Process of Identification & Definition

Review the World Health Organization’s (WHO) definition of health in Chapter 7 of your textbook
Why is the definition of health important to health policy?
Define the term “target population” as it relates to health policy.
How do societal influences impact the identification and definition process of policy?
Research a healthcare organization and highlight how their policies align or misalign with the WHO’s definition of health.
Healthcare Adminhealthcare
ATTACHED FILE(S)
Chapter
7
ThePolicyAnalysisProcess:IdentificationandDefinition
InaDecember1,2005,talkatDukeUniversity,Dr.JulieGerberding,thendirectoroftheCentersforDiseaseControlandPrevention(CDC),suggestedthreeimportantconceptstoconsiderwhenlookingatrecentpublichealthcrises(e.g.,epidemics,terroristattacks,andnaturaldisasters)andpreparingforfuturethreats:
•Imagination
•Connectivity
•Scale
Shearguedthatwehavetodoabetterjobofimaginingproblemsifwearetoprepareforthem.Theconnectivityissues—theeaseandspeedwithwhichinformation,people,anddiseasesmovearoundtheworld,bringingclustersofindividualsintocontact—arewidelyunderstood.Theseissuesareoftencitedindescriptionsofglobalization(Friedman,2005;Naim,2005).Scalerelatestothefactthatwhencriticaleventshappen,theyhappenonascaleofconsiderablemagnitude.CitingtheresponsetoHurricaneKatrinainNewOrleans,Dr.Gerberdingnotedthatthelackofpreparednesswasnotduetoafailureofimagination.Thetragedywaswidelyforecast.Connectivityworkedfavorably,asrescuersandsupportresourcesquicklyarrivedfromallovertheUnitedStatesandMexico.Toher,muchoftheproblemwasoneofscale.Thegovernmentsinvolvedwerenotpreparedtodealwitheventsofthatscale.However,AdmiralThadW.Allen,theU.S.CoastGuardcommandantwhotookoverthefederalresponse,reportedatleastonefailureofimagination.Therewereprocedurestodealwithahurricaneanditsstormsurge,andtherewereprocedurestodealwithaflood;however,therewerenotprocedurestodealwithbothoccurringinthesameplaceonlyadayapart.
Whenitcomestopreparingfororrespondingeffectivelyandimaginativelytoanymajorhealthcareeventorpressinghealthpolicyissue,definingtheproblemiscritical.Imaginationinvolvescallingonmorethanwhatisalreadyknownandexperienced.Thereareanumberofadagesabouthowwellgeneralsarepreparedtofightthelastwar.Learningfromexperienceisagoodthing,butonlywhenitisrelevantexperience.
Identifyinganddefiningtheproblemmaybeonlythefirststeps.Whenexperiencedindividualswhodealregularlywithanissueareunabletoresolveit,oneormoreofthefollowingconditionslikelypertain:
1.Thereisnotasharedunderstandingofthenatureoftheproblem.
2.Thereisasharedunderstanding,butitisnotappropriatetothesituation.
3.Thereisarealisticandrelevantunderstanding,butitisnotinsomepeople’sinteresttoresolveit.
4.Thereisanappropriateunderstandingandashareddesireforasolution,buttherearenotsufficientresourcestoimplementthesolution:
a.Thereareinadequatefacilitationandleadershipskillstoreachthenecessarycompromises.
b.Thereareinadequatelevelsofskilledpersonneltoimplementthepreferredsolution.
c.Thereareinsufficientfinancialresourcestoimplementthepreferredsolution.
d.Theimplementerscannotfocusthepoliticalprocessontheproblemorthesolutionsufficientlytomoveahead.
e.Somecombinationoftheabove.
Inthischapter,wedealprimarilywiththefirsttwoconditions—makingsurethatthereisanaccurateandappropriatedefinitionoftheproblemthatisunderstoodbyallinvolved.Theotherconditionsrelatetotechnologicalassessments,politicalfeasibility,economicfeasibility,implementation,andleadershipandareaddressedelsewhere.
7.1GETTINGTHESCENARIORIGHT
AssessingtheImpactofaHealthPolicy
AWorldHealthOrganization(1999)report,theGothenbergConsensusPaper,definesahealthimpactassessmentas,“Acombinationofprocedures,methodsandtoolsbywhichapolicy,programmeorprojectmaybejudgedastoitspotentialeffectsonthehealthofapopulationandthedistributionofthoseeffectswithinthepopulation.”Asweshallseelater,thedistributionaleffectsmaytakethesestudieswellbeyondthepopulationatimmediaterisk,especiallyinamarketsystemliketheUnitedStates.
