Research and reform: toward a high-value health system.

Years from now, when we look back at the health care reform discussions of 2009, we will undoubtedly learn a lot about the strengths and weaknesses of the process. The current process has followed a different path than that of the early 1990s. I hope that, in addition to the inevitable scrutiny surrounding the politics of the debate, we pay some attention to the role that evidence played in shaping the options and outcomes. Although often behind the scenes, health services research plays a crucial role in policy development. The impact of reform (or lack thereof) on the economy is one area of particular importance where research can play a valuable role. Proponents of health care reform argue that it will improve not only the health care system but the economy as a whole. This position is described in detail in a paper released in June by the Council of Economic Advisors. They argue that increased efficiency in the health care sector will improve welfare by allowing individuals to divert resources to other goods and services with little detrimental effect on health status. Moreover, reduced health care spending will alleviate pressure on the federal debt, which will stimulate economic activity, and reform will improve the functioning of labor markets, further boosting general economic activity. The arguments that underlie these claims are complex. Regardless of one's view, discussion surrounding the merits of these claims requires more theoretical and empirical research. Interpretations of findings may differ, but every piece of reasonable evidence helps. The article by Sood, Ghosh, and Escarce (2009) in this issue illustrates the type of research that speaks to this debate. Much of the existing debate is based on theoretical arguments or anecdotes. In fact, some economic theory suggests that, because health care costs are ultimately borne by workers in the form of lower wages, private firms may not respond to higher health care costs. In this case, the impact of high and rising health care costs would have minimal impact on industry-level outcomes. Sood and colleagues conduct a careful study of the economic performance of industries as a function of the extent to which those industries are likely burdened by rising health care spending. They find that rapid growth in health spending adversely affects those industries that provide insurance to a larger percentage of their workers. They conduct careful sensitivity analyses, demonstrating that the effects are not observed in a matched sample of Canadian industries. Certainly, like all similar work, this study has limitations. Other studies, using different data and methods, are needed to increase confidence in these results. Ideally, policy should be based on a body of research rather than a single study and we should not expect that one study in an area will always provide the information necessary to guide decision makers. Moreover, this study was not designed to assess the impact of rising health care spending on the aggregate economy. Although Sood and colleagues identify economic distortions due to rising health care costs, that impact may be mitigated to some extent by general equilibrium adjustments. Yet the insight that health care spending growth distorts economic activity has important ramifications for the imperative of improving our system. These results, and hopefully others in a similar vein, will help shape our thinking as we move forward. While the Sood and colleagues' results help quantify the consequences of failing to control health care spending, they do not speak to how we should accomplish this elusive goal. Observers agree that our efforts to control spending must promote value—the amount of health we gain per dollar spent—while yielding a fiscally sustainable budget path. Importantly, we should not strive to save money simply so we can finance coverage expansions, but instead we must strive to create an efficient health care system. Health services research will play an important role in how we choose to address cost growth and reform in the health care system. First, health services research can help develop tools to promote innovative payment and quality improvement initiatives. Studies by Hirth et al. (2007) and Karter et al. (2009) in this issue illustrate such work. The Hirth et al. (2007) study recognizes that the process of enhancing value is complex because responsibility for outcomes is spread across many providers and organizations. They examine one area of health care—dialysis—recognizing that outcomes reflect both nephrologist and facility behavior. In our current health system, many strategies for improving efficiency require assessment of the contributions of each provider type to outcomes. Hirth and colleagues provide a detailed, sophisticated examination of this issue, concluding that in this case, facilities are responsible for more of the variation in outcomes than nephrologists, which suggests that cost-constraining or quality-enhancing initiatives must recognize this dual locus of control. The Karter et al. (2009) study similarly provides information that can support efforts to enhance value in the health care system. It focuses on adherence to prescription drugs, which has been identified as an important way to promote value. The paper proposes a particular measure of adherence and suggests that interventions to improve adherence to medications for treating chronic disease might focus on individuals in the period shortly after they receive their first prescription for a new medication. Whereas Hirth and colleagues focus on improving our ability to target providers, Karter and colleagues focus on improving our ability to target patients. Like all research, the details matter and these studies are only building blocks in larger bodies of research. Yet they represent the types of research that can help support public and private efforts to improve our system. If health care reform is to succeed, individuals designing systems of care must have information to support their efforts. Health services research plays an additional fundamental role in reform because it is the backbone for assessing the cost of different reform proposals. Federal agencies such as the Congressional Budget Office rely heavily on research. They recognize that, although any given study is imperfect, collectively research provides the basis for the assumptions used in models to estimate the impact or scores given to various policy changes. Without health services research, policy makers would be flying blind. I have confidence that future scholars will look at this record and identify the great value provided by health services research. Yet they will likely also see our shortcomings. Reform of the magnitude discussed in 2009 entails big changes and ideas that have not yet been attempted. Research is not good at assessing synergies created in a transformed system because researchers must base inferences on the limited pieces of information that they have. Theory and modeling can help, but the uncertainty is substantial. Analysts, appropriately conservative, may find that the gaps in research result in forecasts that do not provide the support for reform that proponents would like. This does not imply that reform should not move forward. Rather, we must recognize that reform is not a one-time event, but a continuous process, and that additional evidence for adjusting and fine-tuning the reform effort will unfold over time. Hopefully, through the combined evidence from many studies, we will construct a system that achieves the ambitious but attainable goal of providing high-value care at a sustainable cost.