Editorial: health services research in 2020: an assessment of the field's workforce needs.
Growing up, health services research has continually explored the relationships between the issues and methods of core interest to those who would study and improve the health care system, and other, often much older, disciplines that can contribute to the understanding of these issues. In some conceptualizations, particularly early ones, health services research is an oleo of ideas and approaches. William Specter, the first editor of Health Services Research, wrote about the need to communicate to the "numerous fields" of health service research (Spector 1966). Today, although cohesion is more and more apparent, the field remains, as Thomas Ricketts describes in this volume, a sponge with permeable boundaries, expanding, contracting, and attracting others as it interacts with and incorporates a wide range of intellectual perspectives.
The Institute of Medicine once defined the core of the field as examining "the use, costs, quality, accessibility, delivery, organization, financing, and outcomes of health care services ..." (Field, Tranquada, and Feasley 1995) and has emphasized the impact on individuals and populations. In 2000 the Board of Directors of the Association for Health Services Research broadened the definition to include the impact of social factors and personal behaviors on people's health and well-being (Lohr and Steinwacks 2002). David Kindig advocated that the field should include research that "will allow us to understand how to maximize the health of individuals and populations..." (Kindig 1999). This journal recognized that there are more powerful factors affecting health than medical care when it published a special issue on social determinants of health in 2003 (Lurie, McLaughlin, and House 2003), though around the same time, John Eisenberg, Director of the Agency for Healthcare Research and Quality, wrote that the ultimate purpose of health services research is to produce better health care (and, hopefully, as a result produce better health) (Eisenberg 2001).
The flexible and evolving foci and boundaries of the field, driven by the push of intellectual progress as well as the pull of societal changes and policy events, make consideration of the future of the field a challenging but important undertaking. As the field approaches its 50th anniversary, it is a particularly propitious time to reexamine its contributions and its potential. To reexamine the field, AcademyHealth has conducted a series of activities with support from the Agency for Healthcare Research and Quality and the Robert Wood Johnson Foundation. This volume contains articles discussing the health services research workforce. A unique aspect in the development of these articles involved a summit meeting of 50 educators, employers, and funders of health services research in 2007. Summit attendees made recommendations for the future of the health services research workforce.
In an evolving field, tracking the workforce and predicting workforce needs can be challenging. Many people work in the field of health services research and identify themselves with the field. The work of others intersects with the issues and methods that characterize health services research, but not all of these individuals would self-identify with the field. And, as is common in disciplines that interact in important ways with business and policy processes, the field includes people working in a variety of different types of institutions in a range of capacities.
Grappling with the issues involved in defining the health services research workforce, understanding its current state, and evaluating the evolving needs for individuals with skills in health services research are not easy, but each is important. Workforce has long been a critical issue for the field. In 1995 the Institute of Medicine estimated that there were nearly 5,000 health services researchers. Taking a fresh look at this question, Susan McGinnis and Jean Moore in this volume estimate the size of the field to be about 12,000 people with another 6,000 who conduct health services research, but on a periodic basis. The field of health services research has more than doubled in the last dozen years, although it faces challenges of an aging workforce and an increased need for diversity.
In 1970, Paul Sanazaro, the head of the National Center for Health Services Research and Development, noted that "the absolute limiting factor on the current productivity of health services research is the small number of trained investigators" (Sanazaro 1970). Today training has changed. In his article, Thomas Ricketts identifies about 300 master's degree and doctoral programs training health service researchers, graduating nearly 5,000 per year. At the present time, he concludes that the supply of graduates is meeting the demand.
Approaching this topic from the demand side, in their article Craig Thornton and Jonathan Brown demonstrate that spending for health services research has not kept pace with the growth of health care in the United States. Thus, there has been no growth in demand for health services research and employers have not experienced difficulties in hiring health services researchers. Employers, however, may experience shortages of health services researchers, if there is a dramatic increase in demand due to changes in the health care systems or greater federal funding.
Patricia Pittman and Erin Holve in their article reflect on the recommendations from the summit meeting. Health services research should continue to conduct periodic studies to track the workforce. Developing leadership training, offering scholarships, and mentoring should be done to boost the number of minority health services researchers, support women in the field, and develop junior faculty. Training of health services researchers must include core competencies as well as skills necessary for private sector work. Finally, health service research needs to increase both thought leader and public awareness of the field.