Ifwearetoreachagreementaboutthescopeofpotentialandexistingproblems,possiblealternatives,anddesiredoutcomes,wehavetoreachsomeagreementonseveralkeyareas(UniversityofBirmingham,2003):
1.Therelevantdefinitionofhealth
2.Identificationofthetargetpopulation
3.Thecurrentorlikelyfuturestatusofthehealthofatargetedpopulation
4.Thefactorsthatdeterminethehealthstatusofconcernwiththatpopulation
5.Themethodsrealisticallyavailabletochangethathealthstatus
6.Theresponsibilitiesofthevariousactorsindealingwiththeidentifiedissues
7.Thesocietalvaluesthataretogoverntheselectionofalternativesandtheacceptabilityofalternativeoutcomes
Ahealthpolicyanalysisseldomstartswithacleanslate.Thestartingpointisusuallyarecentmajorevent.Oftenthatleadstoovercorrectingforearliermistakes,ratherthantakingafreshlookatthesituation.Complexsystemsarefullofproblemsinsearchofsolutions,buttheyarealsofullofsolutionsinsearchofproblems.Apolicyproposalisoftenputforwardbysomeonewithaspecificsolutionalreadyinmind.Itisimportant,however,toaskwhetherabroaderrangeofalternativesolutionsshouldbeconsidered.OnesecretaryofdefenseusedtocomplainthattheJointChiefssentuptherequisitethreealternatives,twoofwhichdidnotcount.Itisawasteofscarceresourcestoevaluatealternativesthatdonotcount.Screeningforadditionalalternatives,however,canbeenlightening.Thefollowingboxdescribesanactualsituationinwhichthisoccurred.
FindinganAlternativeDefinition
Theadministratorsandtheboardoftrusteesofalargeacademicmedicalcenterwereatanimpasseoverthedesignoftheirnewfacility.Atissuewaswhethertopurchaseanewandrelativelyuntriedmonorailsystemforthedistributionofsupplies,laboratorysamples,paperwork,andsoforth.Theinvestmentwouldbelarge,andtheriskwasrelativelyhigh.Finally,oneoftheseniormedicalstaffaskedaconsultanttomeetwiththem.Afterlisteningtotheargumentsonbothsides,theconsultantasked,“Whyareyouinahurrytomakeadecisionnow?”Theyreplied,“Thearchitectforthefirstbuildingneedstoknowhowbigtomakethepassagewaysandutilitychannelsintheplanswhicharenearlycomplete.”Afterlisteningtothevariousconcerns,theconsultantasked,“Howmuchadditionalwoulditcosttodesignthebuildingtotakeeitherthenewortheoldtechnology?”Herewasanewalternative.Itturnedouttheadditionalcostwasnotmuchwhencomparedwiththeuncertaingambleonthenewtechnology.Bothsidesquicklyagreedonthatnewalternative.
DefiningHealth
Table7-1
presentstheviewofhealthandhealthcareespousedintheconstitutionoftheWorldHealthOrganization.AlthoughtheUnitedStatesisaU.N.memberstate,onewouldbehardputtofindconsensusintheUnitedStatesonanumberofthepointsthatitcitesasbasicprinciples.
AskingpeopleintheUnitedStatesifhealthismorethantheabsenceofillnessorinfirmitycouldproduceahostofdifferentresponses.Somerespondentsmightcomedownonthesideofphysicalandmentalwell-beingbuthaveaproblemwithtryingtoaddresssocialwell-beingundertheheadingofhealth.Indeed,thefactthatwehavemillionsofuninsuredanddonotprovidementalhealthcaretoalargeproportionofthepopulationwouldseemtoindicatealackofcommitmenttophysicalandmentalwell-being.
Thoseanalyzingordecidingonapolicyneedtounderstandthedifferencesintheoperationaldefinitionsofhealththatarerepresentedaroundthetable.Inthebestofallpossibleworlds,thoseseatedatthetablewouldagreeonthatdefinitionandmoveon,butsometimestheartofpoliticsdepends,inpart,onknowingwhentotrytoagreeonprinciples,oronactions,oronboth,andwhethertouselimitedpoliticalcapitaltotrytobringthemintoalignmentpublicly.
Table7-1ExcerptsfromthePreambleoftheConstitutionoftheWorldHealthOrganization
…thefollowingprinciplesarebasic…
•Healthisastateofcompletephysical,mental,andsocialwell-beingandnotmerelytheabsenceofdiseaseorinfirmity.
•Theenjoymentofthehighestattainablestandardofhealthisoneofthefundamentalrightsofeveryhumanbeingwithoutdistinctionofrace,religion,politicalbelief,oreconomicorsocialcondition.
•ThehealthofallpeoplesisfundamentaltotheattainmentofpeaceandsecurityandisdependentonthefullestcooperationofindividualsandStates.
•Theachievementofanystateinthepromotionandprotectionofhealthisofvaluetoall.
•Unequaldevelopmentindifferentcountriesinthepromotionofhealthandcontrolofdisease,especiallycommunicabledisease,isacommondanger.
•Healthydevelopmentofthechildisofbasicimportance,andtheabilitytoliveharmoniouslyinachangingtotalenvironmentisessentialtosuchdevelopment.
