In This Issue

A strong case can be made that long-term care services should be high on the health research agenda. In their article, “Strengthening Research to Improve the Practice and Management of Long-Term Care,” which begins this issue of the Milbank Quarterly, Penny Hollander Feldman and Robert Kane note that people over age 65 today have a 40 percent chance of spending time in a nursing home and an almost 75 percent chance of receiving home care services. Chronic disease and disability are not, of course, limited to people in this age group.

Feldman and Kane survey past research to assess contributions to improvements in practice and to identify where future research may stimulate positive change. They first sort through some of the complexities regarding the definition of long-term care (LTC), which combines elements of both medical care and supportive or custodial care. LTC has evolved to become less identified by site of services (nursing homes) than by type of services, which can be provided in many places, including the patient’s home.

Feldman and Kane discuss the role of research in four areas. The first is in defining goals, which is problematic in LTC because the recipients of services are often on a downward health trajectory from which full recovery is not likely. The second is in designing practical tools for documenting the nature and magnitude of patients’ problems and measuring outcomes. The third is in assessing interventions and strategies for improving care. The fourth is broader: evaluating new models, programs, and systems of service delivery. The authors also reflect on the continuing challenge of translating research findings into practice, drawing lessons from some of the most successful examples in the LTC field, such as the widely used Index of Activities of Daily Living. Feldman and Kane conclude by recommending a “portfolio” of research that would yield future dividends in improved quality and outcomes of long-term care.

The translation of research into practice is the central topic of the second article in this issue, “How Can Research Organizations More Effectively Transfer Research Knowledge to Decision Makers?” by John Lavis and several colleagues. There is intense interest in many countries in the return on investment in health services and policy research. Lavis and his colleagues present a framework for analyzing knowledge transfer from researchers to target audiences and report the results of a survey of the directors of research organizations in Canada regarding their practices and experience in the knowledge-transfer process. The analysis focuses on five deceptively simple questions: What knowledge should be transferred to decision makers? To whom should it be transferred? By whom? How? With what effect? They find opportunities for improvement in the knowledge-transfer process by comparing the way these questions are answered in the research literature with responses obtained in their survey of research institute directors.

Racial and ethnic disparities in health status and services have become a major health policy concern in the United States. A recent report (2002) by the Institute of Medicine documented their pervasiveness, and the U.S. Department of Health and Human Services has undertaken a broad initiative to eliminate such disparities by 2010 (U.S. Department of Health and Human Services 2000). Disparities between blacks and whites appear on a wide array of indicators. A few years ago, José Escarce and Frank Puffer (1997), using data from the 1987 National Medical Expenditure Survey, found that in the aged Medicare population, medical expenditures for whites exceeded those for blacks. This finding caused some concern because the health status of whites was better. In this issue of the Quarterly, Escarce and Kanika Kapur report on a similar study using data from a decade later. They analyze expenditures for white, black, and Hispanic seniors using data from the 1996—1998 Medical Expenditure Panel Survey.

Escarce and Kapur’s article, “Racial and Ethnic Differences in Public and Private Medical Care Expenditures among Aged Medicare Beneficiaries,” goes beyond previous research on seniors to examine racial and ethnic differences in the composition of expenditures, focusing on differences in public and private sources. They conducted both “need-based” and “demand-based” analyses to determine whether expenditures reflect differences in the need for medical care, on the one hand, and differences in the factors that influence demand, on the other. The inclusion of Hispanic seniors in the analyses is itself unusual and noteworthy. They report that aggregate differences in expenditure have largely disappeared but that differing patterns of public and private expenditures demonstrate the importance of public programs in reducing racial and ethnic disparities in health expenditures.

One of the least heralded but most consequential pieces of legislation in recent years was the Balanced Budget Act (BBA) of 1997, which introduced a variety of cost-saving provisions into Medicare. Although the financial impact on providers has elicited the greatest reaction and response, the possible harm to Medicare beneficiaries was also a serious concern. The BBA’s changes regarding services after hospitalization elicited such concern. In “Reforming Medicare Payment: Early Effects of the 1997 Balanced Budget Act on Postacute Care,” Nelda McCall, Jodi Korb, Andrew Petersons, and Stanley Moore use administrative data from a 5 percent sample of Medicare beneficiaries to examine post-BBA changes in the use of postacute care services for five diagnoses. They also looked for evidence of adverse outcomes. They found the former—for example, an increase in the percentage of beneficiaries who received no posthospitalization services—but not the latter. They conclude that the money-saving changes in use patterns of services such as home services, rehabilitation hospitals, and long-term care institutions do not necessarily translate into measurable reductions in the quality of care.

Olaug Lian’s article, “Convergence or Divergence? Reforming Primary Care in Norway and Britain,” is a comparative study of health systems and health politics. Lian examines developments in primary care in Norway and Britain over the past ten years from the perspective of one of the broadest themes in this literature: the extent to which common global trends regarding economic growth, health care costs, demography, expanding medical knowledge, and technology change are producing a convergence in the health care systems of industrialized nations. Lian examines reforms in a central feature—primary care—in the health systems of two countries that have many similarities, looking particularly at policy goals, changes in organizational structures and remuneration systems, and the policy process. She found more evidence of divergence than of convergence, which she explains in terms of historical, institutional, and political factors, including the position of the medical profession. Her analysis of the importance of the density and political power of physicians should interest policy analysts from health care systems that are unlike those of either Norway or Britain.

The final article in this issue is “Alternative Models of Hospital-Physician Affiliation as the United States Moves Away from Tight Managed Care,” by Lawrence Casalino and James C. Robinson. The rise of managed care has led to major changes in the formal relationships between hospitals and the doctors who admit patients. A variety of alternatives replaced the traditional model in which the only linkage between hospitals and their medical staffs was the physicians’ admitting privileges. The purchase of medical practices by hospitals was the most extreme example. Casalino and Robinson describe three basic forms of physician-hospital affiliations: the traditional medical staff model, the hospital-owned practice, and hybrid arrangements. They use concepts from organizational theory to analyze the strengths and weaknesses of different models and why changes in purchasers’ strategies have led to changes in physician-hospital relationships. They present case studies of physician-hospital affiliation arrangements in four hospital systems in New York and California to illustrate how the factors identified in their theoretical analysis have actually played out in real-world situations.

Bradford H. Gray
Editor, The Milbank Quarterly

References

Escarce, J.J., and F.W. Puffer. 1997. Black-White Differences in the Use of Medical Care by the Elderly: A Contemporary Analysis. In Racial and Ethnic Differences in the Health of Older Americans, edited by L.G. Martin and B.J. Soldo, 183-209. Washington, D.C.: National Academy Press.

Institute of Medicine. 2002. Unequal Treatment: Confronting Racial and Ethnic Disparities in Health Care. Washington, D.C.: National Academy Press.

U.S. Department of Health and Human Services. 2000. Healthy People 2010: Understanding and Improving Health. Washington, D.C.: U.S. Government Printing Office.

Author(s): Bradford H. Gray

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Volume 81, Issue 2 (pages 175–178)
DOI: 10.1111/1468-0009.00183_1
Published in 2003