A Marriage Waiting to Happen: Health Services Research and Healthcare Management

(Keynote presentation given on June 2, 2019 at AcademyHealth’s Annual Research Meeting)

Many young boys grow up dreaming of becoming a fireman or a policeman. Others dream of becoming professional athletes or rockstars. Ladies and gentlemen, when I was a young person, I turned to my parents and said “Mom, Dad, when I grow up, I want to be a health services researcher.”

And if you don’t believe me, I can offer you an excerpt of my medical school personal statement where I wrote almost 20 years ago:

“Hopefully, over time, in working as an academic physician and policy researcher, I will have developed the knowledge to achieve my dream of designing and introducing effective policies at the state or federal levels of government.”

This was written in 2001 (and, yes, I am a proud nerd).

My life has taken some twists and turns since then, but I want to use my time with you this morning to reflect on lessons learned trying to create change through health policy, health services research and healthcare management over the last 2 decades.

My very first college internship got started 20 years ago this week right here in Washington, DC and it was at the Alpha Center—a small Dupont Circle think tank that eventually became a part of AcademyHealth. That summer, I worked on a few projects for Deborah Chollet, a noted health economist. 

I remember going to work every day with a simplistic operating model of how we create change through health policy. I believed that acclaimed health services researchers like Deborah analyzed policies and their effects in published papers—and policy-makers and regulators gleaned insights from those papers and effectuated changes in policies. 

It seemed clean, precise, and rational. 

There were producers of insight. And there were consumers of their insight. And they worked together to improve health. 

It was a mental model that made perfect, logical sense—which was great.

Except for the fact that it was dead wrong.

I learned over time that the straight line that I imagined was actually a twisted tangle where many insights that arose from policy—often times common sense observations—never made their way into practice. There were the usual methodological debates about whether the insights were valid or replicable. There would be challenges getting the attention of regulators or policy-makers. And even if you got their attention and succeeded in navigating politics—there might be a failure to uptake the new policy or regulations by the individuals or institutions responsible for implementing them. And then, of course, there were the unintended consequences when policies are implemented in the real world. 

Nowhere was this more apparent than in the early days of the Obama Administration.

There were so many whose work and insights failed to make their way into the implementation of the HITECH Act or the ACA. It might sound funny now, but my overly simplistic mental image before I worked at the Department of Health and Human Services was that there were legions of well-intentioned government employees like my friend Aman Bhandari at the Centers for Medicare and Medicaid Services whose job it was to read JAMA, HSR, HealthAffairs, and the New England Journal of Medicine and drive insights they gleaned from their reading into practice.

There were a few instances of a straight line where the work of people like Larry Casalino and Julia Adler-Milstein clearly informed the design and implementation of policy. Larry’s studies on the cost of implementing EMRs were used to quantify the size of meaningful use subsidies and Julia’s work on the state of health information exchange shaped the administration’s approach to state-operated HIE’s. These, however, were the exceptions. 

Only after becoming one of those well-intentioned government officials a decade ago, did I realize that in the complicated world of health policy and healthcare politics—happenstance plays a far more important role than anyone would ever like to admit.

Sometimes, who you know might be just as important as what you know.

The identity, persuasiveness, and credibility of the messenger of the evidence often matters as much as the evidence itself. 

Oh—yes—-and timing matters. A lot. 

Of course, I am not the first person to make this latter observation. The legendary political scientists John Kingdon and Deborah Stone both noted the importance of “policy windows.” Policy windows, you’ll remember, are brief moments in history when big, monumental pieces of legislation are passed—and when a large legion of homeless ideas find a home in legislation or regulation. 

Nowhere was this more evident than the ACA where long-heralded ideas like ACOs and bundled payments finally found a place—and in finding a place, found life. It was incredible, remarkable, even breathtaking, to watch so many ideas brought to life and change catalyzed at scale—but, as a young staffer in government, raised a critical question for me at the time when I still thought my full-time career would be that of a health services researcher.

Waiting for that generational window is a great strategy to create impact for the deeply committed, dedicated souls who are patient enough to wait for one. 

But what are those among us who are less patient to do? 

For we could all write papers whose punchlines begin with “Policy-makers should....”

But what if our politicians only open these windows in healthcare every 10, 15, 20 years? How will the work of this community still be relevant and drive the change we hope to see in the world?

I fundamentally believe that the opportunity for health services researcher to drive impact is far greater—and the audience of interested parties is far wider than just policy-makers.

My own way of resolving this question was to go to work in the management of health systems where I believed I could make more immediate impact. 

The move to management, however, has not been without occasional feelings of loss.