•Theextensiontoallpeoplesofthebenefitsofmedical,psychological,andrelatedknowledgeisessentialtothefullestattainmentofhealth.
•Informedopinionandactiveco-operationonthepartofthepublicareoftheutmostimportanceintheimprovementofthehealthofthepeople.
•Governmentshavearesponsibilityforthehealthoftheirpeopleswhichcanbefulfilledonlybytheprovisionofadequatehealthandsocialmeasures.
Source:Reproducedfrom:ConstitutionoftheWHO,BasicDocuments,45thEd.Supplied2006,Octoberatwww.who.int/governance/eb/who_constitution_en.pdf
DefiningtheTargetPopulation
Justwhatpopulationarewetalkingabout?Thehistoryofcommunitymentalhealthcentersillustrateshowdifficult—andcritical—itcanbetoanswerthisquestion.Asystemdesignedtohelpthedevelopmentallydisabledandseverelyandpersistentlymentallyillmorphedintoageneralmentalhealthtreatmentsysteminwhichmanypractitionersavoidedtheoriginaltargetgroupandconcentratedonthemorerewarding(professionallyandfinancially)cases(Torrey,1997).Asmoreandmorestatesnowfocusmoreintentlyontheoriginaltargetpopulation,manyofthosepreviouslyservedmustrelymoreonprivatepaymentorinsuranceorgowithout.
Ananalystinchargeofdevelopingamaternalhealthprogrampolicywhowantedtodeterminethehealthstatusofthetargetpopulationmightstartbylookingatthehealthofallfemalesofchildbearingage.Butwhatconstituteschildbearingagewhen8-year-oldgirlsandwomenintheir50scangivebirth?Ananalystwouldhavetoputbothanupperandalowerlimitontheagerangeinordertogetacountofthetargetpopulation.
IdentifyingtheHealthStatusoftheTargetPopulation
Thenextstepafterdefiningthetargetpopulationistoassessitshealthstatus.Manydatasourcesareavailableforthistask,butsometimestheydonotmatchupexactlywiththetargetpopulationthathasbeenidentified.TheCDCdemonstratedthecomplexconnectionbetweendefiningthetargetpopulationandassessingitshealthstatususingavailabledatain2000whenitreportedonchangesinserumfoliatelevelsinnoninstitutionalizedwomenages15–44whoparticipatedintheNationalHealthandNutritionExaminationSurveysfrom1991to1994andin1999(CDC,2000).Itdidnotconductaspecialstudyofpregnantwomenorwomenofchildbearingage,therecommendedtargetgroup.Instead,itsegmentedthedataintheexistingsurveysandanalyzedthat.Therecertainlyarewomenbearingchildrenafterage44,beforeage15,andininstitutions;however,theagerangecoveredmostofthepotentialrecipients,andthedifferencesinoutcomesweresogreatthattheanalystsdidnotfeeltheneedforfurtherrefinements.
Lookingatthehealthstatusofthetargetpopulationintheaggregatecanoftenobscuredifferencesbetweensubgroups.OnefrequentlyhearsaboutthemillionsofpeopleintheUnitedStateswholackhealthinsurance.Doestheirhealthstatussufferbecausetheylackinsurance?Sometimesandsometimesnot.Historically,manyoftheuninsuredhavebeenyoungpeoplewhohavemadeacalculatedtrade-offbetweenthecostofhealthinsuranceandthefactthattheyareyoungandhealthy(agroupsometimesreferredtoas“theyoungimmortals”).Yes,theyaremorelikelytohavesevereautoaccidentsthananolderpopulation,butuntilonehappenstheyarenotpartofthe20%ofthepopulationthataccountsfor80%ofhealthcarecosts.Theyaretransferringtheriskoflow-probabilityeventstothepublicatlargebecausetheywouldprobablyreceivecareanyway.Othersmaywantinsuranceandneedit,butaresimplyunabletoaffordit.Thepointisthatthereisplentyofroomtotalkateachotherratherthansolveproblems.Onecantalkabouttheissuebydiscussingtheuninsuredasablocorabouttheneedsofspecificsegments.Theimportantthingisthatanalystsdefineclearlywhomtheyaretalkingabout.
IdentifyingtheFactorsDeterminingtheHealthStatusofConcernWithinThatPopulation
Causationisthebaneofthepolicyworld.Politiciansandpolemicistswouldhaveusthinkthattherightpolicyiscertainlythisordefinitelythat.Ifitwerethatsimple,however,therewouldbelittleneedforanalysis.Theconclusionsofstudiesseekingcausationareseldomasclearasobviousresultsoftakingthehandleoffthelocalwaterpumpandwatchingthecholeraepidemicstop.MostpolicyproblemssupportthecharacterizationbytheDanishmathematicianandpoetPietHein,whowrote,“Problemsworthyofattackprovetheirworthbyhittingback.”Inferenceisonething,andcausationisanother.
