Making Health Care Work

    • May 2, 2013

A human perspective on the uninsured. People without health insurance will never be just a statistic to Kelly Devers, PhD.

When she was a senior in high school, her father lost his job as an electronics technician in the auto industry. It was the 1980s auto recession, and many of their neighbors in Waterford, Mich., northwest of Detroit, also were being laid off.

"Seeing people lose their jobs and health insurance was heartbreaking and made me more interested in health policy," Devers recalls.

Devers' own family was uninsured for brief periods when her father was laid off or between jobs. Once, when she had an ear infection, "I remember my mother saying, 'I don't know if we can afford to go to a doctor. Can you ride it out a little bit?'"

Those experiences stayed with Devers as she started on a path that would eventually lead her to the Robert Wood Johnson Foundation Scholars in Health Policy Research program in 1994.

The path to policy reform. Devers first entered the world of scholarship through the back door, with an athletic scholarship from Ohio State University for softball and volleyball. She soon realized she needed a greater academic challenge and transferred to the University of Pennsylvania. Without her athletic scholarship, she worked nights in the library and took out loans to pay her way. And she studied with renowned medical sociologists Renee Fox, PhD, and Charles Bosk, PhD.

Devers wrote her senior thesis at Penn on primary care physicians, and her PhD thesis in sociology at Northwestern University on triage in intensive care units and its implications for cost and quality.

At the time, hospital "merger mania" (a phrase many used to describe this period of rapid hospital consolidation) and the development of organized delivery systems were in full swing, Devers says, raising concerns about the implications for patients and communities. Would these mergers and systems mean more access, higher quality, and lower costs, or would they reduce competition and have other negative impacts on patients and communities? There was "a lot of dialogue going on between sociologists and economists about organizations and these kinds of issues. I was studying a lot of similar issues as economists, but from a sociological perspective."

After receiving her PhD in sociology in 1994, Devers received a two-year fellowship from the Robert Wood Johnson Foundation Scholars in Health Policy Research program, which she spent at the University of California's campuses in Berkeley and San Francisco. The Scholars program provides paid full-time two-year fellowships to outstanding new PhDs in economics, political science, and sociology to advance their involvement in health policy research. See Program Results Report for more information about the program.

The RWJF Scholars program, Devers says, "really gave me a much stronger foundation in other social sciences and applied health policy. I was able to round out my own sociological training and apply it to the practical policy world. It's the expertise, the breadth, the really smart people you run into in this program that make such a big difference."

In particular, she cited her sociology mentor, Neil Fligstein, PhD, who is a leading scholar of organizational theory and economic sociology, and Joan Bloom, PhD, a professor of public health with whom she did research on Medicaid capitation for mental health patients (that is, paying providers a set fee for each patient they serve, rather than reimbursing them for individual services). She also worked with Hal Luft, PhD, director of the Institute for Policy Studies at the University of California at San Francisco and an early researcher on health maintenance organizations.

A career in health policy research. Among the jobs Devers has taken on since she left the Scholars program in 1996, she worked on the first-term transition team of President-elect Barack Obama, helping decide what changes the new administration would propose in its ambitious reforms of the nation's health care system.

Devers spent most of her time with the transition team analyzing the discussions that took place during more than 3,000 town hall meetings that had been held in communities across the United States. The point of the meetings was to gather on-the-ground first-hand opinions about what was needed in health reform from those who would be directly affected by it—average citizens, including those who can't afford health insurance.

After that experience Devers considered entering the federal health care establishment full time again—she had been working as an associate professor at Virginia Commonwealth University—but decided instead to return to her first love, full-time policy research. Devers had previously worked for the federal Department of Health and Human Services, Agency for Healthcare Research and Quality (AHRQ), and another independent health policy think tank, the Center for Studying Health System Change. She joined the Urban Institute in 2009, focusing on the implementation of health reform and the study of organizational changes in the health care system that will both save money and improve patient care.

"I like to toot our horn a little bit," she says of the Urban Institute. "We're one of the oldest and most respected think tanks in the country. We were founded in 1968 by President [Lyndon] Johnson when a lot of the big social programs were getting underway. Our charge has always been to do rigorous but applied work that would inform federal and state policy.... We're considered the gold standard as far as research."

Health Reform 2.0. Asked how she would describe the big picture of her 2013 research agenda, Devers says she thinks of it as Health Reform 2.0. The general perception people have of the Obama administration's Patient Protection and Affordable Care Act, she says, is that it's solely about making sure everyone in the country has health insurance but there is a lot in the legislation about how to improve the delivery system. Health Reform 2.0 focuses on what happens after insurance coverage expansion.

"Most of what I work on," she says, "is how to reform the delivery system to provide high quality, efficient health care. If the reforms we have in place now give millions more Americans access to health insurance but we don't have an efficient delivery system that's providing good access and high quality care, we'll all be in a lot of trouble."

