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The Health Services Research Work Force
To a greater degree than is true of many professions requiring
postbaccalaureate education, health services researchers are defined by their
work, not by their degrees. Physicians, nurses, and dentists, in contrast, are
identified by their degrees, even when they are not actively practicing.
Furthermore, although some health services researchers have degrees in the field
of health services research, many have disciplinary degrees in public health,
sociology, economics, or other fields. They may identify themselves as much
with their discipline as with the field of health services research, perhaps because
the field is relatively young.
The health services research work force is marked by diversity along many
dimensions. It includes individuals with widely varying backgrounds social
scientists, behavioral scientists, statisticians, public health specialists, physicians,
nurses who come to the field by many different educational paths. These paths
include master's, doctoral, and clinical degrees as well as fellowships, on-thejob
training, and summer or other short-term programs.
Employment settings are also varied and include universities, academic
health centers, government agencies, health care delivery and insurance
organizations, consulting firms, and freestanding research organizations. Some
organizations employ more than 100 health services researchers; others choose
to contract for all or most of the research they need. Many organizations employ
a wide variety of types and levels of researchers, who frequently work as teams.
Such teams may include clinicians and master' e-level and doctoral-level
researchers who have backgrounds in such diverse areas as internal medicine,
nursing, health economics, epidemiology, and health care administration. In
43
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44 / HEALTH SERVICES RESEARCH
addition to working as members of multidisciplinary teams, individual
researchers must, in many cases, consider the perspectives of multiple disciplines
in their own particular research projects.
As described in Chapter 1, the health services research work force has three
components: ( 1 ) investigators who originate, design, supervise, and report basic
and applied health services research; (2) researchers who assist in the conduct of
health services research under the direction of others; and (3) individuals who
analyze information and apply the tools of health services research in
management and policy settings. The first group is composed largely of
individuals with research doctorates; the latter two groups include many with
master' e-level education. Depending on their level of education, experience, arid
interest in health services research, clinicians may be found in all three groups.
This chapter presents the results of this committee's efforts to identify and
describe the work force, to relate current supply to demand, and to project future
trends. The discussion illustrates the complexities created by the
multidisciplinary character of the field, its relative youth, and the diversity of its
membership.
THE CURRENT WORK FORCE
A major objective of the current study was a more comprehensive count of
current health services researchers than has been available in the past. The
database compiled for this report will provide others with a starting point for
more detailed surveys of work force characteristics, career paths, and other
important information.
Methodological Issues
Any effort to count and describe the health services research work force
must overcome several challenges. First, because the field is multidisciplinary
rather than marked by a defining degree, discipline, or credential, it is not readily
tracked in yearly censuses or biennial sample surveys of individuals who have
earned or are working toward doctoral degrees.' These data are a major
'The National Research Council (NRC) administers the Survey of Doctorate
Recipients, a longitudinal sample survey that began in 1973. The data are collected by
the NRC on behalf of the National Science Foundation. Samples are based on a yearly
doctorate census that the NRC has administered since 1958. In alternate years, samples
are drawn either humanities' doctorates or science and engineering doctorates. Those
selected are then reinterviewed until they reach age ?° die, or drop out of the survey.
Although certain categories of individuals who might be health services researchers (e.g.,
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THE HEALTH SERVICES RESEARCH WORK FORCE / 45
resource for those attempting to determine the supply of researchers in a field
and describe their demographic characteristics, employment status, and career
paths. Other databases such as those maintained by the American Medical
Association also lack codes that would identify health services researchers.
A second arid related difficulty is that academic researchers, a major
component of most research work forces, are not concentrated in identifiable
health services research programs. Rather, they are widely scattered across a
variety of disciplinary departments (e.g., economics, sociology), professional
schools (e.g., medicine, dentistry, business, nursing), and variably named health-
related programs (e.g., health policy, health administration). Even in more
traditional fields, it is "surprisingly difficult" to compile reliable information on
faculty positions and openings (Browne, 1995, p. 16~.
