A great deal of mythology exists regarding how changes blanketing the healthcare landscape have affected patient care. But until now there has been little concrete evidence to support either the advocates of change or the naysayers.
Soon, however, physician executives will have access to information on how cost-reducing innovations in healthcare delivery affect both patients and providers, thanks to an unprecedented amount of new research by the federal Agency for Health Care Policy and Research.
As many as 18 agency-supported research projects that focus on the impact of market changes fostered by managed care will be completed during the last half of this year. The results of several of the studies are scheduled for publication this fall.
The research is intended to benefit Congress, HCFA, state officials and private employers. "We hope all those policymakers get enough answers about the relative outcome (of different delivery techniques) to make good decisions," says Irene Fraser, director of the AHCPR Center for Organization and Delivery Studies.
The result of a $3 million effort by the agency, the studies examine the effects of recent market forces. Among the topics explored are the effects of hospital mergers on efficiency and profitability, the impact of managed care on physician practices and whether HMO and PPO patients use more efficient, lower-cost hospitals.
Other studies measure the quality of primary care under managed care and the effects of gatekeeping and risk transfer on use of services. Also examined are changes in the delivery and location of care and how managed-care companies determine access to medical technology.
The research, according to James Rodgers, M.D., American Medical Association vice president for health policy, "will be very helpful for everyone," particularly managed-care organizations that are "constantly searching for ways to improve the quality of healthcare they deliver."
While larger managed-care groups have been examining quality of care for some time, Rodgers says the national scope of the new research can identify areas where managed care "may want to take a look."
Rand Corp. researcher Jose Escarce, M.D., who is participating in the program, says there has been an "enormous number of innovations in the last decade and (the rate) has accelerated in the last few years." He believes this body of research will document the effects of that change and "lay the groundwork for ongoing research."
Collecting and disseminating data on the effects of organizational techniques on delivery of care is a priority of AHCPR Administrator John Eisenberg, M.D., and it's a subject he wants to pursue with more resources in the future.
"We need to measure and understand the effects of (market) change in the way we organize medical care, both the positive and the negative effects," he says.
"We need to measure these effects with the same scientific rigor" used in clinical studies.
In June, the agency announced an additional $800,000 in grants to track the impact of managed care on the healthcare system and to improve the quality of healthcare services provided in primary-care settings.
Among the topics funded were factors influencing hospital contracting with managed-care plans and assessing health data needs in a changing environment.
The agency and its predecessor, the National Center for Health Services Research, have long supported research on the organization and payment mechanisms of medical care, including studies of the DRG methodology adopted by Medicare in the 1980s. But in recent years, the emphasis on market forces research has increased, Fraser says.
Among the catalysts for the new emphasis on market research was the increase in "natural experimentation" occurring in the marketplace and expanded reliance on the private sector for market innovations, Fraser says. Those factors led the agency to boost funding in market research and to establish CODS in 1995 as one of the newest of its nine research centers.
One early example of the agency's efforts is a study published in 1996 that found physicians earned almost 4% less in 1994 than in 1993, marking the first time nominal wages decreased for physicians since salary data collection began in 1982. The authors of the study, Carol Simon and Patricia Born, suggested the decline could be attributed to managed care. Simon is an associate professor at the Institute of Government and Public Affairs and the School of Public Health at the University of Illinois; Born is an economist at the American Medical Association Center for Health Policy Research.
"The 1994 physician income numbers . . . may be the first evidence that managed care has had a widespread effect on physicians' earnings in particular and on health spending in general," the study concluded. The findings were published in the fall 1996 issue of Health Affairs.
Ongoing research is revealing some unexpected patterns, Simon says. For example, earnings of primary-care physicians are slowing, as are those of specialists.
So far, few of the studies have found new cost-cutting techniques to be harmful to patients, Fraser says. "For the most part, what the research has shown, happily, is that when you try to improve quality, you end up saving costs as well," she says. "That's really the major finding."
Nellie Bristol is senior editor for Health News Daily, Washington.