The Evolution of Health Services Research

The field of health services research is poised for a major sea change. It is not so much that researchers are being asked to focus on new topic areas as that the role that they are expected to play in conducting research is evolving. The implementation of provisions within the Affordable Care Act (ACA) will encourage a greater partnership than has traditionally existed between health services researchers and end-users of the results. This change in how health services research is conceptualized, funded, and disseminated has implications for journals including Health Services Research (HSR), which aim to reflect and promote advances in the field.

The origins of health services research as a scientific field of inquiry dates back to the 1960s when several key academic leaders from a small number of institutions developed conceptual approaches to studying important questions about access, cost, and quality of care (National Library of Medicine 2011). There are examples of occasional scholarly work that predate this period, but the academic field did not coalesce to form a sustainable scientific community until the 1960s. As a reflection of this coming of age, academic journals recognized today as being associated with the field, including HSR, began publication at that time.

From the beginning, the field of health services research has been multidisciplinary in nature, and this has contributed to its evolution. Over time there have been significant new areas of focus within the general framework of the field. For example, patient safety became a major topic of interest for the health services research community following the publication of the Institute of Medicine's report entitled “To Err is Human,” (Institute of Medicine 1999), and more recently there has been a growing interest in the role that electronic health records can play in improving quality and lowering costs.

While progress in knowledge and new developments regarding health and health care will inevitably lead to further evolution in the topic areas on which health services researchers focus, the passage of the Affordable Care Act (ACA) has the potential to serve as a catalyst for an expansion of health services researchers' role. To address several provisions in the ACA with substantial financial consequences, health services researchers are being asked by providers, payers, policy makers and other stakeholders to not just observe and measure the impact of policy change, but to take an active part in collaborating with them in designing and implementing the change.

The concept of participatory research has most commonly been applied to a method of conducting research in collaboration with members of the community (Horowitz, Robinson, and Seifer 2009), but many of the concepts are directly relevant for partnerships between health services researchers and other end-users such as providers, payers, and policy makers. The key difference between traditional health services research and participatory forms of research is that in participatory research there is engagement between the researcher and the intended end-user of information throughout the entire research process. It is common in the traditional health services research model for an investigator to act independently to formulate a question, seek funding, collect data, perform the analysis, and disseminate the findings through a scholarly journal, with the path through which potential end-users can learn about the results and act on them being less precisely identified in advance. By contrast, in participatory research the researcher performs each of these steps in collaboration with an end-user whose involvement throughout makes it more likely that a policy-relevant question will be addressed and that the end-user will act on the results.

New funding mechanisms established by the ACA, including the Center for Medicare and Medicaid Innovation (CMMI) and the Patient Centered Outcomes Research Institute (PCORI) are rewarding health services researchers for their willingness to establish collaborations with end-users of their findings. In the case of CMMI, a $10 billion program within the Centers for Medicare and Medicaid Services, the focus is on partnerships with providers and payers; in the case of PCORI it is partnerships with patient groups. A goal of both of these new funding organizations is to identify strategies that improve value (greater quality at lower cost) and that can be scaled up to ensure that they achieve maximum benefit for the population. These new funding mechanisms differ from traditional funding approaches that focus on the researcher's capacity to conduct the investigation, but place relatively less weight on the perceived likelihood that the researcher's work will directly and immediately impact the access, cost or quality of care that is delivered. The Agency for Health Research and Quality, which has a role in distributing some of the new funding available through PCORI, is adapting its approach to funding to align with the strategy of linking health services researchers with end-users of the results.

