Crossing the Policy Chasm:Crossing the Policy Chasm:How to Connect Health How to Connect Health Services Research with Services Research with
Decision-MakingDecision-Making
Andrew Bindman, MDAndrew Bindman, MD
Professor Medicine, Health Professor Medicine, Health Policy, Epidemiology & Policy, Epidemiology & BiostatisticsBiostatistics
University of California San University of California San FranciscoFrancisco
Traditional Research to Policy Traditional Research to Policy ModelModel
Problem identified with help of Problem identified with help of researchresearch
Decision making about actions Decision making about actions supported by research on optionssupported by research on options
Policy implementedPolicy implementedMonitoring and evaluation through Monitoring and evaluation through researchresearch
Research at the core of rational Research at the core of rational decision making based on decision making based on consideration of all the optionsconsideration of all the options
Traditional Model Not So Traditional Model Not So TraditionalTraditional
Real life decision making not Real life decision making not linearlinear
More iterative processMore iterative process Too complex to consider all the Too complex to consider all the options and insufficient data to options and insufficient data to do sodo so
Rather than finding ideal Rather than finding ideal solution looking for a “good solution looking for a “good enough” oneenough” one
Incremental PolicyIncremental Policy
““Good enough solutions” lead Good enough solutions” lead to small scale changesto small scale changes
Research not at the heart of Research not at the heart of assessing all the options but assessing all the options but used in selective ways by used in selective ways by competing groups that move in competing groups that move in a diffuse way toward consensusa diffuse way toward consensus
Two CommunitiesTwo Communities
Research and policy worlds Research and policy worlds culturally distinctculturally distinct
Distinct language, timing, Distinct language, timing, and valuesand values
ValuesValues
AcademicAcademic– Publish or Publish or PerishPerish
– A Mile DeepA Mile Deep– Peer ReviewPeer Review– Teaching Teaching – Research/Research/GrantsGrants
– DepartmentDepartment– Endowed ChairEndowed Chair– TenureTenure
The HillThe Hill– The Power of the The Power of the PressPress
– A Mile WideA Mile Wide– Public opinionPublic opinion– Meet and GreetMeet and Greet– FundraisingFundraising– Committees (A/B)Committees (A/B)– Committee ChairCommittee Chair– ReelectionReelection
Researchers tend to see Researchers tend to see decision making as an event-decision making as an event-they deliver their edicts to they deliver their edicts to the impenetrable cardinals’ the impenetrable cardinals’ retreat and await the puff of retreat and await the puff of smoke that signals decision smoke that signals decision while grumbling about while grumbling about irrationality within the irrationality within the conclaveconclave
Decision makers tend to see Decision makers tend to see research as a product they research as a product they can purchase from the local can purchase from the local knowledge store, but too knowledge store, but too often it is the wrong size often it is the wrong size needs some assembly, is on needs some assembly, is on back order, and comes from back order, and comes from last year’s fashion line last year’s fashion line
Knowledge BrokeringKnowledge Brokering
Conduit for two way communication Conduit for two way communication between researchers and decision-between researchers and decision-makersmakers
Informing decisions is as much Informing decisions is as much social as it is technicalsocial as it is technical
Requires re-formulated Requires re-formulated communication and social communication and social interaction to bridgeinteraction to bridge
Attributes of Knowledge Attributes of Knowledge BrokersBrokers
Understands cultures of research Understands cultures of research and decision making environments and decision making environments
Able to find and assess relevant Able to find and assess relevant research in a variety of formatsresearch in a variety of formats
Facilitates, mediates, Facilitates, mediates, negotiatesnegotiates
Trusted and credibleTrusted and credible Clear communicatorClear communicator
Who Are Knowledge Brokers Who Are Knowledge Brokers in Federal Health Policyin Federal Health Policy
• Congressional think tanksCongressional think tanks CRS, CBO, GAOCRS, CBO, GAO
• Congressional CommissionsCongressional Commissions Medpac, MACPACMedpac, MACPAC
• Institute of MedicineInstitute of Medicine• FoundationsFoundations• Universities and other Universities and other
research organizationsresearch organizations
Others Who Seek to Fill Others Who Seek to Fill the Knowledge Voidthe Knowledge Void
Washington think tanksWashington think tanks
Interest groupsInterest groups
Voluntary Health AssociationsVoluntary Health Associations
American Heart AssociationAmerican Heart Association American Cancer SocietyAmerican Cancer Society American Diabetes AssociationAmerican Diabetes Association Paralyzed Veterans of AmericaParalyzed Veterans of America National Alliance Mentally National Alliance Mentally IllIll