In 2020, awareness of the value of the field and the demand for health services researchers will depend on the field continuing to demonstrate its ability to solve practical problems for the country. In the past, health services research emphasized its usefulness to policy makers and practitioners. With Medicare and Medicaid facing financial challenges in the 1970s (U.S. Senate, Committee on Finance 1970), health services researchers proposed, piloted, and evaluated different approaches to cost containment with new payment methodologies. (1) William Dowling, a health services researcher at the University of Michigan, suggested that prospective payment to hospitals would be a solution to the cost of hospital care. About the same time, John Thompson and Richard Averill at Yale University developed what became an important element of prospective payment, diagnosis-related groups (DRGs). The DRG work at Yale became the basis for New Jersey's all-payer, prospective payment system. (2) After health services researchers found that the New Jersey system was successful in restraining costs, Congress enacted a prospective payment system for Medicare in 1983. Following the implementation of Medicare's prospective payment system, health services researchers studied its impact. In a similar fashion, health services researchers, such as William Hsiao at Harvard, documented flaws in the physician payment system. Then health services researchers designed solutions ranging from bundled payments to relative value scales. Eventually, Congress adopted a relative value scale fee schedule based on the work of William Hsiao and his colleagues, along with expenditure targets (Ginsburg and Lee 1991; Oliver 1993; Mayes and Berenson 2006, pp. 81-92).
Health services researchers solved problems for policy makers, providers, health plans, pharmaceutical companies, employers, and foundations. Demand for health services researchers will depend on its ability to continue to answer important questions that matter to both public and private decision makers. Recent interest in comparative effectiveness, purchasing for value, quality improvement, and cost containment provides a fertile basis for strong demand. In 2020, we must meet the challenge that John Eisenberg posed for the field: Put research to work to improve policies, clinical practice, and outcomes (Eisenberg 2001)!
Altman, S. H., and E. K. Ostby. 1991. "Paying for Hospital Care." In Health Services Research: Key to Health Policy, edited by Eli Ginzberg, pp. 46-68. Cambridge, MA: Harvard University Press.
Eisenberg, J. M. 2001. "Putting Research to Work: Reporting and Enhancing the Impact of Health Services Research." Health Services Research 36 (2): xvi-xvii.
Field, Marilyn J., Robert E. Tranquada, and Jill C. Feasley (eds.). 1995. Health Services Research: Work Force and Educational Issues. Washington, DC: National Academy Press.
Ginsburg, P. B., and P. R. Lee. 1991. "Physician Payment." In Health Services Research: Key to Health Policy, edited by Eli Ginzberg, pp. 69-92. Cambridge, MA: Harvard University Press.
Kindig, D. A. 1999. "Beyond Health Services Research." Health Services Research 34 (1, Part II): 212-3.
Lohr, K. N., and D. M. Steinwacks. 2002. "Health Services Research: An Evolving Definition of the Field." Health Services Research 37 (1): 15-17.
Lurie, N., C. McLaughlin, andJ. S. House. 2003. "Guest Editors' Introduction: In Pursuit of the Social Determinants of Health: The Evolution of Health Services Research." Health Services Research 38 (6, Part II): 1641-3.
Mayes, R., and R. A. Berenson. 2006. Medicare Prospective Payment and the Shaping of U.S. Health Care. Baltimore: Johns Hopkins University Press.
Oliver, T. R. 1993. "Analysis, Advice, and Congressional Leadership: The Physician Payment Review Commission and the Politics of Medicare." Journal of Health Politics Policy and Law 18:113-74.
Sanazaro, P.J. 1970. "Health Services Research and Development." Health Services Research 5 (1): 7-11.
Spector, W. S. 1966. "To and from the Editor." Health Services Research I (1): 3-4. U.S. Senate, Committee on Finance. 1970. Medicare and Medicaid: Problems, Issues and Alternatives. Washington, DC: Government Printing Office.
Widman, M., and D. W. Light. 1988. Regulating Prospective Payment. Ann Arbor, MI: Health Administration Press.
(1.) For thorough reviews of this history, see Mayes and Berenson (2006, pp. 13-63); Altman and Ostby (1991); and Ginsburg and Lee (1991).
(2.) For more information on New Jersey's system, see Widman and Light (1988).
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|Title Annotation:||Special Section: Health Services Research in 2020: An Assessment of the Field's Workforce Needs|
|Author:||Colby, David C.; Baker, Laurence C.|
|Publication:||Health Services Research|
|Date:||Dec 1, 2009|
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