Third, the major professional organization for the field, the Association for
Health Services Research (AHSR), is relatively young and small. Compared to
larger and longer-established professions and disciplines, it has limited personnel
and employment databases. The American Mathematical Society and the
American Institute of Physics, in contrast, survey new doctoral recipients each
summer and then resurvey them in the spring to determine their employment
status, and the American Chemical Society recently undertook a survey to help
assess unemployment and underemployment (Browne, 1995; COSEPUP, 1995~.
Committee Data Collection Strategies
To identify members of the health services research work force, the
committee used two different strategies: one that combined existing data sources
and the other that collected new information. (See Appendix A for more details
on the work, which was supported by the Robert Wood Johnson Foundation and
the Baxter Foundation and was carried out in early 1995 by the Wisconsin
Network for Health Policy Research at the University of Wisconsin-Madison.)
The first strategy was to combine lists of health services researchers from a
variety of sources, most notably, the membership list of the AHSR2 and the list
those awarded doctorates in public health, biostatistics, or epidemiology) are categorized,
the survey is of little use for identifying new entrants to the field of health service
research. NRC staff report that health services research has not met their criterion for
adding a category to the survey. That criterion requires that at least ten survey recipients
in each of the past three surveys identify the category in the space provided for "other"
fields to be mentioned.
2This listing excludes individuals who take advantage of an employer's institutional
membership, which provides AHSR benefits such as discounted registration for the
annual meeting-to up to 10 individuals from the member institution.
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of principal investigators in HSRProj, the National Library of Medicine database
of funded health services research projects. To these lists were added names
from brochures of about 50 health research centers and names from other,
smaller lists, including those participating in recent AHSR annual meetings and
members of the Sigma Theta Tau, the nursing research honorary society. This
combined database is the most comprehensive listing of health services
researchers to date. It contains the following information (if available) for each
individual: degree, address, name of employer, and telephone number.
The second strategy involved new data collection through a survey of
organizational employers of health services researchers (see Appendix A for more
details). This survey was sent to nearly 500 organizations identified from AHSR
records and other sources. It asked respondents to provide information about
their health services researchers, their current and future research priorities, and
current and future hiring. The categories of organizations that received the
survey included university-based research centers, private research organizations
and think tanks, research units in health plans, managed care organizations,
insurance companies, pharmaceutical companies, and federal and state
government agencies. Although the Wisconsin group and this committee believe
that these organizations represent a large percentage of major employers of health
services researchers, no data are available to document the survey's
comprehensiveness or representativeness. Moreover, the response rate for the
survey was only 31 percent so the committee interpreted the results with caution.
To strengthen its qualitative understanding of the demand for health services
researchers, the committee also conducted telephone interviews with 28
individuals representing several categories of health-related organizations
including insurers, pharmaceutical companies, integrated health systems, state
government agencies, and consulting firms. (Although the committee made an
effort to contact a range of organizations, those participating were not a random
sample, and responses may not be representative of the larger universe of
organizations.) Questions focused on the type of issues currently being studied
or considered for study in the next five years, the number and type of researchers
employed, and experience in recruiting well-qualified candidates.
Size and Characteristics of the Work Force
The database that resulted from the two data collection strategies described
above includes information on 4,920 health services researchers. Information on
the type of degrees earned was available for just under two-thirds of those listed.
Of these, 49 percent were reported as having Ph.D.s (or, in a relatively small
number of cases, Sc.D.s or Ed.D.s). Clinicians accounted for about 28 percent
of the group, and more than three-quarters of these were physicians.
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THE HEALTH SERVICES RESEARCH WORK FORCE / 47
Geographically, 27 percent of the researchers in the database are located in
the South Atlantic region of the country, primarily because of the concentration
of researchers in Maryland and the District of Columbia. The next highest
concentrations of health services researchers are seen in the Pacific region (16
percent) and the East North Central region (16 percent). California, with 567
health services researchers, has the largest state contingent, followed by Maryland
(423), the District of Columbia (321), Massachusetts (317), and Pennsylvania
(305~.
