Insurance Coverage & Costs
Access to Care
Quality & Care Delivery
Health Care Markets
Issue Briefs
Data Bulletins
Research Briefs
Policy Analyses
Community Reports
Journal Articles
Other Publications
Surveys
Site Visits
Design and Methods
Data Files
Research Approach
seemingly simple question is at the heart
of the national debate about managed care: Are the changes underway in the
health care system going to result in better or worse care for Americans?
It was this question that largely drove leaders at The Robert Wood Johnson Foundation (RWJF) to set up HSC in 1995. They believed that one of the ways we could answer this critical question was by systematically studying how change is occurring, and assessing what effect such change is having on consumers. The Foundation also believed that it was critical to examine these changes over a number of years so policy makers could understand the pace and nature of these shifts and begin to predict the next point in the change trajectory.
While other research organizations examine particular communities or sectors, HSC’s focus is broad to provide overall context for the decisions of public and private policy makers. HSC researchers assess the impact of change and lay out the range of policy responses. To maintain objectivity, we do not advocate policy prescriptions. Our information is used by a wide spectrum of policy makers with divergent views about whether the changes underway are largely positive or negative, and what, if anything, should be done in response.
The Community Tracking Study
Since health care is organized and delivered at the community level, the focus on communities is central to HSC’s research approach. The Community Tracking Study involves surveys of people who are a part of or affected by the change process, namely households, physicians and employers. Of the 60 communities HSC surveys bi-annually, 12 are studied in depth by researchers who visit the communities every two years and interview health system leaders. The 12 communities are: Boston, Mass.; Cleveland, Ohio; Greenville, S.C.; Indianapolis, Ind.; Lansing, Mich.; Little Rock, Ark.; Miami, Fla.; Northern New Jersey (formerly cited as Newark); Orange County, Calif.; Phoenix, Ariz.; Seattle, Wash.; and Syracuse, N.Y.The two critical questions the Community Tracking Study focuses on-whose answers can help to inform the debate about the direction of our health care system-are:
- How are the different components of
the health system changing, and what forces
are driving these changes?
- How do these changes affect the care people are receiving with respect to access, cost and perceived quality?
The first round of surveys and site visits, completed in 1997, constituted the baseline against which changes will be tracked. Data from the Household Survey and the Physician Survey were made available in public files for use by outside researchers in 1998. The second round of site visits has been completed, and the second round of the Household and Physician Surveys will be finished by fall 1999; the Employer Survey was not fielded this round. The third round of surveys and site visits will begin in summer 2000.
The surveys and site visits provide researchers with a wealth of data, which allows them to:
- place findings about change in the 12
communities within the context of the nation as a whole;
- draw statistically reliable conclusions about the nature and impact of change across the
entire country; and
- show how market characteristics such as managed care relate to differences across communities on important dimensions such as access, cost and quality.
Information gleaned from interviews conducted as part of HSC’s site visits provides researchers with valuable community-level insights that are difficult to get in surveys, such as what strategies health care organizations are pursuing. Visits to the communities provide context for interpreting the survey results and, in turn, the survey data help in analyzing the qualitative data obtained through site visits.
The surveys-which are conducted by telephone-are nationally representative and community-based, with half of the respondents carried over from the previous round.
The Household Survey
Sixty thousand persons in 33,000 families are interviewed to gauge access, satisfaction, service use and insurance coverage, and to determine if their access to the health system is improving or declining. The Household Survey also obtains information about health status and sociodemographic characteristics.
To obtain more detailed and reliable information about the characteristics of health plans, HSC has conducted a follow-back survey of the plans these families are enrolled in. This survey enables researchers to evaluate the effect of plan type and attributes, for example, financial in- centives on access, perceived satisfaction and other important dimensions. Mathematica Policy Research, Inc., (MPR) conducts both the Household Survey and the follow-back survey for HSC.
The Physician Survey
Twelve thousand practicing physicians provide insight into how care delivery is changing by responding to questions about how they are paid, the changing nature of their practices and whether they believe they can provide high-quality care to all of their patients. The Gallup Organization conducts this survey for HSC.
The Employer Survey
Twenty-two thousand public and private employers are interviewed to better understand how they shape the health system. These employers are asked questions about the plans they offer, how they control costs, the amount employees contribute to cover their insurance and what plan quality information they make available. HSC collaborates with RAND on the Robert Wood Johnson Employer Health Insurance Survey.
Other Researchers Using HSC Data
In 1998, HSC made data from the first round of the Household and Physician Surveys available in public use files. Data from the Community Tracking Study have been made public far more quickly than is the norm so that researchers with varying perspectives can use these files to further policy makers’ understanding about market changes and the resulting effects on consumers.