Ifwereturntoourhistoricalpopulationofuninsuredindividualsasatarget(itwilltakeyearstounderstandthefullimpactoftheACA),wefindthattheyhavepoorerhealththantheaveragepopulation,anddatashowthattheyaremorelikelytopostponecareandnotfillaprescriptionbecauseofcostandhaveanavoidablehospitalization.Onemightcounterthatsomelackcoveragebecausetheyareinpoorhealthandcannotfindemployment.Also,whenonedealswithapolicyissueofuninsuredpopulations,oneprobablyneedstoaddressissuesoftheunderinsuredaswell.Problemsofdefinitionandcausationarealsothornierbecausesomanystudiesandanalysesrelyoninformationenteredintotheclaimsdatabank,whichdoesnotincludeinformationontheunderinsuredbecausetheydonotgenerateclaims.
IdentifyingMethodsRealisticallyAvailabletoChangeHealthStatus
Withallthealternativesolutionsbeingofferedforhealthpolicychanges,theanalystneedstoidentifythefewthataremostrealisticeconomicallyandpolitically.Bypoliticallyrealistic,wemeanacceptabletothosewhoarelikelytofundandusetheanalysisandimplementitsfindings.Manypotentialactorsmayexpressapreferenceforspecificalternativesapriori.Theanalystmustrespectthesepreferencesandstillkeeptheprocesssimpleenoughthatdecisionmakersarenotlikelytoignoretheworkorbeconfusedbyit.
DefiningtheMethodsOperationallyandOptimally
Inanindustrywitharecognizedhighdegreeofwastelikehealthcare,onehastoaddthestepofdefiningthealternativesoperationallybyansweringthefollowingquestions:
1.Hasthealternativebeeninuse?
a.Ifso,determinehowitcouldbeimprovedpriortoapplyingitinthiscontext.
b.Ifnot,defineitinmoredetailtoestablishoperationalfeasibility.
2.Forthemorepromising,feasible,andrelevantalternatives,determineoptimalmethodsandproceduresfordelivery.
3.Usetheseoptimalprocessestodeterminecostsandeffectivenesswhererelevant.
7.2HIDDENASSUMPTIONS
Otherassumptions,oftendealingwithvalues,canimpingeonananalysis.Theymaygetaddressed,ortheymaybeleftimplicitortacittomaintainorganizationalcivilityorpoliticalcompromise.Theyincludeprofessionalperspectivesandpersonalconceptionsofequity,dueprocess,decision-makingmethods,andrights.Thisisnotanexhaustivelist.Itdoesnotincludemanyvalueissues,suchasthevalueofahumanlife.
Ifthegroupdoingtheanalysisseemstobeagreeingonmostthingsbutcannotreachclosure,lookforhiddenassumptionsthatmightbeholdinguptheprocess.Iftheproblempersists,itmaybenecessarytobringinaskilledprocessobserverwhowilllistencarefullytowhatpeoplearesayingandidentifythestumblingblocks.Itisunlikelythattheteam’sleadershipcanpushsuccessfullytowardclosureuntilhiddenassumptionshavebeenaddressed.
ProfessionalPerspectives
Socialsciencedisciplineshavebuilt-inassumptionsabouthowsocietalandpersonaldecisionsaremade,andtheseunderlieknowndifferencesbetweeneachdiscipline’sjargon,researchmethods,andnotionsaboutthingssuchascognitiveprocesses,equity,andappropriategovernance.Theseassumptionsalsosupportaggregateassumptions(sometimescalledvisions)ofinstitutionalrolesandhoweffectivechangetakesplaceinasociety.
Eachdisciplineappearstoredefineissuesinitsowntermsandresearchapproaches.MacRae(1976,pp.109–110)usedhisbackgroundinpublicpolicyresearchtocharacterizehowsocialsciencedisciplinesapproachdecisionmaking.Henotedthatdisciplinestalktothemselves,trytoemulatethephysicalsciences,liketobelievethattheyengagein“value-free”activities,andrewardresearchthatconformstoexistingtheory.Hecharacterizedfourpolicy-relateddisciplines,asfollows:
•“Economicsdealswiththesatisfactionofexistingindividualpreferences.”
•“Psychology—especiallyinitsrelationswitheducationandpsychotherapy—isconcernedwiththechangesthatmaybeproducedinpreferencesandtheirstructuresinindividualpersonalities.”
•“Sociologyisconcernedwithsocialnorms,andarelatedemphasisisonjointactionundertakentochangethem.”
•“Politicalscience,insofarasitescapesfromtheeconomicperspective,dealswiththoserolesandinstitutionsinwhichresponsiblecitizensandpublicofficialsmaybeexpectedtoconsiderthegeneralwelfare.”
Inbusinesseducation,mostdecisionsareassumedtobeindividualratherthansocialoutcomes.Marketersusuallyseepreferencesasmalleable.Decisiontheoristsusuallyassumethattheyareagiven.TheassumptionscitedbyMacRae,althoughsubjecttochallenge,stillseemtodominatetoday,andthedisciplinesdifferintheirapproachestocommonissuesofoursocietyinvolvedwithethics,markets,socialchangeprograms,politicalregimes,andsocialnorms.
