Health Services Research: Key to Health Policy
reviewed by Marilyn Rawnsley - 1992
The passage of the Title XIX Amendments to the Social Security Act in 1965 was a watershed in U.S. health care policy. More commonly known as Medicare and Medicaid, this legislation to provide publicly sponsored health care for the elderly and the indigent meant that the federal government became the largest purchaser of health care services for these groups, thereby ensuring its involvement in what had been largely a private, professionally controlled enterprise. Since that time, there has been a continued national focus on issues of escalating costs, inequitable access to services, regional differences in resources, and quantity and quality of technological and human interventions in health services. Despite heated political debates, particularly notable in election years, and a considerable body of ongoing research, these problems are persistent; twenty-six years later, most remain unresolved. Disentangling the effects of demographic changes in population, increased demand for health services, advances in biomedical technology, and economic flux embedded in a matrix of professional opinion and political rhetoric requires perhaps not only an expert but a seer. Fortunately, Eli Ginzberg, editor of this volume and author of its introductory and closing chapters, is such a person.
The stated purpose of this book, generated as a report of the Foundation for Health Services Research, is to provide a historically grounded description of the ways in which health services research has informed and sometimes influenced national health policy formulation since the 1965 legislation. For the uninitiated, some chapters may seem overly detailed and the multiple acronyms and abbreviations intimidating. However, a listing of abbreviations is included at the beginning of the book, and-chapter notes and the excellent reference lists are nondistractingly compiled in a separate end section. The thirteen contributing authors, all scholars in the field of health policy, present a comprehensive, internally consistent account of the successes and limitations of health services research in clarifying the underlying issues that health policies are intended to address. The subjects include health services research as a political resource, federal policy regarding hospital and physician reimbursement, health forecasting of projected physician supply, financing health care for elderly and poor Americans, health maintenance organizations and preferred provider groups as alternatives to the traditional fee-for service model, the RAND Health Insurance studies as an example of controlled experimentation, and last, but in this reviewers opinion, most central, a chapter that addresses quality of care.
No overstated claims are made about the impact of study data on health policy decisions. If anything, the authors appear reluctant to connect legislative actions to health services research. In general, they caution against over-optimism in attributing the outcomes of the political process to research findings; as one author notes, one may describe health services research as an attempt to enhance the folklore upon which policymakers make their decisions (Reinhardt, p. 283). Nevertheless, each of the nine contributed chapters thoroughly documents the facts surrounding its topic, summarizes the relevant health services research, and attempts to analyze the policy recommendations that were instituted, or repealed, in connection with those health care issues, The result is an interesting, objectively presented narrative of the contemporary struggle to balance the national interest in maintaining the health of a majority of citizens against the special interests of groups involved in health care services as private enterprise.
While it is evident that the book is heavily weighted toward economic interpretations and prescriptions, and although the term health services is repeatedly used as a synonym for medical services, thereby excluding other disciplines making essential contributions to health care, it is nevertheless an insightful account of the twenty-five years of policymaking that is shaping our collective health care future. As such, this book should be required reading for graduate students in health administration, health education, medicine, dentistry, nursing, public health, social work, or any other discipline whose scholarship or practice interfaces with the health care field. Since the long-range effects of federal regulation on health services eventually alter delivery of services in the private sector, even educated consumers who have begun to notice that increased health insurance rates are no protection against balance billing for medical procedures may want to expend the effort to decipher the bureaucratic health legislation codes. Such global applicability is not merely due to the objectivity and accuracy of this book, although that would be sufficient recommendation for its adoption. It is because this work, like any true scholarly effort, goes beyond its stated purpose to raise provocative questions about the human forces and motivations underlying health care services that may be more powerfully persuasive in policy formulation than dispassionate methods of providing facts.
Several compelling issues emerge. Can the economics of the U.S. health care system be meaningfully explained by market theory? Can the target-income hypothesis, which postulates that regardless of supply, physicians will generate demand for services to meet an expected income level, be substantiated? If there were an oversupply of physicians, could it negatively affect the national health? Should measures of quality health care be refocused from individual patient outcomes to population parameters? Are hospital cost-containment models actually cost-shifting strategies? Does cost-sharing reduce indiscriminate use of health services or might it keep individuals from seeking needed care? Can professionals be counted on to control costs voluntarily, and, if not, are there sanctions? When are federal solutions to health care problems warranted and when do they impinge on professional judgment? Identified problems and demonstrated solutions notwithstanding, who will ultimately bear the costs?
There are limitations in a predominantly economic approach. While most persons would support in principle models that purport to control escalating health care costs, in practice, the selection of a health practitioner or service is a personal choice. When the issue is prevention or maintenance, cost containment that prescribes and regulates services may be of little concern to a consumer, but when a health problem is life-threatening, disabling, or persistently painful or when it requires technological intervention and professional skill that lie outside the scope of routine practice, persons do not look for bargains. The term doctor-shopping does not refer to comparison pricing; it means the search for hope.
In classifying three distinct camps of health service researchers as economists, technocrats, and planners, Brown (pp. 36-39) makes a passing reference to their lack of integration of insights from health-related studies in disciplines such as psychology, history, anthropology, and sociology in prescribing solutions. In the closing chapter, Ginzberg cites alteration of physician knowledge base and modes of practice as fundamental to improved medical/health services. While it is unreasonable to expect a single volume to address the multiple issues that surround health services, perhaps a second volume on health services research, one that gives voice to the ethicists, historians, medical anthropologists, and sociologists, as well as to researchers in health disciplines making significant contributions independent of medicine, would accelerate the inclusion of insights about human dimensions of health services into physician education and health policy planning. Health is, after all, a profoundly human affair.