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How does health services research become health policy? What is the role of such research in controlling health care costs? In developing prospective payment systems for hospitals? In helping states to respond to federal cutbacks? In reforming the reimbursement of nursing homes? This book addresses these questions.
Marion Ein Lewin is director of the Center for Health Policy Research at the American Enterprise Institute. She is the editor of “The Health Policy Agenda: Some Critical Questions” (AEI, 1985).
Introduction
In the world of policy making and politics, the discipline of health services research has often experienced rough sledding. Not as widely acclaimed or as well understood as biomedical research, this field, along with many of the other social sciences, has had to struggle for recognition and support. A number of reasons can be cited to explain this state of affairs. In health services research, as opposed to the “hard” sciences, cause and effect are not always readily apparent; the contribution of a specific piece of research to better health care is often difficult to trace.
Health services research has never garnered the powerful constituencies that some other disciplines enjoy. People do not see themselves as immediately affected by the fruits of this kind of research. In health care as in other areas, moreover, support is always easier to rally in behalf of a solution to a particular problem than in the cause of a general area of study.
Perhaps most significant, a chasm of misunderstanding has long existed between researchers and the decision makers who use their product. Policy makers have often perceived researchers as addressing principally other researchers and their aims as obtaining tenure or publishing articles in professional journals. In the eyes of many policy makers, researchers often do not focus on the key questions or write in language that supports decisive action. Researchers feel that decision makers’ demands for quick solutions and bottom-line answers, as well as their propensity to mix facts with value judgments, can undermine standards of scientific integrity.
Recent years, however, have witnessed a resurgence of interest in health services research. Efforts have been mounted to make the field more cogent and more relevant by bridging the gap between the spheres of researchers and decision makers. The chapters in this book can be seen as success stories in behalf of these objectives. They not only underscore the key role that health services research can play in shaping new directions in public policy but also show us the potential value of closer collaboration and better communications between social scientists and political actors.
Looking at national health policy over the past fifteen years, Lynn Etheredge, in “Government and Health Care Costs: The Influence of Research on Policy,” traces the significant influence of health services research in expanding government and private sector efforts to come to grips with health care financing and delivery and cost containment issues. A number of major federal initiatives during this period—in health professions training, prepaid capitated delivery systems such as health maintenance organizations (HMOs), utilization review, health planning, and technology assessment—stemmed directly from health services research.
According to Etheredge, however, the evolution of health policy research into health policy is not an orderly process. Political realities have often led to the hasty nationwide implementation of new programs based on the research findings available at the time. Later, armed with new information and practical experience, decision makers may ask to reshape or reverse gears on measures once enthusiastically adopted. The lack of orderliness and predictability has other causes. Health research constitutes a vast marketplace of ideas with divergent views about the health care system, about how different reforms would work, and about which outcomes are desirable. The government, contends Etheredge, has nurtured research, but that research has more often than not led to conflicting conclusions about optimal health policy in areas such as the allocation of health resources, HMOs, professional standards review organizations (PSROs), and disease prevention and health promotion.
The author further suggests that the policy debate in health has been in great measure shaped by the competing ideas and frequent rivalry among three disciplines: public health, economics, and medicine. Each has its own ideology and orientation. The public health perspective, that of matching funds with needs, has traditionally been influential in steps taken both to expand and to regulate the supply of health resources. Economics has played a growing role in health policy affairs since the 1970s and has been largely responsible for the dramatic and far-reaching swing to a more competitive, market-oriented health system, based chiefly on incentives rather than regulatory controls. A dominant position in the making of health policy has long been enjoyed by the nation’s physicians and medical schools. Only recently has their preeminence begun to be challenged by large purchasers of care wielding increasing power. Over the years the medical profession has been strongly opposed to moves—financial or other—that would interfere with the traditional relationship between physician and patient or would undermine the various missions of academic medical centers.
A theme sounded by Etheredge and echoed by the other authors in the book is that those who labor in the field of health policy analysis and research must always contend with powerful economic, political, and cultural forces. Interest groups exert at least as much influence as the research community on the policy-making process.
One of the most dramatic effects of health policy research has been the development of diagnosis-related groups (ORCs) and their adoption in 1983 as the basis for Medicare’s prospective payment system. In “From Health Services Research to Federal Law: The Case of ORCs,” Joel Menges points out that this watershed legislation was speedily enacted for a number of reasons. Perhaps most important was the availability of a knowledge base accumulated over many years as the direct result of impressive health services research efforts to develop stronger and more precise hospital payment methods.
Menges reminds us that the inflationary characteristics of Medicare’s reasonable-cost formula were already apparent in the early stages of the program. The Social Security Amendments of 1967 sanctioned experiments with alternative methods of reimbursing both institutions and physicians. Sections 222 and 223 of the Social Security Amendments of 1972 marked a further thrust in this direction by authorizing additional testing of prospective and other payment methods. At about this period the government began to finance a group at Yale University that was developing a conceptual framework for identifying a hospital’s “output” through the use of a case mix or ORCs. In 1974 New Jersey propelled this concept into practical application by adopting the ORC system as a basis for paying hospitals and thus provided a valuable laboratory for researchers, who were increasingly interested in this payment method as a basis for Medicare hospital fees.