ImplicationsforProblemSolving
Thinkaboutameetingcalledtoconsiderchroniclocalunderemploymentandhomelessness.Oneparticipantciteseducationaldifferences,whereasanothermentionsdisparitiesineducationalopportunities.Thenanotherspeaksofimperfectionsinthelocallabormarket.Oops!Bynow,themeetingisreadytoderail.Someconsiderthetermlabormarkettobedehumanizing.Othersseeitasjargon.Whatisaconcrete,definedconcepttoonedisciplinemayhaveastrongnegativevalenceforanother.
Multidisciplinarygroupswillbebetterabletoworktogethercooperativelyiftheydiscussthefollowingearlyonintheirwork:
1.Howcanweexpressourpersonalassumptionsandvisionandincorporatethemintointellectualdiscoursethatrespectsothers’pointsofview?Thisincludesacceptanceofthesensitivitiesofthosewithotherapproaches.
2.Whatnotionsofsocialequityandsocialchangeprocessesdowehold?
3.Whatisareasonableobjectiveforsocialchange?
4.Ifwecannotagreeonthoseassumptionsandvisions,howcanwebestcooperateonlimitedobjectivesthatarecompatiblewithourdisparateviewpoints?
Isitunrealistictoexpectanyadhocgroupofbusyprofessionalstospendthetimenecessarytoachievethisleveloftrustandunderstanding?Yes,butwithoutthatlevelofinvestment,thegroupmaybewastingitstimebyconveninginthefirstplace.Withoutthattrustandunderstanding,participantsareunlikelytorespondeffectively.Ataminimum,thinkingaboutone’sownassumptionsandvisionsandtheirtopic-specificandtemporalinconsistenciesisaprerequisiteforapersonalcommitmentandcontributiontointerdisciplinarywork.Sowell(2002,p.254)suggestedthat“ananalysisoftheimplicationsanddynamicsofvisionscanclarifyissueswithoutreducingdedicationtoone’sownvision,evenwhenitisunderstoodtobeavision,notanincontrovertiblefact,anironlaw,oranopaquemoralimperative.”Alltoooftenvisionsareunexaminedafteryearsofimmersioninone’sprofession,andbecomingawareoftheminone’sselfandinothersisprobablyhalfoftheuphillbattletowardsuccessfulinterdisciplinaryproblemsolving.
ProfessionalConflicts
Similarproblemsareofconcernamongthephysicalandmedicalsciences,accordingtotheNationalAcademyofSciencesandtheInstituteofMedicine(IOM,2000a).Whenworkingwithamultidisciplinarygroup,youhavetobesensitivetotheseprofessionalvisions.Ifyouareincludinghealthprofessionalsinthegroup,youalsohavetodealwiththeanimositiesbetweenprofessionsthathaveexistedforyears,especiallythoserelatingeithertostatusdifferentials(suchasnurses’angerattheirtreatmentbyphysicians)orconflictingeconomicinterests(suchasbetweenacademicandcommunity-basedphysicians).Peoplewillbringthoseexperiencesandattitudesintothemeetingroom.
Equity
Discussionaimedatdefiningasituationmaystallbecauseindividualshavenotreachedconsensusaboutthedefinitionofequitytobeapplied.People’sassumptionsaboutequityareseldomonthetableunlessthegroupisveryhomogeneousintermsofvaluestructures.Ifitishomogeneous,thenthegroupfacestheproblemofallofthemembersseeingthingsthesameway,sometimescalledgroupthink.Inalmostanyhealthcarepolicyanalysis,theissuearisesofhowthecostsandbenefitsaredistributed.Thenfollowstheissueofwhatisfair.Individualsinapolicygroupcandefineequityatleastfiveways:(1)equalpayment,(2)equalinputs,(3)equalrisk,(4)equalsatisfactionofdemand,or(5)equalprocess(McLaughlin,1984).
EqualPayment
Inlegalterms,equityrequiresequalpaymentforequalservices.Thisconceptiswrittenintoanumberofrequirementsofgovernmentprograms;however,thatnotionofequityomitstwoimportantconditions:externalitiesandabilitytopay.Externalitiescanbeillustratedbythefactthatyoucannotgotoschoolwithacaseofmeasleseventhoughyouarenotgoingtocatchmeaslesagain.Inotherwords,thecostsofyouractionsareexternaltoyourframeofreference.Aneighbormaynotinoculateherchildrenbecauseshecannotpayforthevaccine.Thecountyhealthdepartmentmayprovidetheserviceforfreebecauseitisinthepublicinteresttoavoidthespreadofthediseaseandthepermanentinjurythatmightresultfromadditionalcases.Thehealthdepartmenthasanumberofpolicychoicesinprovidingthevaccinefromtaxrevenues.Itcouldprovideittoallcomersasafreepublicgood.Itcouldsubsidizetheprocessandchargelessthanprivate-sectorproviderstoencourageparticipation,oritcoulduseasliding-feescalebasedonabilitytopay.
