An Update on the Community Tracking Study:
A Focus on the Changing Health System
Issue Brief No. 18
February 1999
major research project of the Center for Studying Health System Change (HSC)
analyzes how the health system is evolving in 60 communities across the United States
and the effects of those changes on people. Underway since 1996, the Community Tracking
Study, which is funded exclusively by The Robert Wood Johnson Foundation, is a
longitudinal project that relies on periodic site visits and surveys of households,
physicians and employers. The study is intended to provide a sound information base
for decisions made by health care leaders. This Issue Brief provides an update of the
study’s design and research agenda.
Community-Focused and Longitudinal Research
he health system is changing in
virtually every city across the country. Market competition is increasing, and
various forms of managed care are becoming dominant. While some argue that these
changes are controlling costs and improving quality through better management of
care, others are concerned about barriers to specialized services and poorer quality.
A public backlash against these health system changes and calls for increased
regulation of managed care are indicative of the national debate about the future
of health care.
While many studies have examined leading markets in California and Minnesota and
analyzed local or selected data, there has been no systematic study of change in
a broad crosssection of U.S. markets or analysis of the effects of those changes
on service delivery, cost and quality. The Community Tracking Study is designed
to provide sound empirical evidence that will inform the debate about health
system change. The study addresses two broad questions that are important
to public and private health decision makers:
- How is the health system changing? How are hospitals, health plans, physicians,
safety net providers and other provider groups restructuring, and what key forces
are driving organizational change?
- How do these changes affect people? How are insurance coverage, access to care,
use of services, health care costs and perceived quality of health care changing over time?
Focusing on communities is central to the design of the Community Tracking Study.
Understanding market changes requires studying local markets, including their
culture, history and public policies relating to health care. HSC researchers randomly
selected 60 communities stratified by region, community size and type
(metropolitan-nonmetropolitan) to provide a representative profile of change
across the United States.
Of these communities, 12 are
studied in depth, with site visits and survey samples large enough to draw
conclusions about change in each
community. These communities are a randomly selected subset of the sites that
are metropolitan areas with more than 200,000 people.
The 12 metropolitan areas selected are:
- 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.
- Syracuse, N.Y.
The 48 additional communities, which also include small metropolitan and
nonmetropolitan areas, are studied less intensively, with smaller survey samples
and no site visits. The information from all 60 communities enables researchers
to: (1) place findings from the 12 communities in the context of health system
change in the nation; (2) draw statistically reliable conclusions about health
system change nationally; and (3) relate access, cost and quality to health
system differences, such as the amount and type of managed care, across
communities and over time.
Since the focus is on change, the study is longitudinal. By collecting and
analyzing information every two years, the study tracks changes in the same
communities. Data for round one spans 1996-1997 and round two, 1998-1999.
Researchers in other organizations are studying the same communities in an
effort to gain additional knowledge and insights about health system change.
These collateral studies are looking at issues outside the focus of the
Community Tracking Study - for example, clinical quality of care, alcohol
and substance abuse treatment, mental health services and public health
(see Collateral Studies in the Community Tracking Study Sites below).
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Combining Multiple Data Sources
ne of the key design features of the
Community Tracking Study is the collection of data from a variety of sources in
the same communities. Having data from household, physician and employer
surveys in the same communities permits researchers to track multiple measures of
access, service delivery, cost, perceived quality and health system characteristics
at the community level. Data in common sites also permit analysts to relate the
measures obtained from one survey to health system characteristics at the market level
obtained from the other surveys -
for example, to relate physicians’ assessments of quality to the type and amount of
managed care, physician practice arrangements and supply of physicians in the market.
And conducting site visits in the same communities provides an in-depth, qualitative
understanding of the health system to inform the analysis of the survey data.
Site Visits
During site visits to the 12 communities, researchers gather information through
interviews with individuals in the major sectors of the health system, including
purchasers, health plans, hospitals and physician organizations as well as other
key organizations in the market. These
visits provide valuable community-level information that is difficult to get in
surveys, such as the strategies of health
care organizations and local norms. The
visits also provide a context for
cross-market variation in measures of access,
service use, cost and perceived quality drawn from the surveys. HSC conducts the site
visits in collaboration with The Lewin Group.