Through its Changes in Health Care Financing and Organization (HCFO) Program, RWJF made funding available over a two-year period to support researchers interested in using HSC’s survey data. Ten researchers-among them Mark Pauly from the University of Pennsylvania, Doug Wholey from the University of Minnesota and Katherine McLaughlin from the University of Michigan-have been awarded grants to conduct studies using Household Survey data.
Research Focus
HSC has disseminated its findings from round one surveys and site visits through a number of different media, including Issue Briefs and Data Bulletins, journal articles and formal and informal presentations.
A new publication series, Community Reports, documents changes that have taken place at the community level over the two years between round one and two site visits. These reports-published within five months of the site visit- are the first longitudinal information HSC has released. Trend information from the surveys will be released starting in early 2000.
The site visits-which involve interviews with 40 to 60 key individuals in each of the 12 communities-allow HSC researchers to examine how purchasers, public policy, community norms and history constrain and shape the evolution of change. In turn, the visits provide insight into how local plans and providers respond to these forces.
In addition to examining the overarching forces and responses on the part of health care organizations in the sites, HSC researchers and collaborators will publish reports that focus on pressing issues that cut across all communities. These topics include: How are hospital mergers being implemented? How are safety net providers responding to market changes and Medicaid managed care? How widely implemented are financial and nonfinancial care management techniques? How is the role of specialty physician organizations changing?
The surveys and site visits as well as secondary data allow HSC researchers to examine how all of these changes affect consumers, particularly with respect to access, cost, quality and service use. Following are examples of studies HSC researchers have completed or are working on by key topic area. Visit HSC’s web site for a full listing of publications (www.hschange.com).
- Access to Care. HSC researchers have
published studies documenting that managed
care may be threatening access to care for the medically indigent and that variation exists
across communities with respect to both
employers offering insurance and ease of
referral to specialists.
- Costs. Premium rates vary across communities and HSC researchers are looking at the
reasons why. They have published articles tracking costs over time at the national level,
examining the factors behind cost and premium increases and speculating on what the future
may hold.
- Use of Services. Researchers are examining whether managed care
organizations are delivering
more preventive care and fewer intensive services, whether patients are seeing
physicians more
or less and what kinds of health services they are receiving across plan type.
- Quality of Care. Consumer satisfaction levels differ across communities, and researchers are examining the reasons why as well as how satisfied physicians are with the care they deliver-for example, in terms of the time they spend with patients. HSC researchers have also looked at how well consumer and physician perceptions about quality correlate at the community level.
These and other HSC studies have provided private and public policy makers with contextual information to inform their deliberations. The following are illustrative examples.
HSC research about how private insurance plans function with respect to care management and other dimensions informed the deliberations of the Senate Finance Committee as its members contemplated how to reform Medicare. An HSC Community Report and a related presentation provided information about how Phoenix compares to other markets for the Competitive Pricing Advisory Commission, the group providing advice to the Health Care Financing Administration as it pilots competitive pricing for Medicare+Choice plans. HSC studies about physician charity care, published in the Journal of the American Medical Association, and access for the uninsured, published in Health Services Research, were presented to 120 safety net hospital CEOs as they contemplate how to respond to the pressures their institutions face.
The number and complexity of the changes underway in the health system is daunting to some
and overwhelming to many. The community sketches that follow provide some sense of the pace
and nature of those changes based on events that occurred in 1998. They
suggest how challenging
these times are for those making health-related policy decisions. It is
our hope that HSC research can
provide decision makers-both public and
private-with sound, objective and timely diagnoses of what has changed and what those changes
mean. It is the accumulation of such decisions, both small and broad-based, that
will determine nothing less than the future
of our health system.
Collateral Studies in Community Tracking Study Sites
Researchers at other organizations are also conducting studies in the Community Tracking Study sites, enabling them to draw on HSC research to help interpret their results. These studies are funded by RWJF and federal agencies.
Clinical Quality
RAND researchers are assessing the quality of care delivered to children and people with chronic diseases in the 12 communities HSC is studying intensively. To gauge clinical quality, researchers are examining medical records and, in three sites, offering free health exams.
Public Health
Researchers at MPR are examining how local health departments are changing as a result of Medicaid managed care in HSC’s 12 study sites.
Alcohol, Drug Abuse and Mental Health
RAND researchers are examining how public policies and markets are affecting access to alcohol and drug treatment and mental health services. Interviews are being conducted with a sample of individuals from HSC’s Household Survey.