One issue that has occupied a significant amount of Devers' attention is the "medical home"—a way to revive primary care as the centerpiece of patient care and to provide a new model of primary care delivery. Medical homes are designed to combat the fragmentation that's taken place in health care over decades. Instead of being a way-station for referrals to specialists, the primary care physician's office would become a home base that takes responsibility for providing more preventive, chronic, and other care appropriately in their purview as well as actively navigating the patient through whatever treatments are required.

"We're really struggling to strengthen what I would consider the backbone of our health care delivery system," Devers says, "which is the good old primary care physician that you see first. Medical homes are designed to give you better access to care and to help you coordinate care and perhaps provide more of that care to you directly."

Devers is spearheading components of two major projects involving medical homes. One entails evaluating the quality demonstration grant program in 18 states authorized by Children's Health Insurance Program Reauthorization Act (CHIPRA) and sponsored by the Centers for Medicare & Medicaid Services (CMS). Many of the states are testing several types of quality measurement and improvement interventions, including the efficacy and implementation of the medical home concept to health care delivery for children and adolescents.

A second study is evaluating The Multi-Payer Advanced Primary Care Practice sponsored by CMS. In this project, Devers and her colleagues are examining how states and their Medicare and private payer partners are paying for and implementing medical homes and whether medical homes can reduce cost at the same time they improve the quality of medical services delivered, especially for Medicare, Medicaid, and other vulnerable populations.

In 2011 Devers co-authored a detailed analysis of the strengths and weaknesses of the medical home concept. The paper is available online.

Medical homes are not the only focus of Devers' research. Other studies include evaluations of Health Information Technology for Economic and Clinical Health (HITECH) provisions of the American Recovery and Reinvestment Act (ARRA) programs designed to stimulate the adoption and meaningful use of electronic health records, and evaluation of attempts to apply to health care some of the efficiency innovations, such as process redesign techniques (LEAN and Six Sigma), that have proved successful in manufacturing. She has also served as the lead evaluator of the National Cancer Institute's Community Cancer Centers Program, which is designed to improve the quality of cancer care in community hospitals.

Devers co-authored for RWJF a detailed progress report on electronic health records, "The Use of Electronic Health Records and Health Information Exchange to Improve Quality: Where Are We and What Are the Key Issues to Watch?" which is not yet published.

Looking back. The scope of the projects Devers finds herself involved in, and their potential impact on the health care of millions of Americans, makes her grateful for the perspective she gained during her stint in the Scholars program.

"The thing that's unique about the Robert Wood Johnson program," she says, "is that it helps you understand concretely what health policy makers need to know...what their concerns are. If you're trained in a disciplinary sociology department or even in a business school, you're not necessarily thinking like a health policy person who's charged with trying to run the Medicare or Medicaid program or regulate a piece of the private sector. What you get in the Scholars program is a very strong grounding in what the health policy issues are, and how health policy-makers think, and also what kinds of research will be credible to them, yet useful in a timely way."

Devers adds that she has discovered an ancillary benefit to those skills that has surprised her: She now frequently receives requests from people working in other sectors of social services delivery—foster care, unemployment, housing, and education are examples she mentions—who are eager to hear what she has learned in health care about how to improve the quality of services delivered while at the same time cutting costs.

"In the Scholars program we learned a lot about economics and political science and other disciplines as well," Devers says, "so I can bridge what's going on in health care with other parts of the world because I've had to learn how to articulate clearly what we're doing in health care and how it might relate to what they're trying to do."

RWJF perspective. The Robert Wood Johnson Foundation Scholars in Health Policy Research program is designed to foster a new generation of creative thinkers in health policy research within the disciplines of economics, political science, and sociology. The fellowship program, established in 1991, annually selects a total of nine recent PhD graduates from among those three disciplines to spend two years studying at one of three participating sites (currently Harvard University, University of California-Berkeley/San Francisco, and University of Michigan).

Participants learn about health and health policy, gain exposure to the perspectives of the other two disciplines through seminars with peers, receive mentoring from prominent scholars, develop research ideas, and conduct research while receiving a stipend and benefits that free them from other professional obligations. "We're looking for people who aren't too far along in pursuing a specific research agenda. Our goal is to catch people early and tempt them into the field of health policy," says Lori Melichar, PhD, RWJF director for the program.

While in the Scholars program, participants have conducted research on issues and policies related to individual health, public health, social and economic determinants of health and health care, health care financing, and health care systems and institutions. After completing the program, alumni stay connected to their peers through a network facilitated by the Boston University Health Policy Institute, which serves as the national program office.

Scholars from the Health Policy Research Program have made significant contributions to their disciplines and to the field of health policy research. The program's 200-plus alumni, many of whom hold faculty appointments at universities and colleges, have authored hundreds of widely cited books and articles; held editorial posts at top scholarly journals; sat on scientific advisory panels; served as senior advisers to presidential, Congressional, federal agency, and national scientific councils; and received numerous professional awards for their research.

Although the original purpose of the program—to increase the number of economists, sociologists, and political scientists conducting health policy research—remains important, RWJF's focus has expanded to include "building the community" of health policy researchers and supporting them at institutions nationwide. "Now it's more about creating a critical mass so that we have a self-sustaining community [of researchers]," Melichar says.