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An Update on the Community Tracking Study:

A Focus on the Changing Health System

Issue Brief No. 18
February 1999

major research project of the Center for Studying Health System Change (HSC) analyzes how the health system is evolving in 60 communities across the United States and the effects of those changes on people. Underway since 1996, the Community Tracking Study, which is funded exclusively by The Robert Wood Johnson Foundation, is a longitudinal project that relies on periodic site visits and surveys of households, physicians and employers. The study is intended to provide a sound information base for decisions made by health care leaders. This Issue Brief provides an update of the study’s design and research agenda.

Community-Focused and Longitudinal Research

he health system is changing in virtually every city across the country. Market competition is increasing, and various forms of managed care are becoming dominant. While some argue that these changes are controlling costs and improving quality through better management of care, others are concerned about barriers to specialized services and poorer quality. A public backlash against these health system changes and calls for increased regulation of managed care are indicative of the national debate about the future of health care.

While many studies have examined leading markets in California and Minnesota and analyzed local or selected data, there has been no systematic study of change in a broad crosssection of U.S. markets or analysis of the effects of those changes on service delivery, cost and quality. The Community Tracking Study is designed to provide sound empirical evidence that will inform the debate about health system change. The study addresses two broad questions that are important to public and private health decision makers:

  • How is the health system changing? How are hospitals, health plans, physicians, safety net providers and other provider groups restructuring, and what key forces are driving organizational change?

  • How do these changes affect people? How are insurance coverage, access to care, use of services, health care costs and perceived quality of health care changing over time?

Focusing on communities is central to the design of the Community Tracking Study. Understanding market changes requires studying local markets, including their culture, history and public policies relating to health care. HSC researchers randomly selected 60 communities stratified by region, community size and type (metropolitan-nonmetropolitan) to provide a representative profile of change across the United States.

Of these communities, 12 are studied in depth, with site visits and survey samples large enough to draw conclusions about change in each community. These communities are a randomly selected subset of the sites that are metropolitan areas with more than 200,000 people.

The 12 metropolitan areas selected are:

  • Boston, Mass.
  • Cleveland, Ohio
  • Greenville, S.C.
  • Indianapolis, Ind.
  • Lansing, Mich.
  • Little Rock, Ark.
  • Miami, Fla.
  • Newark, N.J.
  • Orange County, Calif.
  • Phoenix, Ariz.
  • Seattle, Wash.
  • Syracuse, N.Y.

The 48 additional communities, which also include small metropolitan and nonmetropolitan areas, are studied less intensively, with smaller survey samples and no site visits. The information from all 60 communities enables researchers to: (1) place findings from the 12 communities in the context of health system change in the nation; (2) draw statistically reliable conclusions about health system change nationally; and (3) relate access, cost and quality to health system differences, such as the amount and type of managed care, across communities and over time.

Since the focus is on change, the study is longitudinal. By collecting and analyzing information every two years, the study tracks changes in the same communities. Data for round one spans 1996-1997 and round two, 1998-1999.

Researchers in other organizations are studying the same communities in an effort to gain additional knowledge and insights about health system change. These collateral studies are looking at issues outside the focus of the Community Tracking Study - for example, clinical quality of care, alcohol and substance abuse treatment, mental health services and public health (see Collateral Studies in the Community Tracking Study Sites below).

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Combining Multiple Data Sources

ne of the key design features of the Community Tracking Study is the collection of data from a variety of sources in the same communities. Having data from household, physician and employer surveys in the same communities permits researchers to track multiple measures of access, service delivery, cost, perceived quality and health system characteristics at the community level. Data in common sites also permit analysts to relate the measures obtained from one survey to health system characteristics at the market level obtained from the other surveys - for example, to relate physicians’ assessments of quality to the type and amount of managed care, physician practice arrangements and supply of physicians in the market. And conducting site visits in the same communities provides an in-depth, qualitative understanding of the health system to inform the analysis of the survey data.

Site Visits

During site visits to the 12 communities, researchers gather information through interviews with individuals in the major sectors of the health system, including purchasers, health plans, hospitals and physician organizations as well as other key organizations in the market. These visits provide valuable community-level information that is difficult to get in surveys, such as the strategies of health care organizations and local norms. The visits also provide a context for cross-market variation in measures of access, service use, cost and perceived quality drawn from the surveys. HSC conducts the site visits in collaboration with The Lewin Group.