The development and passage into law of the prospective payment system employing ORCs is a fascinating case study of what is possible when policy research and politics are attuned to the same issue. A consensus was growing that relentless double-digit inflation year after year in the hospital industry could no longer be tolerated, that regulatory programs that had been instituted to dampen the cost spiral had been singularly ineffective. The time was ripe to try an entirely new approach to hospital payment. The Reagan administration came to power on a platform of leaner government and market-oriented reforms in health care.
The unusually rapid congressional approval of this fundamental change in Medicare payment was due to other factors as well. Hospitals were operating under the restrictive reimbursement limits mandated by the Tax Equity and Fiscal Responsibility Act (TEFRA) of 1982. Although little was known about the effect DRGs would have on different classes of institutions, an incentive-based prospective payment system seemed on the face of it the lesser of two evils. Minimal time was provided to debate the pros and cons of this far-reaching legislation; less than a month passed between the introduction and passage of the bill that became Public Law 98-21.
If the development of the prospective payment system and DRGs demonstrates the substantial effect health services research can have on the policy-making process, its implementation has provided a fertile field for further research and evaluation. From the very beginning it was clear that ORCs as a hospital payment method would require considerable modification. At the request of Congress, the Prospective Payment Assessment Commission (ProPAC) was created as a nonpartisan, independent group charged with recalibrating DRG rates to reflect changes in treatment patterns, technology, and other factors that may change the relative use of hospital resources. The new payment system has been criticized for not taking sufficiently into account the severity of illness and thereby putting at a disadvantage hospitals that treat sicker patients. The effects of DRGs on access to care and on quality of care remain high-priority concerns and topics of keen interest to researchers. Lively debate continues on how to incorporate payment for capital expenditures into the DRG-based prospective rates. A host of research efforts have been launched to examine the feasibility of developing DRGs for physicians, long-term-care facilities, and mental health services.
The chapters “Health Services Research and the Policy-making Process: State Response to Federal Cutbacks in Programs Affecting Child Health” and “Doing Research for Decision Makers: Nursing Home Reimbursement” present two thought-provoking case studies on brokering health policy research so that it can be used more effectively and persuasively by state decision makers. By coincidence, both focus on efforts spearheaded in Minnesota. Ira Moscovice discusses the role of research in assessing the effects of federal cutbacks on child health and in developing a state response to those reductions. Barbara Manard addresses the pressing issue of the reform of nursing home reimbursement.
A notable trend in recent years has been the states’ leadership in charting new health care reforms. As states and localities have been granted greater leeway and responsibility for health care financing and delivery, the need of elected officials and senior program experts for information has escalated. Both are now viewed as active and influential markets for health services research and its products.
The Moscovice and Manard articles offer valuable insights into the differences between the culture of research and the realities of the political process. The constraints and opportunities of the policy world place a premium on timely and relevant responses to immediate concerns. The challenge for policy researchers, the authors point out, is to match the scope and design of the research to the subject and to the uses required of the findings. The emphasis, Manard contends, “is more on finding a ‘not too badly wrong’ answer right now than on finding a ‘correct’ answer at some later date.”
Policy researchers working with decision makers need to recognize that most programs and policies—whether state or federal—are built incrementally and are more likely to be changed by tinkering than by wholesale restructuring. Policy research that argues, however convincingly, for major program overhaul may be of marginal value to elected officials operating within a restricted budget, period of time, and political environment. Moscovice’s chapter provides a case in point. He describes Minnesota’s interest in expanding maternal and child health services to low-income uninsured families. After considerable analysis and debate, two options were proposed: a statewide insurance pool and Medicaid expansion, both to serve poor pregnant women and children. Medicaid expansion was chosen as the preferred strategy largely because it built on an existing program with an established administrative structure.
High-quality research that is useful to policy makers requires access to good information and reliable data. The rapid pace of change that characterizes today’s health care system means that the most relevant and timely information may be found not among published works in university libraries but in a variety of other settings, such as government agencies, trade associations, and consulting firms. As the focus of decision making is increasingly shifted to state and local government, Moscovice stresses, the need arises to develop local data bases and related resources. Unfortunately, data collection and program evaluation have been severely curtailed in recent years because of budget cuts and changing federal policies.
Researchers are called upon throughout this volume to work closely with political actors to learn more about the conditions that stimulate the effective use of research in the making of policy. Among them is the overriding importance of communicating the results of health policy research to decision makers clearly, pertinently, and expeditiously and of maintaining research integrity while simplifying extremely complex information.
The essays in this book indicate that the field of health services research is alive with opportunity. Whereas past policy research was primarily focused on federal programs and policies, today states and local governments, as well as the private sector, are becoming extensive users of this kind of expertise. In an era of limited dollars and growing needs, well-informed decision making has become a premium commodity. Forging a stronger partnership between health policy researchers and decision makers can help us reap the profits.
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