EqualInputs
Acommunicablediseaseprogrammightchoosetoallocateitsresourcestoprovidesomanyserviceresourcespercapitathroughoutthecountiesofastate.Thatwaytherewouldnotbeanyhasslesoverwhetheranyonesectionofthestateisbeingshortchanged.
EqualRisk
Ifillegaldruguseishighinaparticularsectionofacity,preventionprogramsarelikelytobeconcentratedinthatarea.Thisislikelytoincreaseproductivity,butonemightobjecttosomeversionsofthatapproachastryingtoequalizeriskacrossthewholecommunity.IfIliveinaneighborhoodthathasarelativelylowincidenceofcrackcocaineuse,Istillmaywantitstoppedinmyneighborhood.Residentsofupscaleneighborhoodsmightbearguingthattheyareentitledtolessriskbecausetheyarepayingmoreintaxes.
EqualSatisfactionofDemand(orNeed)
Manyhealthcareorganizationsstartoutallocatingresourcesonthebasisofneed,asprofessionallydetermined.Afterawhile,needmayormaynotturnintoconsumerdemand,evenwhentheresourcesavailableareadequate.Staffwillultimatelybeassignedtoclinicsinproportiontothenumberofpatientvisits,andambulanceswillbeassignedtovarioussectionsoftownbasedonthefrequencyofemergencycalls.
Equal(Due)Process
Peoplewantthesameaccesstohealthcare,regardlessofwhethertheyuseit.Theywanttobetreatedwiththesamerespectregardlessofabilitytopay,andtheydonotwantunreasonablewaitingtimes.Thesedesiresarerelativelyindependentoftheequalityofinputs,risks,andsoforth.Theyarerelatedtowhatonewouldcallequalprocess(Drucker,1974).
DecisionMaking
Ateamalsohastoaddressthemembers’hiddenassumptionsabouthowthegroupreachesdecisions.Itisunlikelyinpolicyanalysisthatdecisionswouldbereachedbymajorityvote;however,thegroupdoesneedtothinkabouttheconceptofconsensusandhowtodeterminewhenandwhetherithasbeenreached.Thegroupalsohastodecidehowtohandledissent.Insomesettings,adissentingreportornoteisappropriate,whereasinothersitwouldnotbeacceptable.Sometimessensitivityanalysiscanbeusedtoaddressdisagreementsovernumericalvalues.
Rights
Paradoxically,nohiddenassumptiongetsmoreattentionthanwhetherhealthcareisaright.Ayesornoanswergetsusnowhere.Isonetalkingaboutantibioticsforaseriousillness,cosmeticsurgery,orinvitrofertilization?Again,thereisaneedtotrytodefinewhatoneisarguingaboutratherthanrepeatingassertionsbasedonundefinedassumptions.Whatabouttheexampleofapatient’srighttoseehisorhermedicalrecord?Whatiftherearecommentsonitaboutthepatientorthepatient’sfamilybeinguncooperative?Towhatextentisthehealthrecordabusinessassetofthephysician,thehospital,orthehealthmaintenanceorganization(HMO)?Again,statelawsmaydifferonthis,but,increasingly,thepatientisgainingmoreaccess,asignofthewaningdominanceofthemedicalprofessions.
Insomecases,issuesofrightsmaybeextremelycontentious,butthosesituationsareusuallypoliticizedwellbeyondthedomainofthepolicyanalysisteam.Certainly,thishasbeenthecasewithLevittandDubner(2005)andtheirassertionthatthepassageofabortionrightslawsbythestatesandthentheRoevs.Wadedecisionarecloselyassociatedwithadeclineinseriouscrimeratessome20yearslater.Bothliberalsandconservativeshavebeenleftunhappybythatfinding.
CollectiveVersusIndividualResponsibilityforHealth
Socialwelfareversusindividualwelfareistheelephantintheroominhealthcarepolicy.Garrison(2009)makesthispointinlookingatthewaysthattheUnitedKingdomandtheUnitedStateslookatutilityinallocatingpublicresources.TheUnitedKingdomclearlyhascomedowninfovorofhavingexpertsdetermineutilityusingquality-adjustedlife-years(QALY)andcostdata,whereastheUnitedStateshasprettymuchlimiteddiscussionoftheconcepttoacademicpapers.
Garrison(2009)notedthatthesechoicesaredeterminedbythefollowingeconomicapproaches:
•Monoposony(U.K.position):ExpertsuseQALYandcost-utilityanalysestomaximizesocialbenefit.
•Administeredsystemcompetition:Expertsdetermineminimalbenefitpackageandusecomparativeeffectivenessandcostfordecisionsatthemargin.
•Consumer-driven(freemarket):Buyers(patientsandpayers)areprovidedwitheffectivenessandcostdataandarethenlefttoletthemtradeoffutilities.