As far as the committee could ascertain, only one survey of health services
researchers, which was conducted in 1978 by a special National Research
Council (NRC) panel, has attempted to describe the work force in more detail.
That study (Ebert-Flattau and Perkoff, 1983) identified two populations of
researchers. The first group, principal investigators, was older and more than 90
percent were male; more than one-third held medical degrees and two-fifths had
research doctorates. The second group, former trainees (i.e., recipients of health
services research traineeships), was younger and nearly one-half were female;
two-thirds held research doctorates but only one-tenth held a medical degree
(NRC, 1981, p. 107~. Both groups were overwhelmingly Caucasian, but the
trainee group was somewhat less so (94 percent versus 97 percent). More than
three-quarters of each category were engaged at some level in health services
research. The percentage of time spent in research (as opposed to management
or other activities) was lower than for biomedical researchers but higher than for
behavioral science researchers. About 66 percent were employed in academic
institutions, and about 4 percent of former trainees and 11 percent of
investigators were employed in business or industry (not including health care
delivery). Unemployment was very low (2 percent).
Based on its familiarity with the health services research community (but
lacking explicit information from the researcher database), the committee
believes it likely that women are better represented in the class of principal
investigators than in the 1978 survey, although they probably remain a minority.
As in 1978, clinicians (especially physicians) appear to remain more common in
the leadership segment of the research work force than in health services research
as a whole. (For example, in 1995, more than one-third of the members of the
Boards of the AHSR and the Foundation for Health Services Research (FHSR),
had clinical degrees. At the association's 1995 annual meeting, 6 of the 11
individuals featured in "meet-the-expert" sessions were clinicians.)
No reliable longitudinal data on the health services research work force are
available. Certainly, AHSR membership, both individual and organizational, has
grown from 450 individual and 25 organizational members in 1983 to 2,248
individual members and 128 organizational members in 1994. Such membership
figures, however, constitute an unsatisfactory measure of overall work force size
and growth for a number of reasons. Not all AHSR members are producers of
health services research; some are users of this research (e.g., public and private
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48 / HEALTH SERVICES RESEARCH
sector administrators, students, journal editors and writers).3 In addition, some
health services researchers may not hold individual membership in AHSR if they
are affiliated with organizations that hold institutional memberships, and some
individuals will choose not to join, perhaps because they already belong to
several other professional groups. Once created, an organization can expect fast
growth as it draws from an existing pool of potential members. Even later, when
a greater proportion of new members will be new entrants to the field, some new
members will be established researchers who have, for one reason or another,
finally decided to join the organization. In sum, AHSR membership is not a
good indicator of the size of the health services research work force or its
growth.
Supply in Relation to Demand
The data Fathered by the committee did not allow quantitative assessments
~,
of the relationship between the current supply ot and demand tor neaten services
researchers. For example, the committee found no recent statistics on
unemployment and underemployment rates, salary trends, or job vacancy rates
for health services researchers. Qualitative information suggested healthy
demand for researchers in academic settings (e.g., clinical departments that have
added health services research to their research portfolio) and private sector
organizations (e.g. health plans or insurers that have recently created or
~ _,
strengthened research units).
The committee also found some qualitative evidence of demand pressure in
certain areas. Overall, more than half of the 154 responding organizations in the
employer mail survey indicated that they have had difficulty recruiting certain
types of health services researchers in the last few years. The areas most
frequently mentioned were outcomes and health status measurement, health
economics, biostatistics, epidemiology, and health policy analysis. (See
Appendix A for a discussion of this survey and its limitations.)
These results of the written survey (which as previously noted had a low
response rate) were reinforced by telephone interviews conducted by the
committee with representatives of health-related organizations. In these
interviews, committee members heard of problems in recruiting well-trained and
experienced researchers in health economics, epidemiology, database
management, biostatistics, psychometrics, and organizational behavior. Those
fin recent years, the AHSR has attempted to identify such individuals by asking
member applicants to indicate whether or not they consider themselves health services
researchers. As described in Appendix A, the database created for this study excludes
those who answered "no" to this question.