While my time in health services research highlighted a host of challenges the field faces, much of what I love about the best health services research—

Methodological rigor;

A high degree of creativity and originality;

A passion for getting to the bottom of the hairy truth

—is often difficult to translate into management practice, no matter how badly it is needed.

The need to drive conclusions in the face of imperfect information often trumps a more natural instinct towards careful study to arrive at the “right answer.” 

That said, I have a small, provocative, and potentially controversial proposal to make that I believe is worthy of your consideration.  

Now, a little known fact, is that I am a 5-time matchmaker. I have five marriages to my name. (The skeptics among you will note that I have ignored sharing the denominator—and I could say a bit about how match-making is a thankless art form, but I won’t go there today).

But I’m here today to propose a sixth match and that is the marriage of two tribes that for too long have evolved separately: the health services research tribe and the healthcare management tribe.

These tribes have operated independently of one another for far too long. And the time has never been better to unite them to solve problems of local and national importance. 

Most healthcare organizations—health plans, health systems--do not have an R&D function.

And bizarrely, departments focused on health services research are almost always disconnected from the operations of the organization. 

I believe this represents a missed opportunity and a divide that we should aspire to close. 

I can’t claim to fully understand the origins of this disconnect.

Perhaps it lies in how we are trained. Or perhaps it represents a natural separation based on interest. Or a difference in the reward system across both fields. 

But as someone who has spent time in government, academia, and now in leading organizations that deliver care—I have a strong conviction that the work of the people in this room has the opportunity to drive, shape, and inform evidence-based, data-driven management decisions—that can meaningfully improve the health of the communities in which we work and live.  

Now, I will tell you that it won’t be immediately easy. There are differences in language and communication between the research and management tribes. 

Differences in values and priorities. 

Concepts that everyone in this room takes for granted—like basic experimental design and the idea that correlation and causation are not the same thing—will need explaining and translation. 

You will need change how you communicate so that your insights are properly translated. 

But if you can do this--I believe we will catalyze and accelerate change in healthcare delivery in ways that we never have before.  

Because those of us who are trying to change health care delivery from within need your insights. 

We need your help understanding what does and doesn’t work. 

We need your developing methodologies for identifying who are sickest patients are so that we can target our efforts. 

We need your help understanding how best to structure and organize care delivery and benefits to achieve outcomes. 

But we need guidance that is locally relevant that broader studies and evaluations often don’t capture.  

At CareMore, the healthcare delivery organization, that I lead—we have been focused on building internal research capabilities and partnering with external researchers to glean insights on the effectiveness of long-standing programs—but also test new ideas in practice. The value of these partnerships is immense.

The results of help inform our strategy and capital allocation decisions as we decide what initiatives we should scale and which we should shut down. 

Our research partners take the time to learn our organization and in doing so--ask unexpected questions that force us to think about how programs are designed and implemented. And we have gleaned valuable lessons that we’ve published for others to consider in their own contexts. 

Now I am certain that there are many among you who might bristle at the notion of focusing your efforts on a single institution’s problems—when you are used to thinking on a much grander scale. To which I would say, just try it. You might just find it uniquely rewarding.

Challenge yourself to be in a position of high-degree of local relevance—even as you drive towards influencing a national conversation. We all know the funny caricature in this field of individuals whose work is nationally famous, but locally unknown or irrelevant. Let’s work as hard to change that paradigm.

The work of changing health systems is hard and complex and political and too fraught with consensus-driven decision making in areas where it is clear what needs to be done. Be the voice of conscience and help science and data inform our moral imperatives.

 Call it delivery science, implementation science, health services research, or the learning health system—what we call it doesn’t matter.

What is clear as that we continue to have a crisis in healthcare in this country and we need to bring forth new ways of working together to make things work. 

To be clear, I am not under-estimating the challenge or the obstacles inherent in what I have proposed. Every marriage has its challenges—but as many of you will attest, it is in those challenges that lies incredible growth. And I can say with confidence—that this field and profession is ripe for the next stage of growth that can be catalyzed by a re-imaging the audience and partners with whom you align.

Everyone knows what needs to be done. Now it’s time to go do it. This is not a new idea. These two tribes have been dating on and off for decades. But it’s time to get married.

So in closing, just as Queen Beyonce told us—“if you like it you should put a ring on it!” 

If you can close the deal you will leave an even greater impact on our healthcare system that you already are.

Acknowledgements: Matthew Hayward developed the exceptional graphics and figures and helped shape the content for this dark. I received terrific editorial suggestions from Amy Chen, Serena Foong, Vicki Fung, and Aman Bhandari. I am, however, ultimately alone in my responsibility for the content of this talk.