The Health Policy Process Andy Bindman, MD Professor Medicine, Health Policy, Epidemiology & Biostatistics UCSF.

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