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THE HEALTH SERVICES RESEARCH WORK FORCE / 49
with experience in state government noted that the demand from state
administrative and legislative offices was not for academically oriented
researchers but for people prepared to conduct policy analyses and interpret
research findings in the "real world" of policymaking. Executives in health care
financing organizations mentioned that researchers with work experience in
managed care or research management were hard to find. Several employers
mentioned that they receive weekly calls from "headhunters" looking to recruit
researchers with the backgrounds mentioned above. Some indicated that they
look for people who have experience in health services and that they are
generally indifferent to candidates' specific degrees. Others indicated that they
looked for people who are well-trained in specific disciplines because they feel
that knowledge about health services can be taught on the job.
THE FUTURE WORK FORCE
Estimating the Future Supply of Personnel
To develop a rough estimate of the health services research pipeline, the
committee combined information found in the 1991-1992 FHSR directory of
graduate programs with responses to its own canvass of these programs. (See
Appendix B for more details.) For the 76 respondents whose responses updated
the FHSR directory information, the committee used their report of the number
of students enrolled in each class. For the 45 respondents who did not return the
update, the committee used the enrollment information reported in the 1991-1992
FHSR directory. (For those who responded, the committee compared the
updated and earlier figures and found little change in enrollments for most
programs, but the pattern for nonrespondents might be different.)
The combined figures on enrollment in each class from the two data sources
show approximately 1,015 master's students, 51 1 students in doctoral programs,
and 197 individuals in postdoctoral fellowships. As an estimate of the health
services research pipeline, this number must be interpreted cautiously. On the
one hand, for the master's level and other programs that offer concentrations in
areas in addition to health services research, the numbers may include students
who have concentrations other than health services research. On the other hand,
the numbers refer to enrollments in each class not to total enrollments.4
4By way of contrast, for medical and dental schools, enrollments are reported
separately for the first through fourth years of school as well as for those graduating in
a year. To obtain an estimate of total enrollment, the committee considered multiplying
the enrollment figure for each program by the reported years to complete a degree two
years for most master's-level programs and four to five years for doctoral programs. If
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Beyond attempting to identify researchers in training, projecting the future
supply of researchers is a considerably more difficult task than counting current
researchers in any field or discipline. For its 1994 report, the NRC Committee
on National Needs for Biomedical and Behavioral Research Personnel created a
parcel to examine methods for making work force projections. It critiqued the
traditional demographic projection model used by previous NRC committees and
concluded that the model was unsatisfactory. Specifically, the model (1) con-
fused "age arid cohort effects" such that accurate projections could be provided
only in a steady-state environment "when no projections are needed," (2) pro-
vided no means for incorporating new entrants into a field, (3) made faulty
assumptions that the ratio of students to faculty and support dollars per
researcher were fixed and unaffected by changing economic and technical
conditions, and (4) incorrectly assumed that a current imbalance between supply
and demand would not affect the future labor market (NRC, 1994, p. 21~.
The NRC panel concluded that the best approaches to work force projections
involved the use of"multistate period life tables." (See Appendix C for a more
detailed description.) As described in the report (NRC, 1994, p. 21), such
approaches
begin by listing the characteristics of a given population (e.g., age, sector of
employment, and employment status) and project changes in the population
based on the life his-tory of members of the population.... [Projections] are
generated through a series of statistical calculations making assumptions about
both the rates of transition of individuals from state to state (employed to
retired, for example) and rates of new entrants to the system.
This kind of analysis can help policymakers get a sense of what the
characteristics of the labor force may be in the next several years. The further
out the projections go, however, the less useful they become as unforeseen events
affect individual choices about educational and career options.
