Core Competencies

Financing

The ways in which societies choose to finance, reimburse, and manage health services are central to any analysis of national health care systems. In our pluralistic society, the U.S. has chosen a largely demand-driven, market-based system that nevertheless has a strong government component. Researchers at the Schneider Institutes have focused on private insurance markets and managed care organizations as well as the large government financed programs such as Medicare and Medicaid. Their work encompasses reimbursement methodologies for acute and chronic care as well as for behavioral health. Most other industrialized countries provide universal health insurance to their citizens and often control their systems through supply side regulations, administered prices, and global budgets. Schneider researchers have studied these comparative financing methodologies as well as the manner in which care is financed in less developed countries. Their core competencies in this area focus on the following capabilities:

1. Applying economic analysis to the study of national health accounts and comparative international health care systems. Examining the sources of health care funding and the allocation of services within and across health care sectors.
2. Studying market efficiency, market failure, and the economic nature of competitive and regulatory health care systems.
3. Developing economic models and computer simulations to project financial and economic trends and to predict the financial implications of policy alternatives. Constructing "what-if" scenarios to evaluate policy options.
4. Evaluating the financial implications of particular payment systems such as Medicare, Medicaid, capitated managed care, mixed payment systems, pay for performance, etc. Modeling potential changes to payment systems and their financial and policy implications.
5. Analyzing health insurance markets and products such as indemnity insurance, managed care, individual insurance, group insurance, etc. Modeling potential changes to insurance programs such as changes in copayments, deductibles, community rating, risk bands, etc. Evaluating policy options for insurance products and markets.

Organizations

Formal organizations are the primary engines through which policy becomes action. It has long been understood that in translating policy intentions into concrete action, organizations often alter those intentions in a variety of ways. It is impossible to understand what health policies really mean for people without understanding the way health service organizations operate. SIHP's aim is to explain public and private policy outcomes when policies are implemented through institutions, develop analytical models that allow generalization of findings, and match research methods to research questions and context by:

1. Developing a range of analytical frameworks applicable to the study of organizational behavior for projects focusing on organizational actions and as an adjunct in projects focused on outcomes, costs, quality, access etc.
2. Applying these frameworks to the wide range of health related organizational types including large, complex providers, small, more "open" community based systems and to the study of inter-organizational relationships, partnerships, coalitions etc.
3. Applying these frameworks to organizations in diverse policy areas, including primary and tertiary medical systems, behavioral health and substance abuse systems, long-term care, government health agencies and health advocacy organizations.
4. Developing a range of methodological approaches to the study of organizations to allow optimal fits among research designs, policy questions and organizational contexts. These methods could range from comparative case studies to organizational surveys to the use of existing outcome and performance data.

Costs & Values

Most societies face imbalances in their health systems. Demand for some health services, such as expensive new treatments, exceed the society's ability to pay, while other services, such as prevention, are underutilized. Value measures the impact of health programs, while cost-effectiveness analysis relates programs' costs to their value. This core competency:

1. Develops methods to assess the gross costs of health programs and policies, and applies those methods in randomized trials, routine service programs, and new technologies, including interactive approaches to ensure data consistency.
2. Estimates cost offsets, such as prevention averting the cost of treatment.
3. Develops and applies methods to assess the impact of programs on health, using indexes such as the Quality Adjusted Life Years (QALYs).
4. Examines the relation between cost and value to identify cost-effective health programs, and organizational and design characteristics of a program or policy that make an existing program more cost-effective.

High Risk & Costly Populations

Health care needs, use, and costs are not distributed evenly across the population. Because providers, consumers, and insurers may be aware of the characteristics associated with high or costly use (disability, age, social status, chronic disease or condition), disparities in access can arise through market failure. Disabilities, which may result from health events and injuries or be present from birth, can result in the need for long-term support services (usually called long-term care) that support individual function rather than ameliorating or curing disease.

The SIHP research conducted falls into the following categories:

1. The health care needs, use, and costs for populations with high-risk characteristics, including:
   • Persons experiencing specific chronic illnesses
   • Persons with challenges in accessing the health services, e.g. immigrants, prisoners, homeless
   • Persons with disabilities, including both elders and others
   • Medicaid-enrolled populations, who often fall into one or more high-risk groups
   • Individuals who are dually eligible for both Medicare and Medicaid: aged and disabled
2. Providers serving high risk populations and issues related to the provision of service:
   • Case studies of successful programs serving populations with special needs: integrated long-term care programs, chronic disease interventions, programs supporting access to health services for ethnic minorities.
   • Cost, production, and quality for long-term care providers (nursing homes and home care agencies); work of their front-line care workers
3. Financing and public policy for persons at high risk and the providers that serve them
   • Issues concerning Medicare, Medicaid, and private insurance
   • Insurance for costs of supportive services (long-term care insurance)

Quality

Quality and performance measurement are key factors in current policy discussions. Evidence of the high interest in this topic is demonstrated by the recent publication of influential reports by the Institute of Medicine, the formation of national forums focused on quality, actions by accrediting organizations and health plans to focus on performance measurement, and the identification of quality as a priority area by research funders. Investigators in SIHP are conducting ongoing work in the areas listed below. In addition, new research will investigate the newly emerging concept of "pay-for-performance," which includes the key elements of common performance measures and significant financial payments based on that performance.

1. Evaluates the quality implications of state and health plan level changes in policies such as financial incentives or utilization management.
2. Develops performance measures for substance abuse service and other areas and works with national organizations to assess the measurement properties of these performance measures.
3. Examine the extent to which quality measures are used in health plans across the nation and the implications for quality improvement.
4. Provides information to policymakers, health plans, practitioners and other stakeholders as relates to quality and performance measurement.
5. Examines the impact of racial and ethnic disparities on the quality of health services.

Technology

1. Examines the economic, social and health impacts of new and emerging medical technology, including drugs and biotechnologies, devices, and services.
2. Develops methodologies for assessing and promoting the transfer and diffusion of new treatments and services from research to practice.
3. Documents the impact of public and organizational policies on adoption of, and access to, new technologies in health care.
4. Examines provider and patient attitudes towards various new technologies in practice, through development and use of survey research.