•Oligopolisticcompetition:Vendorsproveeffectivenessandletpayersdetermineutilities.
•Monopoly:Providersandinsurersmaximizeprofitability.
Garrisonsuggestedthatdefiningaminimumbenefitpackage(calledanessentialbenefitpackageintheACA)isacompromisebetweenthetwocontendingapproaches—meetingasociallyacceptableminimumforcare,butleavingmarginalchoicesuptotheindividual.Garrison(2009)andNord,Daniels,andKamlet(2009)alsopointedoutamoresubtledifferenceintheapproaches:expertstendtouseaverageex-anteutilities,whereaspatientstendtouseexperientialonesbasedontheircurrentstateofhealth.
7.3DEFININGWHATISAMEDICALPROBLEM
Onemedicalcaredebateconcernsthemedicalizationofsomuchofhumanexperience.Howmuchisthisimprovingourqualityoflife,andisitworthpayingforindividuallyorcollectively?Increasingly,weareexpandingtheconditionsthatcanbetreated,especiallywithbiochemicaltreatments,yetallofthesetreatmentshavenegativeimpactsbeyondcosts.Theyintroducesideeffects,somehazardous,especiallywhencombinedwithothertreatments.Becausetreatmenteffectsvaryfromindividualtoindividual,whatisthedividinglinebetween:
•Thosewhowouldbenefitfromtreatmentandthosewhowouldnot?
•Thosewhoneedtreatmentandthosewhodonot?
•Thosewhosetreatmentshouldbecoveredbyasocietyandthoseforwhomtreatmentisa“lifestyle”choice?
Table7-2StrategiesAttributedtoDisease-MongeringCampaigns
•Developadrugeffectivewithasmallsegmentofthepopulationthatisheavilyimpactedbythesymptoms.
•Redefinethediseaseintermsofthesymptomsthatthedrugtreats.
•Inflatediseaseprevalencerates.
•Encourageacademicspecialiststopromotenewdiseasedefinitionsinseminarsandarticles.
•Advertisetocreateanxietyaboutthesymptoms,whichmaybequitenormal.
•Promotethedrugasanaggressive,first-linetreatmentforthesymptoms.
•Promotetreatmentofmeasurableriskfactors,especiallyiftheirstatusismeasurable.
•Promotethedrugwidelytoallphysiciansratherthanspecialistshandlingproblematiccases.
Increasingly,thedebatesoverwheretheselimitsshouldbearemovingintotherealmofdiscussionsaboutpermissiblemarketing,advertising,andcommercializationandchargesofoutrightdiseasemongering.Muchofthisdebatecentersontheroleofdirect-to-consumeradvertisingandothermarketingefforts,particularlybythepharmaceuticalindustry.
Table7-2
outlinespromotionalstepsthatseemtoleadtothedevelopmentofnew,highlyadvertisedtreatmentsorscreeningpolicies.Oneexampleistherecommendationthatallpregnantwomenbescreenedforherpes,whichisnotsupportedbytheCDCortheU.S.PreventativeServicesTaskForce,butratherhasbeenadvocatedbycontinuingmedicaleducationinstructorsinprogramssupportedbythesuppliersofscreeningtestsandtreatmentdrugs.Averysmallportionofchildrenborntoinfectedmotherswillexperienceblindness,cerebralpalsy,and/ordeath,butthereisinadequateevidenceoftheextenttowhichscreeningandsubsequenttreatmentforasymptomaticwomenwhosesexualpartnersdonothavethediseasewouldavoidtheseadverseoutcomes,andtherearerisksofsignificantsideeffects.Studyresultsonthecosteffectivenessofsuchscreeningvarywidelyaswell(Armstrong,2006),yetprovidersoftestsandtreatmentsarefreetogoaheadpayingforpresentationsthatsupporttheirpositions.
7.4CONCLUSION
Definingtheproblemandtheprocessappropriatelyiscriticaltoeffectiveanalysis.Thatisnottosaythattherewillnotbelearningalongtheway.Policyanalysisisalearningprocess,andtheremustbesufficientcognitiveflexibilityamongtheactorstoallowforlearning.Atthesametime,itisastepinapoliticalprocess.Somemayviewpolicyanalysisasapurelypoliticalprocessandmayevenobjecttothenotionofanalysis.Thepolicyprocessmustbeopentoinputsfromavarietyofviewpointsandattempttodealwithobjectionsastheyarise.Groupsmayevengosofarastorevealandexplorehiddenassumptionsamongtheparticipantswhenitisessentialtoachievingaproductthatisacceptabletotheworkinggroupand,hopefully,totheusersoftheanalysis.
