the health policy process andy bindman, md professor medicine, health policy, epidemiology &...
TRANSCRIPT
The Health Policy Process
Andy Bindman, MD
Professor Medicine, Health Policy, Epidemiology & Biostatistics
UCSF
Format of Class
Primarily lectures with some discussion and in class exercises
Great guest speakers– Karin Rush-Munroe– Rebecca Smith-Bindman– Cathy Hoffman– Andy Schneider– Drew Altman
Grading Policy
Based on homework assignments and class participation
No final exam Homework due via email to Khoa
Nguyen the Monday evening (6 PM) following each class
Homework intended to extend from your own area of research
Policy Experience
How many have lived in DC?
Policy Experience
How many have lived in DC?
How many have participated in a political campaign?
Policy Experience
How many have lived in DC?
How many have participated in a political campaign?
How many have worked for an elected official?
Policy Experience
How many have lived in DC?
How many have participated in a political campaign?
How many have worked for an elected official?
How many have received a political appointment?
Policy Experience
How many have lived in DC?
How many have participated in a political campaign?
How many have worked for an elected official?
How many have received a political appointment?
How many have held elective office?
Policy Experience
How many have lived in DC?
How many have participated in a political campaign?
How many have worked for an elected official?
How many have received a political appointment?
How many have held elective office?
How many want to run for elective office?
Policy
What government does
Making decisions, discretion, unstructured, consequential
What government chooses to do and what not to do
Major Health Policy Domains
Public health
Research
Workforce
Financing health care
Federal Health Policy Agencies
Public health– CDC, FDA
Research– NIH, AHRQ
Workforce– HRSA
Financing health care– CMS
Health Policy Extends Beyond Federal Level
FederalMedicare, VA, Tricare
State– Medicaid, CHIP– Insurance Exchange
Local– Indigent care including
immigrants
Policy Process
Problem recognized Policy developed to deal with problem Law created Law implemented
Role of Research in Policy Role of Research in Policy ProcessProcess
Problem identified with help of researchProblem identified with help of researchDecision making about actions supported Decision making about actions supported
by research on optionsby research on optionsPolicy implementedPolicy implementedMonitoring and evaluation through Monitoring and evaluation through
researchresearch
Research at the core of rational decision Research at the core of rational decision making based on consideration of all the making based on consideration of all the optionsoptions
Policy Process Not Quite So Policy Process Not Quite So Evidence BasedEvidence Based
Real life decision making not linearReal life decision making not linear More iterative processMore iterative process Too complex to consider all the Too complex to consider all the
options and insufficient data to do sooptions and insufficient data to do so Rather than finding ideal solution Rather than finding ideal solution
policymakers looking for a policymakers looking for a ““good good enoughenough”” one one
Incremental PolicyIncremental Policy
““Good enough solutionsGood enough solutions”” lead to small lead to small scale changesscale changes
Research not at the heart of assessing Research not at the heart of assessing all the options but used in selective all the options but used in selective ways by competing groups that move ways by competing groups that move in a diffuse way toward consensusin a diffuse way toward consensus
Who Brings Problems to Policymakers’ Attention?
Constituents Researchers Journalists Special interest groups
How Do Policymakers Arrive at Their Beliefs
Respectful of scientists and health professionals but not reliant on evidence-based research
Politicians talk to a range of stakeholders to form their sense of the truth
More similar to journalism than science
Why Isn’t Research More Convincing to Policymakers?
Research often more narrowly defined than range of policy options
Rarely available in a way that is both generalizable to the nation and specific to an area
Data are often old by the time they are available
Lots of competing data and policymakers don’t have much ability to distinguish among them
Prerequisites for Government Action
Identification of a social problem
Must be persuaded that problem requires government intervention
Must have a method for how the government can respond to bring about desired change
Is It a Public Problem
Is the problem better solved through policy or can it be resolved through the profession? Or the marketplace?
Ideological debate about role of government
Profession given a significant amount of autonomy for policing its members
25% of Implanted Defibrillators are Unnecessary - JAMA
Should this be corrected by – The profession through education?– The marketplace by educating consumers
about cardiologists’ performance?– Medicare not paying for inappropriate
defibrillators?– Government suing manufacturers who promote
“off label” use of defibrillators and providers who repeatedly insert them in patients without clear indication
Political Context
Punctuated equilibrium - long periods of stability punctuated by occasional major change
Coupling of a policy window of opportunity with a solution
Who Makes Federal Health Policy?
