Center for Studying Health System Change

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P R O C E E D I N G S

Opening Remarks

PAUL GINSBURG: Good morning. I’d like to welcome you to HSC’s third biennial conference on emerging trends in local health care markets. This is a meeting that we hold every two years after we complete our site visits to 12 nationally representative communities to track how the health care system is changing.

Our most recent round of site visits were conducted between June 2000 and March 2001, providing us with very up-to-date information about the state of local health care markets nationally and how they are changing.

I have to admit that every year before we go out on sites, we always have some trepidation. What if there’s no change to report on this time? How are we going to fill up these report. But, to date, the health system has not disappointed us, especially this past round, which was a particularly rich round as far as change.

Today’s conference is going to highlight some of the most compelling results from the last round of visits. We’ll hear about how the managed care toolbox is changing and what is on the horizon for new strategies to control costs and manage care. We’ll hear about how hospital competition is changing and discuss whether a new medical arms race is percolating in local markets. And among other issues, we’ll hear about what we can learn from observing Medicare+Choice from the local perspective over a period of six years.

In addition to the esteemed researchers from our project teams that will be presenting these papers, I’m pleased to welcome individuals from the study communities whom we have invited to enhance the discussion with a local market perspective. We’ll introduce each of these speakers at the relevant sessions, but I just want to stress here how happy we are to include some of our most insightful and thoughtful respondents in the conference. This actually is one of the most enjoyable parts of the conference, debating who of our respondents who are particularly thoughtful, articulate, that could help us here. So I think that they’re going to add a lot to this discussion, and I look forward to their contributions.

I’m also pleased to have Janet Corrigan from the Board on Health Care Services at the Institute of Medicine joining us to reflect on what current market developments mean for the quality movement, and she’ll have really important thoughts to share with us.

We do have a full day, but before we get started, I have some important acknowledgments that I’d like to make.

First, my deepest thanks to the more than 900 local health care leaders that we interviewed in our most recent round of site visits. These individuals generously have taken time from their busy schedules to share their perspectives on how the local market is changing, and many of them have done so on multiple occasions in the past six years, providing a strong continuity for our research. Without these individuals’ contributions, our site visit research would not be possible.

Second, I want to acknowledge the tremendous talent that we were fortunate to have on our project team for our most recent round of visits. We conducted the 2000-2001 round of site visits in collaboration with researchers from Mathematica Policy Research, the University of Washington, and individuals from selected academic institutions, including Lawrence Brown from Columbia University, Lawrence Casalino from the University of Chicago, Jon Christianson from the University of Minnesota, and Robert Hurley from Virginia Commonwealth University.

We’ve had a phenomenal experience working with these individuals to jointly collect the data and analyze the results. With these people and the HSC staff involved in site visits, the process has been a lot of fun, despite the heavy workload.

What you’ll hear about in today’s conference will give you just a glimpse into the extraordinarily high-quality and high-volume work produced by this group. Several other analyses based on our recent site visits are included in your binder, and many others are currently in the works.

Finally, I would like to thank the Robert Wood Johnson Foundation for its support of HSC and sole funding of this research.

Now, before we get into the core of the program, I’d like to turn to Cara Lesser, who is the Director of Site Visits for HSC, who will provide a bit more background on why and how we conduct these visits. Cara?

CARA LESSER: Thank you. Good morning. I just want to start with a brief introduction to give you some background on what you’re going to hear about today.

First, let me tell you a little bit about the Center for Studying Health System Change. HSC’s mission is to provide real-time, real-world insights into how the health system is changing to contribute to the development of sound and meaningful health policy.

As a nonpartisan organization, we strive to bring objective and unbalanced--not "unbalanced"--unbiased--

[Laughter.]

CARA LESSER: --balanced analysis to health policy. Our work is based on independent research conducted through site visits and surveys of households, physicians, and employers. And all of this is under a large research project called the Community Tracking Study.

Our site visits are our primary mechanism for keeping up with what’s happening on the ground in terms of changes in the organization and financing of health care. Because health care markets are fundamentally local, we believe that the best way to capture how the health system is changing is by observing a nationally representative sample of communities’ health care systems. This way we’re able to speak to the diversity of what’s happening in a variety of local health care markets while analyzing national trends.

Unlike other studies that focus on communities that are viewed as the trend setters, our study focuses on a group of communities that were randomly selected to be nationally representative, and that allows us to convey a more accurate picture of the average health care market nationally.

Plus, because we visit these same communities every two years, we’ve developed in-depth knowledge of these communities, and we’re well positioned to talk about how they’re changing.

This map shows the 12 study sites that we focus on in the Community Tracking Study. As you can see, the sample is geographically diverse, and the communities vary in size as well as health system characteristics, such as experience with managed care. We have a number of large metropolitan areas with high HMO penetration, such as Boston and Orange County, California, as well as smaller communities with less experience with managed care, such as Little Rock and Greenville.

As Paul mentioned, we interviewed over 900 people in our most recent round of visits. We strive to develop a balanced and nuanced view of the health system and how it’s changing by interviewing a broad cross-section of local health system leaders in each community.

Typically, we interview approximately 50 to 90 health system leaders in each site, including hospital and physician executives, executives from health plans, representatives of major local employers and benefits consultants, state and local policymakers, and others such as academics and reporters who have a broad perspective on the market. This table just gives you an overview of the number and types of interviews we conducted in our most recent round of visits.

In our analysis of the interview data, we triangulate the results to ensure that we have a fair and impartial view of what’s going on. So, in other words, to understand how health plans are changing in a community, for example, we don’t just take a health plan’s word for it, but we talk with hospitals, physician organizations, employers, and others and put these perspectives together to have a more balanced view of what’s going on.

As Paul mentioned, our site visit research is conducted collaboratively with researchers from our organization, Mathematic Policy Research, and selected academics. The project is organized around four research teams, each focusing on a particular sector or set of stakeholders in the health care system. And today’s conference features work from each of these teams, as well as some cross-team projects.

We’ll be highlighting some of the changes in terms of plans and employers, looking at whether the managed care toolbox is empty, and what role employers have played in shaping local health care markets. In our second session, we’ll be focusing on providers, looking at how risk contracting is changing, and whether changes in hospital strategy imply that there is a new medical arms race developing in local markets.

In the afternoon, we’ll have two sessions: one focusing on the safety net system of care for the low-income uninsured and examining how that’s fared over the past six years; and a second focusing on Medicare+Choice in local markets.

There is a lot to cover, so with that I’ll turn it back over to Paul to start the first session.

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