There is a need for much more information that could be used to describe the health system both in terms of function and in how the relationships of its components are evolving in an era of consolidation, integration, and managed care. The needs in this area correspond to the resource and structural issues we discussed, and to the related concerns about the ability to describe what these changes in functional relationships mean for the process of health care delivery. The perceived need for this kind of information seems relatively recent, and there is both little historical work on which to build and major barriers to progress. For example, some information needs are so “simple” as an inability to even decide which entities should be defined for data capture when both these entities and their linkages are unstable, shifting, and so little documented in the marketplace.
This set of needs is probably the most complicated that HHS will address because work in this area is relatively undeveloped. We suggest that HHS may find it useful to the many focus on four gaps that weaken stakeholders’ ability to understand how the health care system is structured today and how care delivery works.
Census of Insurance/Managed Care Plans/Products.
There are large gaps in data on health insurance products nationwide. Collecting information on health insurance has not historically been viewed as a “health system” function. It has been handled through insurance functions, largely at the state level, and there are many gaps associated with the federal ERISA preemption and with the rapidly evolving managed care marketplace, which has challenged regulators. Working with states, the NAIC has focused closely on the issues of interest here. Federal activity is focused in DOL, which has oversight for ERISA. Yet, the health policy and research community is also interested in this area, since it provides an enumeration set that is important for other kinds of data collection activities and basic structural information that currently is absent.
- Suggestion #1a. HHS should meet with NAIC staff and appropriate federal policy makers to discuss the status of ongoing activity and perceived strengths, limits, and needs.
- Suggestion #1b. An appropriate HHS role could be to help NAIC and DOL understand the needs of the health policy and research community for these kinds of data and what these needs imply for additional activity or priorities that may differ from the regulatory context. To support this role, HHS could convene an ad-hoc working session with staff from provider, health plan, purchaser, and the regulatory community to identify key concerns and issues.
- Suggestion #1c. Follow up this activity with the development of a discussion paper, which reviews the status of current activity in the regulatory arena and the key needs and issues from the perspective of the health policy and research community. Involve regulators in this process and use the document to encourage attention to important health industry, policy, and research needs as systems evolve.
Address Issues in Which the Appropriate “Units” for Data Collection Need to Be Clarified.
There appears to be consensus on the fact that information on individual providers or facilities, and on “health plans” alone is insufficient when the relationships between these entities are varied and complex. Physicians perceive that more functional responsibilities are assumed at the group or physician organization level by large multi-specialty groups, medical IPAs, physical management organizations and other entities. Hospitals perceive the importance of systems of care and point out the complex ways in which these entities relate to their medical staff and others in the provider and health plan community. For example, a given hospital may be part of one or many health care systems. It could also sponsor an HMO or contract with several HMOs and other managed care entities for a diverse set of products. Each relationship would bring different but overlapping sets of physician affiliations. An individual physician may participate directly in that hospital’s HMO, may be part of a group that contracts with other managed care entities, and may be part of a management entity (e.g., an independent practice association) that also contracts with managed care entities. Each of these entities may, in turn, contract with a variety of managed care plans, sometimes directly and sometimes through other entities. Furthermore, many of these relationships are unstable, and the relative importance of different levels of aggregation may vary across and within markets as well as over time. Given this situation, it is not clear how to capture any consistent and universally useful data on these arrangements over time or even at one point in time. Furthermore, the absence of knowledge in this area contributes to difficulties in developing better performance measures.
- Suggestion #2a. Convene a working session of individuals and groups who have been struggling with these issues, including AHCPR staff, policy research staff associated with groups including AAHP, AMA, AHA, AAMC and NCQA, and researchers active in developing new frameworks and techniques in this area (such as Jeff Alexander, Steve Shortell/Gloria Bazzoli, Robert Miller/ Hal Luft, Joseph Newhouse, Paul Ginsburg/Robert St. Peter, Bob Hurley/Marsha Gold) to review perceptions of current needs, work in progress upon which to build, and important next steps.
- Suggestion #2b. Initiate follow-up efforts to develop both a taxonomy to address these issues and a set of recommendations for national and state data collection priorities in terms that address concerns for the conceptually appropriate units for collecting
information and the techniques which need to be used to generate inventories of such units for use by the broad industry, policy, and research communities.
- Suggestion #2c. Plan to initiate follow-up activity that appears warranted from the proceeding suggestions. At a minimum, information should be disseminated to states or public/private consortiums that would focus on these issues. Potentially, there may be inventories that are best developed at the federal level alone or through a public-private partnership.
Review HHS Provider Information to Decide What Changes Are Desirable in Light of the Changing Marketplace.
HHS is involved through a variety of agencies with data collection efforts to count and capture characteristics and process features for certain types of providers/facilities and for various federal programs. In addition to national NCHS surveys, these include diverse and sometimes overlapping or inconsistent data collected by HRSA, SMHSA and other agencies. Given the needs expressed in our interviews, it is not clear that the current HHS structure data collection is the most effective way to focus resources on information needs about the health care system which focus on needs to understand linkages among components as well as the components themselves.
- Suggestion #3a. The Data Council should review the status of federal data collection efforts related to capture of health resources and provider information in light of the information in this report. The committee should identify characteristics of the existing system that should be considered fixed, changes that should be assumed to proceed, and the relevant range of activity that should be considered for review.
- Suggestion #3b. Consistent with the guidance in Suggestion 2, HHS should commission a technical analysis of strategic options for available resources and solicit input on these options from a variety of public and private constituencies to inform its own decision-making process.
Limitations in Purchaser-Related Information.
The absence of information on purchaser activity was a major theme in our interviews. While it is unclear what part of this area should be considered demand side and what part supply side, there is clearly a need for better information on what purchasers offer, how much they pay, what they are doing to influence the health care system and markets, and what this means for public policy.
- Suggestion #4. HHS staff should consider current initiatives that affect employers as part of the HHS survey integration project, through other federal agencies, and outside HHS. They should review this report and determine whether the scope of current activity is adequate or whether additional steps need to be taken to address these needs.