Category Archives: Health policy
Facing What May Be the Affordable Care Act’s Ultimate Challenge: The Gap Separating Evidence from the Policy-Makers Who Need It
David Grande, MD, MPA, is an assistant professor of medicine at the University of Pennsylvania's Perelman School of Medicine, a senior fellow at the Leonard Davis Institute of Health Economics, associate director of the Robert Wood Johnson Foundation (RWJF) Clinical Scholars program and an alumnus of the RWJF Health & Society Scholars program. This is part of a series of essays, reprinted from the Leonard Davis Institute of Health Economics’ eMagazine, in which scholars who attended the recent AcademyHealth National Health Policy Conference reflect on the experience.
It’s a time of unprecedented upheaval in U.S. health care. Big changes are bursting through on virtually every front. Legislators and administrators in Washington and 50 state capitals struggle daily to reinvent their health care systems even as they lack an exact blueprint for the new things they’re supposed to be building.
This was nowhere more evident than at the recent AcademyHealth National Health Policy Conference, where state and federal officials and interest groups lined up to present long lists of policy questions that confront them as they grapple with implementation of the Affordable Care Act and mounting public budgetary pressures.
For instance, in the “Opportunities & Challenges for State Officials” session, New Mexico’s Medicaid Director Julie Weinberg described the unknowns surrounding how “churn” between private and public coverage will change and how new Medicaid eligibility standards will impact enrollment processes.
Brendan Saloner, PhD, is a Robert Wood Johnson Foundation (RWJF) Health & Society Scholar in residence at the University of Pennsylvania and a senior fellow at the Leonard Davis Institute of Health Economics. This is the first in a series of essays, reprinted from the Leonard Davis Institute of Health Economics’ eMagazine, in which scholars who attended the recent AcademyHealth National Health Policy Conference reflect on the experience.
Like Goldilocks wandering through the house of the Three Bears, policy-makers in search of a health care payment model have found it difficult to settle on an option that is "just right."
Fee-for-service—paying doctors separately for each service they provide—leads to too much unnecessary and duplicative care (too hot!). Capitation—paying doctors a fixed fee for caring for patients—leads doctors to skimp on care and avoid costly populations (too cold!). A "just right" payment model should give providers incentives to provide all the clinically necessary care to patients while keeping costs low.
Shared savings models—allowing providers to keep a portion of the money they save caring for patients—have been touted as one method for aligning the incentives of providers and payers. Most prominently, shared savings is a central element of the Affordable Care Act's Accountable Care Organizations (ACOs).
An ACO is a network of providers that have agreed to accept a bundled payment for treating patient populations, and in return stand to gain incentive payments for meeting performance targets (or to lose money for missing targets). In the "happily ever after" version of ACOs, groups of providers will finally have a business case for coordinating patient medical records, reducing costly visits to the emergency room, and improving patient compliance with chronic disease therapies without leading to excessive procedures or gaps in care. Healthy patients, healthy profits.
But will it work?
The New York Academy of Medicine is the National Program Office for the Robert Wood Johnson Foundation Health & Society Scholars program, which works to reduce population health disparities and improve the health of all Americans. The New York Academy recently conducted a survey of 17 thought leaders in primary care and population health. In the final of five blog posts, we share a synthesis of what those leaders had to say. All quotes are printed with permission.
Addressing Social Determinants of Health: Given the current state of the clinical delivery system, it may seem unrealistically burdensome to ask health care institutions to address the social determinants of health (SDH). “In this country it’s an accomplishment if you can reward value for delivery,” noted Arnold Milstein, MD, MPH, “and social determinants approaches are a step or two beyond that.”
Examples of clinical engagement in social determinants, however, can be quite impactful:
· Lloyd Michener, MD, and Bob Lawrence, MD, described how Duke and Johns Hopkins both invested in SDH initially in order to repair or promote their public image. For example, Duke invested in some SDH programs and community partnerships in part to help repair their image in the setting of poor relationships with a minority, low-income community in Durham—though these investments have grown into more lasting partnerships.