March of DimesMarch of Dimes
Trade AssociationsTrade Associations
America’s Health Insurance America’s Health Insurance PlansPlans
American Hospital AssociationAmerican Hospital Association Association of American Association of American Medical CollegesMedical Colleges
Federation of American Health Federation of American Health SystemsSystems
Pharmaceutical Research and Pharmaceutical Research and Manufacturers AssociationManufacturers Association
ADVAMEDADVAMED
Professional SocietiesProfessional Societies
American Medical AssociationAmerican Medical Association National Medical AssociationNational Medical Association American Nurses AssociationAmerican Nurses Association American Pharmacists American Pharmacists AssociationAssociation
American Trial Lawyers American Trial Lawyers AssociationAssociation
Think TanksThink Tanks
Center for American Center for American ProgressProgress
HeritageHeritage CatoCato Urban InstituteUrban Institute New America FoundationNew America Foundation Brookings InstituteBrookings Institute
UNIONSUNIONS
SEIUSEIU AFL-CIOAFL-CIO UAWUAW ILGWUILGWU
Other Major StakeholdersOther Major Stakeholders
AARPAARP Families USAFamilies USA National Governors National Governors AssociationAssociation
National Conference of State National Conference of State LegislatorsLegislators
Knowledge Broker Knowledge Broker CommunicationCommunication
Shopping ideas to sympathetic Shopping ideas to sympathetic staff in Congress, White House staff in Congress, White House and Agenciesand Agencies
Cultivating specific Cultivating specific relationshipsrelationships
Talking to other knowledge Talking to other knowledge brokersbrokers
Communicating back to leadership Communicating back to leadership of organizationof organization
What are They Talking What are They Talking AboutAbout
Updates about what new things Updates about what new things they have learned since last they have learned since last conversationconversation
Information about membership Information about membership concernsconcerns
Updates about where things are Updates about where things are in legislation cyclein legislation cycle
Updates on how other decision Updates on how other decision makers view action itemsmakers view action items
Interest Groups Will Go Beyond Interest Groups Will Go Beyond Information and Promote ActionInformation and Promote Action
Encourage introduction of Encourage introduction of billbill
Write language of billWrite language of bill Strategize politics of Strategize politics of legislation with legislation with Congressional leadershipCongressional leadership
Bring members to hearingsBring members to hearings Liaison with executive branchLiaison with executive branch
Why Do Policy Makers/Staff Why Do Policy Makers/Staff Want to Meet with Knowledge Want to Meet with Knowledge BrokersBrokers
To hear about the latest research To hear about the latest research findingsfindings
To learn about stakeholder To learn about stakeholder positions and prioritiespositions and priorities
To learn what knowledge brokers To learn what knowledge brokers have learned from other decision have learned from other decision makersmakers
To test ideas for solutionsTo test ideas for solutions To activate political pressureTo activate political pressure
Limitations of Knowledge Limitations of Knowledge Broker Model for ResearchersBroker Model for Researchers
Time demanding to be an Time demanding to be an available resource for available resource for decision-makersdecision-makers
Value of objective research Value of objective research evidence can be diminished in a evidence can be diminished in a sea of competing messages from sea of competing messages from biased knowledge brokersbiased knowledge brokers
Promotes style over substancePromotes style over substance
Where Does Research End Where Does Research End and Advocacy Beginand Advocacy Begin
Some researchers never cross the Some researchers never cross the policy chasmpolicy chasm
Others engage policymakers without Others engage policymakers without engaging the communities affected by engaging the communities affected by the policiesthe policies
Increasingly researchers are working Increasingly researchers are working in a collaborative and interactive way in a collaborative and interactive way throughout the research process with throughout the research process with stakeholders to influence policystakeholders to influence policy
Community Based Community Based Participatory ResearchParticipatory Research
““Research subjects become more than Research subjects become more than research objects. They give more than research objects. They give more than informed consent; they give their informed consent; they give their knowledge and experience to the knowledge and experience to the formulation of research questions and formulation of research questions and methods applied…they become active methods applied…they become active partners in identifying key problems partners in identifying key problems and in using the research findings to and in using the research findings to advocate policies and programs and in advocate policies and programs and in program development, monitoring and program development, monitoring and evaluation.”evaluation.”