Unfortunately, despite the progress the present Institute of Medicine (IOM)
committee made in enumerating the health services research work force, it still
lacked the critical current and historical information identified above. The
committee, therefore, chose not to attempt numerical projections of the size of
the future health services research work force. It also did not attempt to
calculate the number of new entrants that would be needed to maintain the
supply of researchers at a particular level. Specifying a target work force size
latter average were applied to the figure for doctoral enrollment reported in the text (51 1),
it would yield an estimated 2,700 doctoral students in the pipeline. Based on committee
members' involvement in the field, this number seemed implausibly high, presumably
because it would not account for attrition.
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THE HEALTlI SERVICES RESEARCH WORK FORCE / 51
requires assumptions about the future demand for workers, a process that is even
more difficult and uncertain than projecting the future supply of personnel.
Estimating the Future Demand for Personnel
Demand is conventionally described as the willingness and ability to pay for
a good or service. Need is a more subjective and often more expansive concept
that may be variably judged by consumers, suppliers, or "experts." Both should
be considered in any discussion of future personnel requirements.
Several recent reports have expressed skepticism about "the possibility of
generating useful forecasts of demand," especially long-term demand for
researchers (NRC, 1994, p. 21; see also COSEPUP, 1995; and IOM, 1995~. One
reason is that making estimates about key factors influencing demand (e.g.,
funding for research, technological developments) is a highly speculative
endeavor. Demand models are "sufficiently subjective and vulnerable to
changing events and data limitations that they are less useful as specific numbers
than as means of illuminating supply-demand dynamics" (IOM, 1995, p. 268~.
In addition, they do not adequately account for the behavioral responses of
students, faculty, and others whose decisions about training, careers, and
educational programs can shift supply away from projected levels (COSEPUP,
1995~.
Even short-term indicators of demand are "of limited use to policymakers
because today's decisions about fellowships and traineeships primarily affect the
scientific labor market a decade from now" (NRC, 1994, p. 219. Such indicators,
however, have some value because current market conditions are important
influences on the career decisions young people make and because a tight current
labor market might suggest different training support strategies.
Unfortunately, the health services research field lacks easily accessible
information to project short-term demand. The committee's surveys of those
employing health services researchers did, however, provide some qualitative
perspectives on future demand as described below.
Future Prospects
Although the committee did not attempt to develop a numerical estimate of
the future supply of or demand for health services researchers, it did discuss what
might be expected of various factors that could affect supply or demand. These
factors include (1) changes in governmental and private foundation funding for
higher education and research generally and for health services research and
education specifically, (2) strains on academic health centers, and (3) other
restructuring of the health care system.
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52 / HEALTH SERVICES RESEARCH
As this report was being drafted, prospects for federal funding for many
programs and activities were highly uncertain. Even such traditionally popular
programs as those for biomedical research and agricultural subsidies were being
questioned. In the first proposals for reductions in expenditures for fiscal years
1996 to 2002, committees in both the U.S. Senate and the U.S. House of
Representatives recommended elimination or major cutbacks in the Agency for
Health Care Policy and Research, the lead agency for public funding of health
services research and education (Brown, 19953.
At the state level, the committee found concerns about the willingness and
ability of many states to support and maintain ail ongoing program of health
services research and sophisticated policy analysis. In telephone interviews, those
with experience in state government cited civil service hiring restrictions,
policymakers' skepticism about researchers' sensitivity to the policy
considerations, and pressures on state budgets as reasons to be cautious about
hiring at the state level. In addition, although health care reform initiatives may
have increased demand for health services researchers (at the master's if not the
doctoral level), several state reform initiatives face difficulties following the 1994
elections.
Private foundations, although not major direct employers of researchers, can
be expected to continue to support health services research undertaken by
academic and other organizations. Foundations, however, are also facing heavy
pressure to use their resources to offset reductions in public spending for social
and educational programs, and this pressure may divert some resources from
research.
