The Community Tracking Study analyses of market change: introduction.

OBJECTIVE: To introduce two articles and describe methods that are common to them. DATA SOURCES/STUDY SETTING: Interviews conducted in person in 1996/1997 with leaders of organizations involved in the financing and delivery of healthcare. STUDY DESIGN: As part of the Community Tracking Study, 12 metropolitan statistical areas (MSAs) were selected randomly from MSAs with populations over 200,000. Researchers made baseline site visits to these communities and conducted from 36 to 60 interviews, depending on the size of the site. The communities were compared to identify common patterns of change and differences across communities. DATA COLLECTION/EXTRACTION METHODS: Researchers conducted interviews with a broad cross-section of leaders in each community. Interview modules were designed to obtain multiple perspectives on a question. PRINCIPAL FINDINGS AND CONCLUSIONS: Fundamental changes in the way care is actually delivered is likely to lag behind the extensive changes in organizational relationships that are taking place.

Organizing and managing care in a changing health system.

OBJECTIVE: To examine ways in which the management and organization of medical care is changing in response to the shifting incentives created by managed care. DATA SOURCES: Site visits conducted in 12 randomly selected communities in 1996/ 1997. STUDY DESIGN: Approximately 35-60 interviews were conducted per site with key informants in healthcare and community organizations; about half were with providers. DATA COLLECTION: A standardized interview protocol was implemented across all sites, enabling cross-site comparisons. Multiple respondents were interviewed on each issue. PRINCIPAL FINDINGS: A great deal of experimentation and apparent duplication exist in efforts to develop programs to influence physician practice patterns. Responsibility for managing care is being contested by health plans, medical groups and hospitals, as each seeks to accrue the savings that can result from the more efficient delivery of care. To manage the financial and clinical risk, providers are aggressively consolidating and reorganizing. Most significant was the rapid formation of intermediary organizations, such as independent practice arrangements (IPAs), physician-hospital organizations (PHOs), or management services organizations (MSOs), for contracting with managed care organizations. CONCLUSIONS: Managed care appears to have only a modest effect on how healthcare organizations deliver medical care, despite the profound effect that managed care has on how providers are organized. Rather than improving the efficiency of healthcare organizations, provider efforts to build large systems and become indispensable to health plans are exacerbating problems of excess capacity. It is not clear if new organizational arrangements will help providers manage the changing incentives they face, or if their intent is to blunt the effects of the incentives by forming larger organizations to improve their bargaining power and resist change.

Hospital employment trends in California, 1982-1994.

During the 1980s California hospitals responded to selective contracting, growth in managed care, and the Medicare prospective payment system (PPS) by controlling their level of spending. This DataWatch examines whether these hospitals achieved these savings by changing the number and/or the mix of hospital employees. We examined employment trends because wages represent the largest component of hospital budgets and because the number and mix of personnel can be changed in the short run. Analysis of the California Health Facilities Cost Report data shows that employment increased steadily during 1982-1994. There is no evidence that hospitals responded to growing competition by altering the rate of growth in hospital personnel and only weak evidence that they altered the mix of personnel by hiring a greater proportion of nonclinical staff. We conclude that increased competition had only a minor effect on hospital employment decisions.

Employment trends in hospitals, 1981-1993.

This paper examines trends in hospital employment from 1981 to 1993. After controlling for changes in the inpatient and outpatient volume and using a proxy for changes in case mix, the number of hospital employees increased steadily during this period. Most of the growth occurred in the nonclinical areas. There was no statistically significant difference in the employment growth in states with high or low penetration of health maintenance organizations (HMOs), or in states with and without all-payer rate-setting programs, suggesting that neither competitive nor regulatory programs influenced employment trends in the hospital industry.

Analyzing health outcomes through international comparisons.

There is increasing interest in the conduct of international studies that compare health care outcomes. This paper draws from the literature in sociology, anthropology, and psychology to examine the problems that can be encountered when collecting primary data for comparative purposes. Issues of study design, selection, development, and adaptation of instruments, problems encountered in collecting primary data, and techniques for analyzing comparative data are discussed. The paper is intended as a primer for health services researchers conducting comparative outcomes research in international settings.