Surveys

Much of the information about changes in the health system and the effects of these changes on people comes from nationally representative telephone surveys of households, physicians and employers (see What People Are Asked: Sample Survey Questions below). Approximately half of the 1998-1999 sample includes respondents to the 1996-1997 surveys and half is new. The longitudinal cohort permits analyses of change for the same respondents at two different times; the new cross-section ensures that the sample continues to be representative of the community’s population, thus permitting tracking at the community level.

  • Household Survey: Many people are concerned about how the changes taking place in health care are affecting them, and the Household Survey is designed to collect objective information about these effects. Is access to services getting better or worse over time? Are more people uninsured today than two years ago? Questions in this survey cover health insurance, access, service use, satisfaction with the care received, health status and sociodemographic characteristics. More than 60,000 persons in 33,000 families are interviewed for the survey, which is conducted by Mathematica Policy Research, Inc.

  • Physician Survey: Practicing physicians provide important insights given the central role they play in health care. For example, has the complexity or severity of the medical conditions that primary care physicians treat without referring patients to specialists increased, decreased or stayed the same over the past two years? What kinds of financial incentives do physicians face? To capture such information, the Physician Survey questions more than 12,000 physicians in direct patient care about their practice arrangements, sources of practice revenue and level and determinants of compensation. Physicians are also asked about their ability to deliver care and the effects of care management strategies on care delivery. The Gallup Organization conducts this survey.

  • Employer Survey: Most people have access to private health insurance through the workplace, and employers are increasingly influential in shaping the health system through their role in purchasing insurance for their employees. To better understand this, more than 22,000 private and public employer establishments are surveyed on the types of plans they offer employees and the cost of premiums to both employers and employees. Employers are also asked what techniques they use to control costs, such as participating in purchasing pools, and what quality information they provide to employees. HSC collaborates with RAND on The Robert Wood Johnson Foundation Employer Health Insurance Survey.

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Tracking Changes in the Health System

nalyses of the dynamics of health system change focus on the forces driving that change and the way health care organizations are responding.

Forces Driving Change

Several major forces of change are at work at the community level. Efforts of purchasers - private employers and Medicare and Medicaid - to control the cost of health care and changes in public policy are two consistent forces across the 12 markets. At the same time, community norms and the history of plans and providers in each market both constrain and shape the evolution of change. Researchers are continuing to track how purchasers, policy and other forces are altering the behavior of health plans and providers.

Responses of Health Plans and Providers

In response to purchasers’ pressure to control costs, health plans, hospitals and physician organizations are consolidating and integrating vertically to increase their bargaining power. In addition to tracking and analyzing these changes by comparing and contrasting the 12 communities, researchers are addressing a number of specific questions in depth. How are Blue Cross-Blue Shield plans transforming themselves in the changing competitive market? How are hospital mergers being implemented? How are safety net providers responding to market changes and Medicaid managed care? How widely are the various financial and nonfinancial tools designed to manage care being used, and how are the tools evolving?

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Tracking the Effects of Changes on People

nalyses of how changes in the health system are affecting people focus on access to care, how care is delivered, costs and the quality of care as perceived by physicians and patients. Most of this information comes from Community Tracking Study surveys.

Access to Care

There is a growing concern that competitive market pressures are resulting in less care for the poor, the uninsured and people in poor health. At the same time, managed care plans may be enhancing access of the insured by, for example, reducing cost sharing and improving management of chronic conditions. Researchers are analyzing these issues and have documented variations among communities in providing insurance coverage, ease of referral to specialists and access to care for the uninsured.

Service Delivery

Of all the changes taking place in the health system, changes in the delivery of care are the ones most likely to have an immediate effect on people. For example, are health maintenance organizations delivering more preventive care and fewer intensive services? Researchers are looking at the changing scope of care that primary care physicians provide and the variations over time in how often patients see their physician and the type of health services they receive.

Costs

Premium rates vary across communities, and HSC is studying the extent of these variations and possible causes for them, including demographics, health status, size of employers and the prevalence of managed care. In addition, researchers are tracking changes in health care costs over time at the national level, addressing, for example, whether the share of costs borne by individuals (as opposed to employers or public programs) is increasing or decreasing.