In many academic medical centers, economic forces and policy decisions are
likely to reduce patient care income and other revenues that may have been used
directly or indirectly to help support various kinds of research including some
limited amounts of health services research (Epstein, 1995~. Government funding
of graduate medical education and payments for services to Medicare
beneficiaries are highly vulnerable to cuts. Equally serious, the relatively high
costs of academic medical centers make them unattractive to managed care plans
that are building provider networks. The resulting loss of patient care revenues
could jeopardize the continued existence of some institutions. For other
institutions, health-related research could be affected (especially in areas not of
direct relevance in a competitive health care market), although cuts in external
research support (e.g., government grants, industry contracts) are a greater
concern.
State agencies reported that civil service rules and legislative skepticism
about funding research (analysis is considered a more acceptable term) made
employment of researchers relatively uncommon except in a few areas such as
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THE HEALTH SERVICES RESEARCH WORK FORCE / 53
epidemiology. States tend to rely heavily on consulting firms and, sometimes,
university-based consultants who can provide policy-sensitive analysis on a
quick-response basis.
In business and industry, employment opportunities for health services
researchers appear bright but still unpredictable in some respects. On the one
hand, demand for data and analysis related to health care utilization, costs, and
outcomes has been increasing as evidenced by the development of specialized
firms and units to analyze organizational, clinical, and other information and to
report on the performance of health care organizations.5 On the other hand, in
a competitive market, the value of research and analysis will be routinely
weighed against the value of other activities in a new decisionmaking
environment that is arguably less supportive of long-term investments than that
which has prevailed in nonprofit environments. In addition, economic factors
may well discourage the hiring of full-time workers eligible for an array of
fringe benefits and other advantages, which could mean that the episodic and
leaner use of outside contractors will be favored over the use of internal staff to
provide research services.
The committee found consulting firms, health insurers, and similar
organizations reporting that they expected to increase their hiring of master's-
and doctoral-level health services researchers in the foreseeable future. Many of
the employers interviewed by committee members, particularly those representing
integrated health systems, pharmaceutical companies, and private consulting
groups, stated they planned to double their complement of health services
researchers during the next five years.
In response to the written survey's request that employers predict their
recruitment plans for the next five years, more than 60 percent of responding
organizations indicated that they anticipated recruiting more health services
researchers in at least one of the 13 identified areas of research. Thirteen of 14
responding managed care, insurance, and similar organizations indicated they
expect to recruit health services researchers in the next five years. The research
areas that most respondents will recruit from are outcomes and health status
measurement, health economics, biostatistics, epidemiology, and health policy
analysis.
Based on respondents' reports about current recruiting difficulties and the
committee's own experience, the committee expected that researchers with (1)
skills in biostatistics, health economics, outcomes and health status measurement,
and epidemiology, and (2) experience in managed care and research management
would continue to be difficult to find for the next few years. Although the
committee did not collect information on other characteristics that would make
5Interest in these organizations is sufficiently high that they are the subject of several
directories, for example, yearly directories in the trade journal Business Insurance.
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54 / HEALTH SERVICES RESEARCH
individuals more attractive in the job market, it notes the conclusion of a recent
study of graduate scientists and engineers: "more employment options are
available to graduate scientists and engineers who have multiple disciplines,
minor degrees, personal communication skills, and entrepreneurial initiative"
(COSEPUP, 1995, pp. 2-17~. The implications of this discussion for training
programs are considered in the next chapter.
CONCLUSION
The committee's success in achieving the study's objectives of describing the
current size and characteristics of the health services research work force and
projecting the future supply and demand for researchers was limited by data
inadequacies. One priority became additional data collection to identify more
completely the existing work force and, to a lesser extent, to gauge short-term
demand for health services researchers. The resulting database of 4,920 health
services researchers and information regarding demand proved illuminating, but
a priority for others should be developing more complete information about the
characteristics and employment patterns of the work force. Data limitations
notwithstanding, the committee understood that the major factor affecting future
employment will be public and private research funding. In the immediate
future, the division of funding between these two major sources may shift
somewhat toward the private side. As discussed in the next chapter, educational
programs that prepare health services researchers will need to pay more attention
to private organizations as potential employers of their students as well as
potential funders of research.
Representative terms from entire chapter:
services researchers