Keyissuesthatarelikelytoariseincludetheoperationaldefinitionofhealthtobeused,thedefinitionoftheproblem,hiddenprofessionalandpersonalvalues,andtheassumptionsofthoseparticipatinginthepolicyprocess.Keydecisionsrelatetohowmuchtime,effort,andpoliticalcapitaltoexpendinattemptingtobringrecommendationsandvaluesintoalignment.
ase7SmallAreaVariations
BACKGROUND
Oneofthewaystoexaminetheefficiencyandefficacyofdifferentapproachestomedicalcareistostudyvariationsinthetypesofcaredeliveredindifferentareasandthencomparetheoutcomes.TheDart-mouthAtlasWorkingGroupatDartmouthMedicalSchoolusesMedicaredatatoconductthistypeof“smallareaanalysis.”
In2006,thegroupreportedthatresidentsofElyria,Ohio,receivedangioplastiesatfourtimesthenationalaverage.Angioplastyisaninvasive,nonsurgicalprocedurewidelyutilizedfortreatingheartattacksandalleviatingsymptomsofheartdisease.Itisalsousedincasesofsevereheartdiseaseinhopesofpossiblypreventingfutureheartattacks.Theprocedureinvolvespushingacollapsedballoonintothecoronaryarteryandthenexpandingtheballoontopressplaqueagainstthearterialwall.Oftenastentisleftbehindinanefforttokeepthearteryopen.Otherapproachestoheartdiseaseincludedrugtherapy,lifestylechanges,andcoronaryarterybypassgrafts.Thelatterprocedurerequiresopenheartsurgery.
Elyriahasapopulation54,533(2010census)andisthecountyseatofLorainCounty.In2003,therateofangioplastiesinElyriawas42proceduresper1,000Medicareenrollees.Bycomparison,therateforallofOhiothatyearwas13.5,andthenationalratewas11.3.Allbut2ofthe35cardiologistsinElyriaatthetimebelongedtotheNorthOhioHeartCenter,whichreliedheavilyonangioplasties.Thecenterperformed3,400angioplastiesin2004(Abelson,2006c).
Thereisconsiderablecontroversyaboutdifferenttreatmentoptionsforblockedcoronaryarteries.Someexperts,accordingtoanAugust2006NewYorkTimesarticleontheDartmouthfindings,“saythattheyareconcernedthatElyriaisanexample,albeitanextremeone,ofhowmedicaldecisionsinthiscountrycanbeinfluencedbyfinancialincentivesandprofessionaltrainingmorethansolidevidenceofwhatworksbestforaparticularperson”(Abelson,2006c).
AccordingtomedicalhistorianDr.DavidS.Jones,neitherangioplastynorcoronarybypasssurgeryhavebeenshowntoprolonglifeexceptincasesofseveredisease.Risksassociatedwithbypasssurgeryincludeinfectionsandbraindamageresultinginmemorylossandcognitiveimpairment.Oneoftheconcernswithangioplastyisthatmostheartattacksstemfromtiny,ofteninvisiblelesions,andangioplastiestendtotargetthelargerlesionsthatshowuponangiograms.Hearguesforagreaterfocusonpreventionthroughmedicinesandlife-stylechanges(Park,2013).
Angioplastyandcoronarybypasssurgeryarehighlyprofitable,andtogethertheymakeupa$100billionayearindustryintheUnitedStates.AtthetimeoftheDartmouthstudy,MedicarewaspayingElyria’scommunityhospital$11,000forangioplastywithacoatedstent,andthecardiologistperformingtheprocedurereceivedabout$800.Bypasses,however,wereperformedbysurgeonsfromtheClevelandClinicwhohadprivilegesatthecommunityhospital.Thosesurgeonsreceivedupto$2,200peroperation,andthehospitalwouldreceiveupto$25,000.
OUTCOMES
ThefounderandpresidentoftheNorthOhioHeartCenterrespondedtotheDartmouthfindingsbytellingtheNewYorkTimesthatthecenterhadgoodresultswithitspatientsandattributedthehighuseofangioplastytoearlydiagnosticinterventionsandaggressivetreatmentofcoronaryheartdiseaseandtoconcernsaboutpatientsafety.Becauseofsafetyconcerns,thecentertreatsmanyofitspatientsinstages,doingmorethanoneadmissionandprocedure.Othercardiologistsmightperformmultipleproceduresatthesametime.Thirty-onepercentoftheElyriacenter’spatientsunderwentmultipleadmissionsandprocedures,aboutthreetimestherateinCleveland.Insurersreportthatthehospital’sresultsaregood,andUnitedHealthhasnameditacenterofexcellenceforheartcare.
DiscussionQuestions
1.WhatdoyouthinkaboutusingsmallareastudiesbasedonlargeMedicaredatabases,suchastheonepresentedhere,toidentifyoutliers?
2.SalariedcardiologistsatKaiserPermanenteinnorthernOhiouseddrugsmoreoftenandperformedcardiacproceduresatslightlybelowthenationalrate.Whatrolemightdifferentfinancialincentivesbeplayinghere?
3.IfyouwereAnthemBlueCrossandBlueShieldinOhio,whatstudieswouldyouconducttoattempttoexplainand/ordealwiththesestrikinglocaldifferencesintreatmentsandcosts?