Green and Mercer, AJPH, 2001Green and Mercer, AJPH, 2001
Who is the Community in Who is the Community in Participatory ResearchParticipatory Research
Those affected by issue being Those affected by issue being studiedstudied– Individuals living in a Individuals living in a geographic areageographic area
– Community based organizationsCommunity based organizations– Government agencies that Government agencies that provide/manage resources provide/manage resources targeting at- risk targeting at- risk individuals/communitiesindividuals/communities
Traditional Research vs Traditional Research vs CBPRCBPR
Formative StageFormative Stage Traditional Traditional ApproachApproach– Researchers Researchers plan projectplan project
– Form teamForm team
CBPR ApproachCBPR Approach– Policymakers Policymakers and academic and academic partners form partners form teamteam
– Develop shared Develop shared mission and mission and decision-decision-making making structurestructure
Traditional Research vs Traditional Research vs CBPRCBPR
Study SelectionStudy Selection Traditional Traditional ApproachApproach– Researchers Researchers choose topic and choose topic and design based on design based on scientific scientific theory, academic theory, academic interest, data, interest, data, feasibilityfeasibility
CBPR ApproachCBPR Approach– Policymakers Policymakers and academic and academic partners also partners also incorporate incorporate community community priorities priorities insights and insights and assets; assets; scientific scientific rigor and rigor and community community feasibilityfeasibility
Traditional Research vs Traditional Research vs CBPRCBPR
FundingFunding
Traditional Traditional ApproachApproach– Grant written Grant written by researcherby researcher
– Funds go to Funds go to researchersresearchers
CBPR ApproachCBPR Approach– Policymakers Policymakers and academic and academic partners co-partners co-develop grant develop grant with equitable with equitable distribution distribution of funds based of funds based on on contributionscontributions
Traditional Research vs Traditional Research vs CBPRCBPR
Implementation/AnalysisImplementation/Analysis Traditional Traditional ApproachApproach– Researchers Researchers solely solely responsible responsible for conducting for conducting study and study and analyzing dataanalyzing data
CBPR ApproachCBPR Approach– Policymakers Policymakers and academic and academic partners partners collaborate on collaborate on all efforts; all efforts; traditional traditional analysis analysis informed by informed by policy driven policy driven questionsquestions
Traditional Research vs Traditional Research vs CBPRCBPR
Disseminate FindingsDisseminate Findings Traditional Traditional ApproachApproach– Disseminate to Disseminate to academic academic audiencesaudiences
CBPR ApproachCBPR Approach– Policymakers and Policymakers and academic academic partners are co-partners are co-authors and co-authors and co-presenters; presenters; disseminating to disseminating to academics, academics, research research participants, participants, involved involved communities and communities and policy makerspolicy makers
Traditional Research vs Traditional Research vs CBPRCBPR
Translate Research in Translate Research in PolicyPolicy
Traditional Traditional ApproachApproach– Research often Research often ends with ends with publishing of publishing of resultsresults
CBPR ApproachCBPR Approach– Policymakers Policymakers and academic and academic partners partners mobilize the mobilize the community to community to use findings use findings to advocate to advocate for policy for policy changechange
Traditional Research vs Traditional Research vs CBPRCBPR
Sustain TeamSustain Team
Traditional Traditional ApproachApproach– When grant When grant ends, ends, researchers researchers often move to often move to new projectnew project
CBPR ApproachCBPR Approach– Sustainability Sustainability built into work built into work from inception; from inception; partners honor partners honor initial initial commitment to commitment to continue continue partnership and partnership and work beyond work beyond funding cyclesfunding cycles
Community Based Community Based Participatory Research Participatory Research (CBPR)(CBPR) BenefitsBenefits
– Direct and indirect funding Direct and indirect funding potentialpotential
– Enhanced access to dataEnhanced access to data– Greater understanding of policy Greater understanding of policy questionsquestions
– Opportunity to participate in Opportunity to participate in applied work that could have applied work that could have direct impact on policydirect impact on policy
CBPR with PolicymakersCBPR with Policymakers
ChallengesChallenges– Relationships take time Relationships take time – Sharing power, resources, Sharing power, resources, decision-makingdecision-making
– Service versus research Service versus research objectivesobjectives
– Academic independence and Academic independence and desire to learn from data desire to learn from data versus a shared mission-driven versus a shared mission-driven set of beliefsset of beliefs
Community Based Community Based Participatory Research Participatory Research with Policymakerswith Policymakers Additional ChallengesAdditional Challenges
– If too aligned with one If too aligned with one political party could be labeled political party could be labeled and isolated by the otherand isolated by the other
– Political environment can Political environment can challenge ability of challenge ability of policymakers to be consistent policymakers to be consistent partnerspartners
– Policy versus academic response Policy versus academic response timestimes
Navigating a University Navigating a University and State Government and State Government PartnershipPartnership
California Medicaid Research Institute California Medicaid Research Institute (CaMRI)(CaMRI)– University of California multi-campus University of California multi-campus research programresearch program
– Master agreement between UC and state Master agreement between UC and state that specifies expectations and that specifies expectations and responsibilities for choosing responsibilities for choosing projects, data sharing and publishingprojects, data sharing and publishing
– Cultivating relationship over time Cultivating relationship over time and deep into organizations - not just and deep into organizations - not just with leadershipwith leadership
– Pursue direct as well as independent Pursue direct as well as independent fundingfunding
CaMRI Medicaid Waiver CaMRI Medicaid Waiver Evaluation Process with Evaluation Process with StateState Formulate questions togetherFormulate questions together Agree on methodological Agree on methodological approachapproach
Approach funders togetherApproach funders together Dissemination plan includes Dissemination plan includes scientific community as well scientific community as well as Medicaid stakeholders as Medicaid stakeholders (counties, patients and (counties, patients and providers)providers)
Closing ThoughtsClosing Thoughts
Research can inform public policy and Research can inform public policy and be a powerful tool for social changebe a powerful tool for social change
To enhance your effectiveness you need To enhance your effectiveness you need to be scientifically rigorous and to be scientifically rigorous and sophisticated in how you disseminate sophisticated in how you disseminate your resultsyour results
Connecting with and forming linkages Connecting with and forming linkages among knowledge brokers is critical among knowledge brokers is critical for influencing the policy processfor influencing the policy process
Community based participatory research Community based participatory research may be a highly effective way to align may be a highly effective way to align the research process with the policy the research process with the policy decision-making processdecision-making process