Perceptions about Quality of Care

The growth of managed care is raising concern among consumers about quality of care. How satisfied are people with the care they receive? How satisfied are physicians with the care they can deliver - for example, in terms of the time they spend with patients? Do the perceptions of consumers about quality correlate with the perceptions of physicians?

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Status of Research

he Community Tracking Study baseline data were collected in 1996 and 1997. A number of Issue Briefs, Data Bulletins, journal articles and reports using these data have been completed since then. The second round of site visits is complete, and analysis of what has changed at the site level since 1996 is available in a new publication series, Community Reports. The second round of surveys is underway, and longitudinal analyses comparing new survey findings to the baseline data will be available starting in 2000.

Peter Kemper, vice president of HSC, has been the principal investigator of the study since its inception. For more information about the Community Tracking Study research design, see "The Design of the Community Tracking Study: A Longitudinal Study of Health System Change and Its Effects on People" by Peter Kemper et al., which appeared in the Summer 1996 issue of Inquiry.

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Collateral Studies in the Community Tracking Study Sites

esearchers at other organizations are conducting related studies in the Community Tracking Study sites. This enables them to draw on HSC’s data collection and analysis when interpreting their results and to use the surveys to identify special subgroups for additional data collection.

Clinical Quality. The quality of care delivered to persons with chronic disease and children is the focus of a RAND collateral study in the 12 site visit communities. Using a sample drawn from the Community Tracking Study Household Survey sample, researchers are focusing on two major questions: How good is the quality of care, and who is at greatest risk for receiving poor quality of care? To get information about clinical quality, researchers are examining medical records in all 12 sites and offering free health exams in three of them.

Alcohol, Drug Abuse and Mental Health. How are public policies and markets for alcohol and drug treatment and mental health services changing across communities, and how do these variations affect the availability of insurance coverage for people needing services? RAND researchers are learning more about changes in services for at-risk persons within and across communities through interviews with a sample drawn from the Community Tracking Study Household Survey sample.

Managed Behavioral Health. Researchers at Brandeis University’s Institute for Health Policy are conducting several studies of managed behavioral health care that are linked to the Community Tracking Study. The core study consists of a telephone survey of managed care organizations in 30 of the 60 Community Tracking Study sites. Researchers are also analyzing the mental health and substance abuse coverage data from the Employer Survey.

Public Health. Most public health departments - a significant component of the nation’s health care safety net - are facing changes as a result of Medicaid managed care. Researchers at Mathematica Policy Research, Inc., are analyzing how the role of the health department is changing in the same 12 communities in which HSC conducts site visits.

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What People Are Asked: Sample Survey Questions

From the Household Survey

  • Was there any time during the past 12 months when you did not get medical care you needed?
  • Do you trust your doctor to put your medical needs above all other considerations when treating your medical problems?
  • How would you rate how well your doctor listened and explained things in a way you could understand?

From the Physician Survey

  • In the last two years, were you part of a practice that was purchased by another practice or organization?
  • During the last two years, has the number of patients whom you refer to specialists increased, stayed the same or decreased?
  • Is it possible for you to provide high-quality care to all of your patients?

From the Employer Survey

  • How many different plans do you offer at this location?
  • Do you pay part of the premium for employees and, if so, how much?
  • Are plan enrollees required to select a gatekeeper to make referrals to most specialists?

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More About HSC

HSC’s mission is to inform decision makers about changes in the health system at both the local and national level, and the effects of such changes on people. HSC seeks to provide objective, incisive analyses that lead to sound policy and management decisions, with the ultimate goal of improving the health of the American public.

In addition to the Community Tracking Study, HSC conducts the following research and activities:

  • analysis of secondary health-related data from government and private sector sources;
  • seminars and conferences on health policy issues and research on health system change; and
  • publications featuring HSC research and seminar findings.

HSC has a commitment to make its study findings and survey data available in a timely and easily accessible format to health care decision makers, researchers, the media and the general public. Information on all of HSC’s publications and the public use files from the round one Household and Physician Surveys is available at www.hschange.com.

 

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