Surveys
Much of the information about changes in the health system and the effects of these
changes on people comes from nationally representative telephone surveys of households,
physicians and employers (see What People Are Asked: Sample Survey Questions below). Approximately half of the 1998-1999 sample includes respondents to the
1996-1997 surveys and half is new. The
longitudinal cohort permits analyses of change for the same respondents at two
different times; the new cross-section ensures that the sample continues to be
representative of the community’s population, thus permitting tracking at the
community level.
- Household Survey: Many people are
concerned about how the changes taking place in health care are affecting them,
and the Household Survey is designed to collect objective information about these
effects. Is access to services getting better or worse over time? Are more people
uninsured today than two years ago? Questions in this survey cover health insurance,
access, service use, satisfaction with the care received, health
status and sociodemographic characteristics. More than 60,000 persons in 33,000
families are interviewed for the survey, which is conducted by Mathematica Policy
Research, Inc.
- Physician Survey: Practicing physicians provide important insights
given the central role they play in health care. For example, has the complexity
or severity of the medical conditions that primary care physicians treat without
referring patients to specialists increased, decreased or stayed the same over
the past two years? What kinds of financial incentives do physicians face? To
capture such information, the Physician Survey
questions more than 12,000 physicians in direct patient care about their
practice arrangements, sources of practice revenue and level and determinants
of compensation. Physicians are also asked about their ability to deliver care
and the effects of care management strategies on care delivery. The Gallup
Organization conducts this survey.
- Employer Survey: Most people have access to private health insurance
through the workplace, and employers are increasingly influential in shaping the
health system through their role in purchasing insurance for their employees. To
better understand this, more than 22,000 private and public employer establishments
are surveyed on
the types of plans they offer employees and the cost of premiums to both employers
and employees. Employers are also asked what techniques they use to control costs, such
as participating in purchasing pools, and what quality information they provide to
employees. HSC collaborates with RAND
on The Robert Wood Johnson Foundation Employer Health Insurance Survey.
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Tracking Changes in the Health System
nalyses of the dynamics of
health system change focus on the forces driving that change and the way health
care organizations are responding.
Forces Driving Change
Several major forces of change are at work at the community level. Efforts of
purchasers - private employers and Medicare and Medicaid - to control the cost of
health care and changes in public policy are two consistent forces across the
12 markets. At the same time, community norms and the history of plans and
providers in each market both constrain and shape the evolution of change.
Researchers are continuing to track how purchasers, policy and other forces
are altering the behavior of health plans and providers.
Responses of Health Plans and Providers
In response to purchasers’ pressure to
control costs, health plans, hospitals and physician organizations are
consolidating and integrating vertically to increase their bargaining power.
In addition to tracking and analyzing these changes by comparing and
contrasting the 12 communities, researchers are addressing a number of
specific questions in depth. How are Blue Cross-Blue Shield plans
transforming themselves in the changing competitive market? How are
hospital mergers being implemented? How are safety net providers
responding to market changes and Medicaid managed care? How widely
are the various financial and nonfinancial tools designed to manage
care being used, and how are the tools evolving?
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Tracking the Effects of Changes on People
nalyses of how changes in the
health system are affecting people focus on access to care, how care is delivered,
costs and the quality of care as perceived by physicians and patients. Most of this
information comes from Community Tracking Study surveys.
Access to Care
There is a growing concern that competitive market pressures are resulting in less
care for the poor, the uninsured and people in poor health. At the same time, managed
care plans may be enhancing access of the insured by, for example, reducing cost
sharing and improving management of chronic conditions. Researchers are analyzing
these issues and have documented variations among communities in providing insurance
coverage, ease of referral to specialists and access to care for the uninsured.
Service Delivery
Of all the changes taking place in the health system, changes in the delivery of care are
the ones most likely to have an immediate effect on people. For example, are health
maintenance organizations delivering more preventive care and fewer intensive services?
Researchers are looking at the changing scope of care that primary care physicians
provide and the variations over time in how often patients see their physician and
the type of health services they receive.
Costs
Premium rates vary across communities, and HSC is studying the extent of these
variations and possible causes for them, including demographics, health status,
size of employers and the prevalence of managed care. In
addition, researchers are tracking changes in health care costs over time at the
national level, addressing, for example, whether the share of costs borne by
individuals (as opposed to employers or public programs)
is increasing or decreasing.