· David Stevens, MD, pointed out the example of the 16th St Community Health Center in Milwaukee, where an environmental wing of the health center was created to combat lead poisoning—and then expanded over years into broader projects, such as combatting brownfields and creating green spaces for exercise.
This is part of a series of blog posts introducing programs in the Robert Wood Johnson Foundation (RWJF) Human Capital Portfolio. The RWJF Investigator Awards in Health Policy Research program supports highly respected and innovative scholars from a wide range of fields to undertake ambitious, cutting-edge studies of significant health policy challenges facing America.
The improvement of health in the United States is a complex undertaking that requires a wide range of health policy research. The prestigious and highly competitive Investigator Awards in Health Policy Research program provides one of the few funding opportunities for outstanding researchers in various stages of career development to explore bold, new ideas for improving the nation’s health and the health care system. The program encourages Investigators to think creatively about the most important problems affecting American health and health care and to contribute to the intellectual foundation of future health policy. The awards have been made to scholars from a broad range of disciplines, including economics, medicine, psychology, law, ethics, political science, public policy, sociology, history, nursing, health services research, and public health.
“It’s been a wonderful, career-changing experience. I do interdisciplinary research working in a medical school, and there aren’t a lot of funding agencies that have such openness to cross-disciplinary research.”
-Aaron S. Kesselheim, MD, JD, MPH, 2009 Awardee
RWJF’s Investigator Awards in Health Policy Research program supports talented researchers by funding projects that produce enduring insights and sophisticated analyses of pressing problems, potential solutions for improving health and health care, and policy-relevant evidence that can inform policy-makers, the media, and the public. Since the program began in 1992, the Foundation has supported 175 projects involving 224 Investigators. Investigators have published more than 100 books.
The New York Academy of Medicine is the National Program Office for the Robert Wood Johnson Foundation Health & Society Scholars program, which works to reduce population health disparities and improve the health of all Americans. The New York Academy recently conducted a survey of 17 thought leaders in primary care and population health. In the third of five blog posts, we share a synthesis of what those leaders had to say. All quotes are printed with permission.
Local and State Health Department Collaboration: Most discussants agreed that clinical systems and health departments use different notions of ‘population’—and historically are not well integrated. As David Stevens, MD, noted, “There’s capacity that needs to be built on a common language on how to work together that isn’t there because they've been separated so long.”
There was, however, a prevailing notion that this dynamic is changing in important ways. Many cited the convergence of IRS Community Health Needs Assessment (CHNA) requirements and new public health accreditation standards as a potential blueprint for future collaborations. Clinical delivery systems, generally well-resourced but with limited community assessment and intervention skills, are now responsible for conducting a CHNA every three years while developing and implementing an action plan to address identified needs.
This is part of a series of blog posts introducing programs in the Robert Wood Johnson Foundation (RWJF) Human Capital Portfolio. The RWJF Scholars in Health Policy Research program fosters the development of a new generation of creative thinkers in health policy research within the disciplines of economics, political science, and sociology.
Some of the nation’s most pressing health policy issues—such as the future of the Affordable Care Act, federal funding for medical research, and the health of underserved populations—are being addressed by a group of top scholars who make up the RWJF Scholars in Health Policy Research program.
"The program has been a once-in-a-lifetime opportunity to focus 100 percent on my research and to expand my research agenda to questions and topics I wouldn’t have considered otherwise."
- Brigham Frandsen, PhD, Cohort 17 Alumni, Economics
The program, initiated in 1992, was created to attract social scientists—economists, political scientists, and sociologists—to health policy research and analysis and to maintain their commitment to these fields in their future positions. Scholars in Health Policy Research frequently go on to careers in academia, government, and think tanks. By fostering a multidisciplinary approach to health policy, the program leads to innovative collaborations that can ultimately improve the health and health care of all Americans.
