How Much Should Individuals Entering Health Professions Know About Health Policy?
The Robert Wood Johnson Foundation Human Capital Blog is asking diverse experts: What is and isn’t working in health professions education today, and what changes are needed to prepare a high-functioning health and health care workforce that can meet the country’s current and emerging needs? Today’s post is by Miriam Laugesen, PhD, an assistant professor of Health Policy and Management at Columbia University's Mailman School of Public Health and the recipient of a Robert Wood Johnson Foundation Investigator Award in Health Policy Research for a study of Medicare physician payment policies.
When people apply to a program to study health policy, their admissions essay sometimes begins "I always wanted to be a physician, but I realized I wanted to impact more people." Health policy students think in terms of systems, and they are therefore different from front-line health care providers. Whereas a nurse may see the uninsured person with uncontrolled diabetes, the health policy student will connect this to failures of public policy; the patient is nested within clinical, social or organizational environments.
To understand that systemic context, our health policy students first need various 'hard' or technical skills such as program evaluation, epidemiology, and health economics, and it's these skills that employers often look for when hiring our graduates. Without a doubt, technical skills are always valuable.
However, one or two years out, and over the long-term, many of our policy students appreciate the 'soft' skills, such as solving problems, lobbying policy-makers, or building new coalitions. Our policy students learn larger lessons about why things happen, and why policies also fail. They become highly attuned to the framing of advocacy messages. They understand how and why Congress punishes federal agency heads when health policies threaten interests such as tobacco farmers, or why Congress enacts unpopular policies even though legislators want to be re-elected.
How much should individuals entering health professions without a focus on health policy, know about health policy? After all, a physician assistant is not tested on the nuances of the relationship between Congress and the Presidency. But maybe all health professionals at the front line should have some exposure to how we got to the Affordable Care Act, and the major issues we face in improving health and the health care system. Not everyone would end up as polymath surgeon and policy wonk writing articles for The New Yorker (like Atul Gawande), but Gawande shows us what's possible when health care professionals unleash their curiosity about the health care system.
This is not so professionals can answer policy questions from their patients, be more informed citizens, or lobby Congress more effectively for higher reimbursement. A broader understanding of health care as a system would enable them to ask fundamental questions about health and health care, such as "How does what I do matter? Should I be more cautious about this new treatment? Why and how do things change in the world of health care?" In doing so professionals would think about how their daily choices have a history, a context, and a future that is subject to larger forces.
In political science, people like to say ideas, institutions, and interests determine policy. John Maynard Keynes put it better in his famous quote that ordinary people unknowingly live under the influence of larger ideas. Keynes was referring here to the longer-term impact of economic ideas.
Individuals receiving care and professionals providing care are far more influenced by public policies and political ideas than they realize. This idea always resonated because I grew up in New Zealand during a rapid period of economic liberalization and structural adjustment during the 1980s and 1990s. In a small country there is no disconnect between policy changes and the lives of individuals; you see change all around you.
In the U.S., the line between policy and practice is longer, but it remains vital to understand how the menu of choices available on a daily basis is policy-driven. Sometimes the policy choices are the right ones, and sometimes those policy choices are wrong. Physicians should understand how unproven treatments diffuse into practice; such as when scientists, courts, and policy-makers encouraged insurers to cover Autologous Bone Marrow Transplantation, a costly and invasive cure for breast cancer that was later determined ineffective. Hospitals were more blasé toward patient safety, medical errors, and hospital-based infections. Making people aware of patient safety was only the first step—real progress began once Medicare policies changed and hospitals thought it might impact their bottom line. In other words, health care operates within a pre-existing policy framework. Each professional is not always making autonomous choices, but responding and reacting to policy changes and incentives.
It's this kind of thinking, of course, that already informs many of the Human Capital programs sponsored by the Robert Wood Johnson Foundation, such as the Clinical Scholars program that aims to expose students to larger public policy issues. It also informs Columbia University's new public health core curriculum. The goal is to integrate the hard skills such as quantitative reasoning and biological approaches to public health within a common core covering health economics, human rights and global health, the historical development of public health, the tensions between science and politics, the nature of evidence, and health systems in the U.S. and globally.
Ultimately we may need to get rid of the idea that there are hard skills and soft skills. Policy, politics, and organizational structure partly determine which patients live and which die, which thrive, and which deteriorate. By educating providers about how the health care system has evolved and how policy levers work, we can help them better understand their role in systemic change.