and Problems in Health Services Research," Milbank Memorial Fund Quarterly/ Health and Society, 56 (Spring, 1978), 127-139. Odin W. Anderson, "Influences of Social and Economic Research on Public Policy in the Health Field: A Review," in Donald Mainland (ed.), Health Services Research (New York: Milbank Memorial Fund, 1966), pp. 11-48. . Much of the historical information in the following sections is from: Anderson, op. cit: E. Evelyn Flock and Paul J. Sanazaro, Health Services Research and R&D in Perspective (Ann Arbor: Health Administration Press, . 1973) ~ pp e 1~81e Ronald Andersen, Toanna Kravits, and We Anderson (eds e ) ~ Equity in Health Services: Empirical Analyses in Social Policy (Cambridge Ballinger Publishing Co., 1975~. Sylvester E. Berki, Hospital Economics (Lexington, Mass.: Lexington Books, (1972), Chapters 2-5. Ibid., pp. 19-29. Robert L. Berg (ed.), Health Status Indexes (Chicago: Hospital Research and Educational Trust, 1973~. Paul B. Ginsburg, "Impact of the Economic Stabilization Program on Hospitals: An Analysis with Aggregate Data," in Michael Zubkoff, Ira E. Raskin, and Ruth S. Hanft (eds.), Hospital Cost Containment: Selected Notes for Furture Policy (New York: 293-323. Provist, 1978), pp.

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43 9 10 Fred T. Bellinger, "An Empirical Analysis of Several Prospective Reimbursement Systems," in Zubkoff, et. al., op" cit., pp. 370-40Q David Se Salkever and Thomas W. Bice, "Certificate-of-Need Legislation and Hospital Costs," in Zubkoff, et" al, Ope cit., pp. 401-428 e

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