Perceptions about Quality of Care
The growth of managed care is raising concern among consumers about quality of
care. How satisfied are people with the care they receive? How satisfied are
physicians with the care they can deliver - for example, in terms of the time
they spend with patients? Do the perceptions of consumers about quality correlate
with the perceptions of physicians?
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Status of Research
he Community Tracking Study
baseline data were collected in 1996 and 1997. A number of Issue Briefs, Data
Bulletins, journal articles and reports using these data have been completed
since then. The second round of site visits is complete, and analysis of what
has changed at the site level since 1996 is available in a new publication
series, Community Reports. The second round of surveys is underway, and
longitudinal analyses comparing new survey findings to the baseline data
will be available starting in 2000.
Peter Kemper, vice president of HSC, has been the principal investigator
of the study since its inception. For more information about the Community
Tracking Study research design, see "The Design of the Community Tracking
Study: A Longitudinal Study of Health System Change and Its Effects on People"
by Peter Kemper et al., which appeared in the Summer 1996 issue
of Inquiry.
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Collateral Studies in the Community Tracking
Study Sites
esearchers at other organizations
are conducting related studies in the Community Tracking Study sites. This enables
them to draw on HSC’s data collection and analysis when interpreting their results
and to use the surveys to identify special subgroups for additional data collection.
Clinical Quality.
The quality of care delivered to persons with chronic disease
and children is the focus of a RAND collateral study in the 12 site visit
communities. Using a sample drawn from the Community Tracking Study Household
Survey
sample, researchers are focusing on two major questions: How good is the quality
of care, and who is at greatest risk for receiving poor quality of care? To get
information about clinical quality, researchers are examining medical records in
all 12 sites and offering free health exams in three of them.
Alcohol, Drug Abuse and Mental Health.
How are public policies and markets for
alcohol and drug treatment and mental health services changing across communities,
and how do these variations affect the availability of insurance coverage for
people needing services? RAND researchers are learning more about changes in
services for at-risk persons within and across communities through interviews with
a sample drawn from the Community Tracking Study Household Survey sample.
Managed Behavioral Health.
Researchers at Brandeis University’s Institute for
Health Policy are conducting several studies of managed behavioral health care
that are linked to the Community Tracking Study. The core study consists of a
telephone survey of managed care organizations in 30 of the 60 Community
Tracking Study sites. Researchers are also analyzing the mental health and
substance abuse coverage data from the Employer Survey.
Public Health.
Most public health departments - a significant component of
the nation’s health care safety net - are facing changes as a result of Medicaid
managed care. Researchers at Mathematica Policy Research, Inc., are analyzing
how the role
of the health department is changing in the same 12 communities in which HSC
conducts site visits.
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What People Are Asked: Sample Survey Questions
From the Household Survey
- Was there any time during
the past 12 months when you did not get medical care you needed?
- Do you trust your doctor
to put your medical needs above all other considerations when treating your medical problems?
- How would you rate how
well your doctor listened and explained things in a way you could understand?
From the Physician Survey
- In the last two years, were you part of a practice that was purchased by another practice or organization?
- During the last two years,
has the number of patients whom you refer to specialists increased, stayed the same or decreased?
- Is it possible for you to provide high-quality care to all
of your patients?
From the Employer Survey
- How many different plans do you offer at this location?
- Do you pay part of the premium for employees and, if so, how much?
- Are plan enrollees required to select a gatekeeper to make referrals to most specialists?
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More About HSC
HSC’s mission is to inform decision makers about changes in the health system at
both the local and national level, and the effects of such changes on people. HSC
seeks to provide objective, incisive analyses that lead to sound policy and
management decisions, with the ultimate goal of improving the health of the
American public.
In addition to the Community Tracking Study, HSC conducts the following research
and activities:
- analysis of secondary health-related data from government and private
sector sources;
- seminars and conferences on health policy issues and research on health
system change; and
- publications featuring HSC research and seminar findings.
HSC has a commitment to make its study findings and survey data available in a
timely and easily accessible format to health care decision makers, researchers,
the media and the general public. Information on all of HSC’s publications and
the public use files from the round one Household and Physician Surveys is
available at www.hschange.com.