Participatory research is a two-way street that requires not only that investigators be ready, willing and able to engage with end-users in conducting their work, but that these end-users are interested in collaborating with investigators. The ACA creates an environment that makes this more likely by tying financial consequences to providers' performance. For example, there are provisions in the ACA that will financially penalize hospitals based on their rates of hospital acquired complications (Affordable Care Act Section 3008) and hospital readmissions (Affordable Care Act Section 3025). Although health services researchers have studied and reported on these performance measures for years (Anderson and Steinberg 1984; Berenholtz et al. 2004) the threat of financial loss is fueling interest among hospital administrators in partnering with health services researchers to find strategies to improve care. Policy makers, payers, and providers are also engaging health services researchers in the design and implementation of health care organizational changes promoted within the ACA including the primary care medical home and accountable care organizations. Payment changes associated with these new organizational arrangements create a shared interest among different stakeholders for comparative effectiveness research and for more rapid ways of translating new knowledge into practice and policy.

The ACA is not being implemented in a vacuum. The federal law reflects and is likely to accelerate a set of activities that were already underway and that will further encourage participatory research among providers, payers, policy makers, and other end-users with health services researchers. For example, many state governments and private payers were already experimenting with payment reforms associated with the primary care medical home model of health care delivery. These activities will most likely gather steam as leaders of these efforts seek the help of health services researchers to align their programs with the availability of resources within the ACA to implement this model in Medicare and Medicaid. Even within the practice of medicine, there are clear signs that providers recognize that the passage of the ACA signals a need to adopt the lessons that health services researchers have been preaching about for years. The “Choosing Wisely” campaign adopted by several professional medical societies focuses on ways that physicians can alter their practices for the purpose of creating greater value in health care (American Board of Internal Medicine Foundation 2013).

Health services researchers who engage in participatory research have unique challenges and opportunities in disseminating the results of their work. One set of challenges has to do with navigating the expectations end-users of the research have regarding the role and timing of dissemination through publication in a scholarly journal (Minkler 2004). This is particularly dicey if the findings from the collaborative work do not confirm prior expectations for everyone involved in the process. Although participatory research tends to place a higher burden on investigators who wish to publish findings, there are unique lessons that are only available from this type of work. To that end, the editorial staff at HSR wants to encourage potential authors to submit work that highlights the role of collaboration between health services researchers and end-users.

We anticipate that in describing their efforts health services researchers who engage in participatory work with end-users will explore issues that are not typically addressed by those conducting traditional independent health services research projects. For example, it would be relevant for authors involved in participatory research with end-users to describe the role of collaborators throughout the research process and to provide insights into how the collaboration impacted the study. Readers of HSR will be particularly interested to learn what end-users of the research perceived to be the benefits of having health services researchers as a part of the implementation process. We expect that HSR readers will also be interested in learning about the development of new methodologies for measuring success and impact as defined by health services researchers and their collaborators. As the focus of much of this collaborative work will involve scaling up successful models of care, we would be interested in publishing scholarly work that describes insights into this process and the measures that are used to determine if an intervention was effective at the target population level. Furthermore, we can anticipate that collaborations with end-users of research will put pressure on investigators to develop methods for making a more rapid assessment of the impact of an intervention than is the case for most evaluation research. Publishing descriptions of “rapid cycle” methodologies can help to inform the field of health services research and provide investigators with an opportunity to validate their approach through the peer-review process.

Investigators of all kinds, including health services researchers, are being encouraged to develop methods to enhance the translation of their findings to influence practice and policy (Zerhouni 2005). For health services researchers, the passage of the ACA marks the beginning of an unprecedented set of opportunities to engage with end-users to use evidence in the process of productive changes in practice and policy. HSR has promoted a vision of providing “researchers and public and private policymakers with the latest research findings, methods, and concepts regarding the financing, organization, delivery, evaluation, and outcomes of health services, and with analysis of their relationships to clinical practice, management, and policy.”

Traditional health services research conducted during the last several decades has helped us gain a deep understanding of how our health care system works; underpinned innovations in health care organization, delivery, and policy, including the ACA; and laid the foundations for the current expansion in the role of health services researchers. This research continues to be essential, as we endeavor to understand the mechanisms and effects of new changes, and HSR will continue to publish the best of this research. However, HSR is also eager to embrace the opportunities stimulated by the ACA. HSR is inviting authors to use the Journal as a forum for sharing the methods and results of their collaborative efforts for the purpose of improving practice and policy.