An Update on the Community Tracking Study:

Originally published by the Center for Studying Health System Change (HSC). HSC was a nonpartisan policy research organization funded principally by the Robert Wood Johnson Foundation.

A Focus on the Changing Health System

Issue Brief No. 18, February 1999

One of HSC's flagship research projects tracked how the health system was evolving in 60 communities across the United States and how those changes were affecting people. Underway since 1996, the Community Tracking Study, funded solely by The Robert Wood Johnson Foundation, was a longitudinal effort built on periodic site visits and surveys of households, physicians, and employers. The goal was to produce a sound information base for health care decision-makers.

Why Community-Level, Longitudinal Research Matters

The health system was changing in virtually every city and town. Market competition was intensifying, and managed care was becoming dominant. No systematic study had tracked change across a broad cross-section of American markets. The Community Tracking Study addressed two central questions: How is the health system changing -- how are hospitals, health plans, physicians, and safety net providers restructuring? And how do those changes affect people in terms of insurance coverage, access, costs, and quality?

HSC randomly selected 60 communities stratified by region, size, and type. Twelve received in-depth study with site visits and large survey samples: Boston, Cleveland, Greenville (S.C.), Indianapolis, Lansing (Mich.), Little Rock, Miami, Newark, Orange County (Calif.), Phoenix, Seattle, and Syracuse. The remaining 48, including smaller metro and nonmetropolitan areas, had smaller survey samples and no site visits. Together, data from all 60 communities allowed researchers to draw national conclusions and relate access, cost, and quality to health system differences across communities over time.

Data were collected every two years, with round one covering 1996-1997 and round two covering 1998-1999. Researchers from other organizations also studied these communities through collateral projects on clinical quality, substance abuse treatment, mental health services, and public health.

Multiple Data Sources in the Same Communities

A distinctive feature was collecting data from several sources within the same communities. Having household, physician, and employer survey data from the same markets enabled tracking multiple measures at the community level and relating measures across surveys. Site visits in the same communities provided qualitative context.

The Household Survey, conducted by Mathematica Policy Research, interviewed more than 60,000 persons in 33,000 families on health insurance, access, service use, satisfaction, health status, and demographics. The Physician Survey, conducted by The Gallup Organization, covered over 12,000 physicians on practice arrangements, revenue sources, compensation, care delivery, and care management effects. The Employer Survey covered over 22,000 establishments on plan types offered, premium costs, cost-control techniques, and quality information provided to workers.

Tracking Health System Changes

Research focused on forces driving change -- purchaser cost-control efforts, public policy shifts, community norms, and local history -- and how organizations responded. Health plans, hospitals, and physician groups were consolidating and integrating vertically to increase bargaining power. Researchers pursued specific questions about Blue Cross-Blue Shield plan transformations, hospital merger implementation, safety net provider responses to Medicaid managed care, and the evolution of care management tools.

Effects on People

Analysis focused on access to care, service delivery, costs, and perceived quality. Researchers documented variations in insurance coverage, specialist referral ease, and access for the uninsured. They examined changing scope of primary care, physician visit patterns, and health service types. Premium rate variations across communities were studied alongside changes in who bore health care costs. Consumer and physician satisfaction were tracked to assess the managed care backlash.

Research Progress and Collateral Studies

Baseline data from 1996-1997 had produced numerous publications. The second round of site visits was complete, with Community Reports analyzing changes since 1996. Longitudinal survey analyses would become available starting in 2000. Peter Kemper served as principal investigator.

Collateral studies by other organizations included RAND's clinical quality study examining medical records in all 12 sites; RAND's alcohol, drug abuse, and mental health research; Brandeis University's managed behavioral health survey in 30 of the 60 sites; and Mathematica's public health study tracking how local health departments were changing in response to Medicaid managed care.

Sources and Further Reading

AHRQ — Health Data Resources — Federal health care data.

Health Affairs — Peer-reviewed health policy research.

Robert Wood Johnson Foundation — Health policy research.

Commonwealth Fund — Research on health system performance.