Iron Triangle– Administration– Senate– House of Representatives
The Administration
Executive Office of the President
Office of Domestic Policy
Office of Management and Budget
Health and Human Services
The Congress
Agenda setting in each chamber– Senate Majority Leader– Speaker of the House
Committees– Senate Finance and HELP Committees– House Energy and Commerce, Ways and
Means, Education and Labor
Who Develops the Policy?
Staff working on behalf of elected members of Congress
Interplay between Congressional staff in Senate and House with guidance from White House staff
Legislative Process
Policy Lifecycle
Identified problem Broad demand for action Realization of costs Difficulties and opposition
Who Figures Out the Cost
Congressional Budget Office (CBO)– Non partisan Congressional think tank– Highly skilled economists– Federal costs– Not cost effectiveness– Model not subject to peer review– Disseminates results on website
www.cbo.gov
Impediments to Change
Interest groups support the policy legacy - often maintaining a status quo they would not have chosen in first place
Making a Law
Dance of Legislation
Typically legislation evolves through subcommittees, and full committees of jurisdiction before full chamber level votes
“Hearings” and “Mark-ups”
If multiple committees of jurisdiction then bills must be merged before chamber votes
House and Senate must pass the same version of bill and President must sign to become law
Congress’s Decision-Making Process
Much more tortured and drawn out than clinical decisions
Visited and revisited with each member
Requires lots of face time
Voting influenced by how member perceives re-election, power relationships in chamber, and quality of the policy
Intended and Unintended Consequences of Policies
Law often purposely ambiguous
Laws create winners and losers
Start and end dates can create policy “cliffs”
Implementation
Executive branch interprets law and writes regulations; interpretations can vary
Opponents can challenge parts or all of a law in court as unconstitutional
Congress can influence by providing or withholding funds to implement
If requires state or local government cooperation they can introduce variation in implementation
Role of Research in Health Policy
Identify problems in need of solution To provide evidence regarding policy
options To monitor/evaluate whether policy is
achieving goals
My Research and Its Connection with Policy
Long standing interest in access to care for low income populations
Focus on the effectiveness of Medicaid. the largest public health insurance program for the poor
Does Medicaid coverage provide adequate access to care?
Some of My Research Findings
For the general population, many California counties have a shortage of primary care physicians
These shortages are greater for Medicaid beneficiaries than the privately insured
In repeated studies over 15 years only half of primary care physicians in California accept Medicaid patients in their practice
Main reason cited by physicians for not participating in Medicaid is poor reimbursement
Related Research of Others
Nationally about 60% of primary care physicians accept new Medicaid patients
Primary care payment rates across states average about 60% of Medicare
States that have significantly improved their primary care payment rates have seen an increase in participation
Why Is This A Problem in Need of a Federal Policy Fix
Physician participation in Medicaid is optional
Problem has been persistent and not corrected by market forces
Profession does not advocate for physician participation in Medicaid
States determine provider payment rates and in a context in which they are not held accountable for access they have a financial interest in paying low rates
Window of Opportunity
Health reform increasing population in Medicaid by 16 million
Reports from Massachusetts that insurance expansion worsened rather than improved ED overcrowding because of inadequate access to primary care
Large Democratic states have some of the lowest Medicaid physician participation and payment rates
Proposed Policy Solution
Require states to reimburse Medicaid primary care visits at Medicare rates
Federal government to provide funds for difference between a state’s current rate and the Medicare rate
CBO estimated it would cost $57 billion to bring Medicaid provider payments to Medicare rates over next 10 years
Opposition
Too costly Not all convinced that Medicaid
beneficiaries have an access barrier or that paying physicians more will solve
Payment and participation in Medicaid tends to be less of a problem in rural states
House approved $57 billion; Senate $0
Compromise:Winners, Losers and Cliffs
Cost reduced to $10 billion
Provision narrowed to cover only primary care (GIM, Peds and FM)
Federal funding guaranteed for only 2013-2014 then a cliff
Evaluating Whether Policy is Achieving Goal
State survey over time to monitor whether primary care physician participation in Medicaid changes in association with increased payment
Using specialist participation in Medi-Cal over time as a comparison group
Homework Assignment
Describe your research
Develop an argument for why your research supports a change in policy - government action
Extra credit for saying level of government and entity of government who could lead the change and why