Most of the current information on the structure of the health system is oriented toward the counting of the individual types of resources (like providers, facilities or health plans) that make up the structure. In contrast, our project showed that there is a need for information that would allow one to interpret the adequacy or change in these resources and to better understand the relationships of these resources both to one another and to the current financing system. (See Table 2 for illustrative questions gathered in the project.)
QUESTIONS HIGHLIGHTING DATA GAPS: STAKEHOLDER CONCERNS
ON RESOURCES AND STRUCTURE I
A. Physicians and Other Individual Providers
- Is the nature of a “doctor” changing from entrepreneur to employee--Who is buying and selling practices, with what deals and effects? How is the form of practice changing?
- What is the meaningful bed capacity taking staffing levels into account?
- What is the right benchmark for assessing change in hospital staffing?
- How is the nature of a “hospital” changing as it develops linkages with other parts of the system and what are these linkages (e.g. how many different arrangements do hospitals have with physicians, what types of arrangements).
- What changes are occurring in the nature of retail outlets for pharmaceuticals?
- What is the role of mid-level providers, how is it changing, and how can we describe “other professionals” meaningfully?
B. Linkages Between Providers, Facilities, and Health Plans
- How can we get consistent and meaningful information on the number and characteristics of health plans in different markets?
- What is really driving market level differences in managed care penetration? For example, what role do employer coalitions play?
- How can one assess whether provider networks are “adequate”? What does a staffing ratio mean? What is the capacity of a given system? Is there genuine access? Is red-lining occurring in some low income or minority areas?
- What is the downstream financial risk? How much risk is being transferred from purchaser to plan to provider? Who actively bears the risk and under which arrangements?
- What does ownership in systems really mean (e.g. real systems versus purchased assets, what are affiliations)?
- What should the unit be for accreditation? For example, there are nested entities and many parts in each entity. What is a taxonomy for classifying and which should be used?
- What are the fixed versus variable costs of different structures and what does this imply for consolidation?
- Is there really a trend toward horizontal networking of providers (e.g. particular specialists?)
C. Integration of Acute Care and Long Term Care
- How can we best track the newer kinds of long term care institutions, like assisted living or domiciliary care? What segment of the market are they serving?
- How should we integrate community based care and institutional long term care?
- What are the implications of developing new services like sub-ealite care?
Physicians and Other Individual Providers. Interest in the structural changes in physician and hospital practice and in how these practices overlap is growing. With respect to resources, for example, those concerned with physicians are interested in understanding how the concept of “doctor” changes as physician practices are bought and group practice grows. In an era of concern about costs and downsizing, there is great interest in knowing the actual bed capacity of the system and the best way to assess the “adequacy” of hospital staffing. For example, when workers are being laid off, it would be useful to have information on what a quality though still “lean and mean” system looks like, and on the difference between this and situations that threaten patient care. These kinds of questions, common to providers and policy makers, are hard to answer when existing systems provide limited information on the characteristics of physician practice and the structural features of provider organizations. Similarly, the absence of information linking resources to performance makes interpretation of physician practice difficult.
The competitive marketplace is altering the nature of existing provider relationships as well as the players and their roles. Those representing hospitals, for example, are most interested in understanding how the nature of a “hospital” is changing with the shift from the provision of inpatient services to broader systems of care with potentially more formal physician affiliations. Those representing mid-level providers or “other” professionals want better data on these human resources to understand how their roles are changing. For example, are they being used more or less, and by whom? It is impossible to know this when existing data systems capture only information on individual entities and not what they do, and when the categories and types of information captured are not consistent across providers or settings that may substitute for one another.
Managed care also is changing the provider mix. For example, retail outlets for pharmaceuticals now include larger roles for mail order and managed pharmaceutical practices. This change creates a need to capture more data if users are to continue to get accurate information on the pharmaceutical sector.
Linkages Between Providers, Facilities, and Health Plans. With respect to structure, our interviews revealed that the most pressing need is for better information on the linkages between providers, facilities, and health plans. The existing information in this area is highly limited. One key gap is the absence of consistent and meaningful information on the number and characteristics of health plans in different markets. While there is some information on HMOs, the information available on other managed care entities is inconsistent, and there is limited information as on which entities serve which markets and to what extent. The absence of such information also makes it difficult to obtain information on other aspects of managed care delivery, which are of key interest. For instance, there is a need for better insight into the adequacy of provider networks when staffing ratios are inadequate and into how to capture, describe, and assess the transfer of risk downstream. The consolidation of providers is also raising other questions. For example, how can structure be understood when parts of the health care system are related to each other through contracts as well as ownership, and through overlapping relationships among associated entities like the hospital, hospital system, and associated physician organizations that may represent primary care physicians, distinct specialties, and other groups? How does one answer such questions when there is often not a list from which to sample, and when it is not clear who can provide what, or when what is provided may be changing over time. We identified some efforts to develop frameworks to support this kind of data collection by researchers like Gloria Bazzoli and Steve Shortell, James Robinson and Harry Castalino, Jeffrey Alexander, and Marsha Gold. However, the activities were at a very early stage and oriented more toward theoretical constructs than ongoing data collection needs.
Integration of Acute and Long-Term Care. The movement to managed care and competition creates the most pressing information needs for the acute care sector. For long-term care, however, developments in the market create a need for a different but analogous kind of information. For instance, most of the historical information on long-term care is specific to institutions. However, the emergence of assisted living facilities and other new types of long-term care, along with a growing emphasis on community-based care, have caused a shift in the marketplace. There is therefore a pressing need for information on the causes and nature of this shift if we are to address immediate long-term care issues in the appropriate context. In addressing the information needs unique to each sector of care, we must also consider the fact that acute and long-term care are part of the same continuum, and that market forces that shape the former will also affect the latter. For instance, the managed care arrangements that continue to define and redefine the system of acute care will also influence how this type of care is received by people in long-term care. As a result, we can expect there to be a growing need for information on the implications of the relationships between these two systems of care, although this need was not made explicit in our interviews. A key example of the significance of this relationship is the emerging work designed to understand how to construct managed care systems that are sensitive to the chronic care needs of those served by Medicaid. These efforts will require considerably more information than we now have on non-institutional providers of long-term care and their relationships to each other and to the acute care sector.