Methods

he findings in this paper are based on interviews conducted in 12 metropolitan areas in the United States: Boston, Mass., Cleveland, Ohio, Greenville, S.C., Indianapolis, Ind., Lansing, Mich., Little Rock, Ark., Miami, Fla., Newark, N.J., Orange County, Calif., Phoenix, Ariz., Seattle, Wash., and Syracuse, N.Y. These 12 sites are treated as intensive study sites among a larger set of 60 sites randomly selected to provide a nationally representative basis for surveys of households, physicians, employers and health plans. Approximately 60 highly structured interviews were conducted at each site with persons representing major medical providers, health plans, community leaders, policy makers, employers, consumer advocates, and others who could provide an interesting vantage point on health system change. In most health care organizations, informants included both administrative and clinical leaders. Interview data were complemented by data from secondary sources.

The sites selected for study are large metropolitan areas that, in some cases, are part of larger regional health care markets. Many of these areas contain distinct sub-markets for the provision of health care services. Interview respondents were selected to reflect the major health care organizations in the overall market with a concentration in a core market, generally the area of greatest population density in the site. An overview of the entire market was obtained through vantage point informants, and by inquiring about market dynamics in other parts of the metropolitan area from informants in the core market, with targeted interviews in peripheral areas. Community leaders, public health organizations, consumer advocates, and informants with a long and established history in the area were selected to provide these perspectives. Leaders of major health care organizations were also asked to provide their point of view on their own organizations as well as others throughout the market.