For analytical purposes, it is possible to identify and functionally differentiate three key health system user groups: (1) provider and health plan/insurer associations and the suppliers they represent, (2) purchaser and consumer organizations and the customers they represent, and (3) regulators/policymakers. The information needs of these groups share many common features but the uses of information also differ, consistent with differences in function and responsibility for each group. Analytically, three kinds of information needs can be distinguished: (1) structure and components of the health system, (2) operational information on the process of care, and (3) outcome information (including both clinical and policy outcome) to guide policy analysis and representation. The functional categories of data requirements encompass the range of data needs expressed by those we spoke with over the course of the project. The three user types were grouped based on shared perspectives and motivations that drive their information requirements.
Providers and health plans/insurer associations and their members represent suppliers of health care services. They include, for example, the American Medical Association (AMA), American Hospital Association (AHA), Association of American Medical Colleges (AAMC), American Association of Health Plans (AAHP), the American Association of Homes and Services for the Aging (AAMSA) and Health Insurance Association of America (HIAA). These entities also tend to be membership organizations, which need information to support themselves and the needs of their members. In contrast, purchaser and consumer entities such as the American Association of Retired Persons (AARP), and Pacific Business Group on Health, represent the demand side of the market, that is, the customers. Policymakers and regulators are responsible for defining the “rules of the game” and providing oversight for the market. This diverse group includes federal, state, and local policy-formulating bodies, regulators, and program administrators. We also include here those involved in developing information needed to support these functions, like the National Committee for Quality Assurance (NCQA) or various research or foundation entities.
There is considerable variation within and overlap between each of these user groups (e.g., when government acts as the purchaser for its employees or for public programs). Functional responsibilities also shift over time. For example, the reliance on market-based solutions means that purchasers, through the choices they make, are increasingly, if not always explicitly, influencing health care policy formulation.
The first informational category encompasses functions which directly require structural descriptive information on the components of the health care system. That is, there is the need to know what entities exist, what their characteristics are, and how they are changing. Provider and insurer associations are paid dues to represent a segment of the industry. Hence, they need information to understand their share of the industry and membership base, to project revenue, and to assess potentially desirable changes in their membership eligibility qualifications. For example, with the growth of managed care products, these users would want to know which entities are eligible to join a managed care association and which products and members should be counted for purposes of dues assessment. The suppliers these groups represent need information to identify trends that may affect their strategic decisions as well as to carry out more operating needs (like contracting). Regulators and health policymakers typically need the same kinds of information as provider and insurers on components of the health system, but their focus is on assessing available resources and entities for whom they are accountable. For example, they would want to know which entities are subject to state insurance oversight. Purchasers and consumers also need information on components of the health system to support their operational needs, as discussed below.
All three entities need operational information on the process of care, particularly information related to performance in both administrative and clinical areas that are relevant to them or their constituency. Provider and insurer associations are expected by their members to provide operational support in terms of measuring and benchmarking performance and developing standardized information such as that used to support clinical practice. For example, members may want to know how their hospitals days per 1,000 covered lives compare to that of peers. Purchaser and consumer organizations are expected to inform or carry out group purchasing activities and help consumers participate more knowledgeably in the system. To do this, they may want to know what choices are available and how each health insurance option performs on such measures as cost, consumer satisfaction, or quality. Regulators and policymakers are expected to monitor performance and provide general oversight. They also have certain regulatory and administrative functions over components of the health system. Therefore, they need enough information to assess and provide feedback on overall performance and improvements. They also need enough information to identify potential problems early on so that steps can be taken to avoid them or to minimize their impact.
All three users are involved in policy analysis to encourage the development of policies that are responsive to the concerns of their particular constituency or interests. The range of policy analysis issues is broad but tends to correspond to understanding the effects of structure and process on policy-relevant outcomes and what both the policy implications and the implications for constituents are. This generates a need for various kinds of information that could be used to assess how constituents will be affected by particular policy options, to support the development of association positions, or to inform members so that they may position themselves and develop individual positions on issues. For example, has proposed changes in Medicare capitation rates that would reduce rate calculations by the exclusion of indirect payments for graduate medical education. Health plan and provider associations need to know the county-specific impacts of these changes so they can identify effects on markets important to their members; purchasers and consumers are concerned with overall fiscal and geographic impacts specific to their reference population; and government policymakers need information to help them both estimate the budgetary effects of the change overall and assess where to fine tune policy to minimize any adverse short-term impacts of rate reductions.
All these groups also represent and advocate--either for a specific constituency or for their associated public policy body. This representation function differs from policy development in that it is oriented more toward supporting an already formulated position and less toward developing that position. Such support requires information that helps to make the case for the organizations’ positions and purpose, including information that would be used to educate policymakers and the public. Such information is needed both at the national level and at the state or locality level where such issues often get considered.