Brendan T. Campbell, MD, MPH, is an assistant professor of surgery and pediatrics at the University of Connecticut School of Medicine and an alumnus of the Robert Wood Johnson Foundation (RWJF) Clinical Scholars program (2000-2002).
Human Capital Blog: What kind of work do you do in the area of child abuse pediatrics?
Brendan Campbell: I am a pediatric general and thoracic surgeon and the medical director of the pediatric trauma program at Connecticut Children’s Medical Center in Hartford. Connecticut Children’s is a Level I pediatric trauma center, which means we see patients with relatively minor and severe multisystem injuries. Caring for abused children is one of the most important services we provide. When children with non-accidental trauma are initially identified, they are admitted to the pediatric surgical service to rule out life-threatening injuries. During their admission we work closely and collaboratively with the suspected child abuse and neglect team (SCAN) to make sure children with inflicted injuries are identified, have their injuries treated, and are kept out of harm’s way.
HCB: Why did you decide to focus on this area?
Campbell: It can be challenging to get a pediatric surgeon interested in child abuse because caring for vulnerable children who are intentionally harmed is not easy, and most of these kids don’t have life-threatening injuries that require an operation. What draws me to the care of injured children is that they are the patients who need me the most. If we don’t identify the risks they are up against at home, no one else will. They need someone to advocate for them.
The other thing that draws me to child abuse pediatrics is that there is an enormous need to develop better ways to screen for and to prevent abuse. Over the last 30 years we’ve made enormous strides in lowering the number of children injured in car crashes by enacting seat belt laws, toughening drunk-driving laws, and improving graduated driver licensing systems. Child abuse in the United States, however, remains a significant public health problem that needs more effective screening initiatives and prevention programs.
If you’re looking for peace and joy this holiday season, don’t invite a liberal and a conservative health economist to your holiday party. Health economists from the political left and the political right tend to have very different views on what ails the U.S. health care system – and what should be done to fix it. After a glass or two of punch, they are likely to become loud and argumentative—dampening the holiday spirit.
But if you’re Barack Obama and John Boehner, and you’re looking to heal our health care system this holiday, invite over a few strident health economists and let the eggnog flow. There are important truths being articulated by both extremes of the health policy spectrum. A wise policy-maker would harness this diversity of wisdom.
The Robert Wood Johnson Foundation (RWJF) recently released a video showcasing its Human Capital portfolio, which invests in innovative, diverse and inspired people who will shape health and health care research, policy and delivery for years to come. Watch the video below to learn more about RWJF Human Capital programs and the scholars and alumni who participate in them.
What the Election Means for Health and Health Care… The Re-Election of President Obama Curtails the Likelihood of Major Medicaid Reductions
Frank J. Thompson, PhD, is a professor at the School of Public Affairs and Administrations and at the Center for State Health Policy at Rutgers, The State University of New Jersey. Thompson is a 2007 recipient of a Robert Wood Johnson Foundation (RWJF) Investigator Award in Health Policy Research, studying Medicaid: Political Durability, Democratic Process and Health Care Reform. The RWJF Human Capital Blog asked scholars and fellows from a few of its programs to consider what the election results will mean for health and health care in the United States.
Human Capital Blog: What do you think the election will mean for the country’s health care system?
Thompson: It means that the country can go forward with implementing the Affordable Care Act (ACA). My research focuses on Medicaid—the federal grant program to the states that insures some 65 million low-income people. Under the ACA, Medicaid is slated to cover most people with incomes up to 133 percent of the poverty line as of 2014. In the recent election, the differences between the two parties on the ACA and Medicaid were stark. The Romney-Ryan ticket pledged not only to repeal the ACA but to convert Medicaid to a block grant and to cut funding for the program by more than 30 percent over ten years. The degree to which a Romney administration would have achieved these objectives remains an open question. But the reelection of President Obama curtails the likelihood of major Medicaid reductions over the next four years.