[Show abstract][Hide abstract] ABSTRACT: Discussions - and definitions - of “integration” in health services and systems are abundant, but little is known about the inducements that organizational leaders use to win the support of physicians within integrated systems. This paper, drawing on a qualitative exploratory survey of sources within 151 integrated care organizations in three nations (the U.S., England, and Germany), explores the mix of monetary and professional inducements these organizations employ to attract and retain physicians. The organizations we sampled do not rely exclusively, and seldom preponderantly, on selective monetary incentives, but rather employ a composite portfolio of the two types. These inducements appear with remarkable consistency at the “micro” level of organizations in our three nations, notwithstanding the marked differences in their “macro” health systemic contexts. Since public policy sets the framework for the design of inducements and individual organizations are in charge of their implementation, our findings call for closer attention to the big motivational picture, and especially to the importance of professional considerations within it, if healthcare organizations hope to deploy effectively the whole spectrum of available incentives for physician-organization integration in the future.
Health Policy 10/2014; 118(1). DOI:10.1016/j.healthpol.2014.08.001 · 1.91 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: Background:
In recent years, there has been growing interest in evaluating the health and economic impact of medical devices. Payers increasingly rely on cost-effectiveness analyses in making their coverage decisions, and are adopting value-based purchasing initiatives. These analytic approaches, however, have been shaped heavily by their use in the pharmaceutical realm, and are ill-adapted to the medical device context.
This study focuses on the development and evaluation of left ventricular assist devices (LVADs) to highlight the unique challenges involved in the design and conduct of device trials compared with pharmaceuticals.
Devices are moving targets characterized by a much higher degree of post-introduction innovation and "learning by using" than pharmaceuticals. The cost effectiveness ratio of left ventricular assist devices for destination therapy, for example, decreased from around $600,000 per life year saved based on results from the pivotal trial to around $100,000 within a relatively short time period.
These dynamics pose fundamental challenges to the evaluation enterprise as well as the policy-making world, which this paper addresses.
International Journal of Technology Assessment in Health Care 10/2013; 29(4):365-73. DOI:10.1017/S0266462313000561 · 1.31 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: The development of professional policy analysis was driven by a desire to apply "science" to policy decisions, but the vision of apolitical policy analysis is as unattainable today as it was at the inception of the field. While there is powerful evidence that schemes to "get around" politics are futile, they never seem to lose their popularity. The contemporary enthusiasm for health technology assessment and comparative-effectiveness research extends these efforts to find technical, bureaucratic fixes to the problem of health care costs. As the benefits and costs of health care continue to grow, so too will the search for analytic evidence and insights. It is important to recognize that the goal of these efforts should not be to eliminate but rather to enrich political deliberations that govern what societies pay for and get from their health care systems.
Journal of Health Politics Policy and Law 08/2013; 38(6). DOI:10.1215/03616878-2373139 · 1.37 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: Because the United States often seems (and seems eager to present itself as) the home of the technological imperative and of determination to brand all challenges to it in end-of-life care as a descent into death panels, the prospects look unpromising for progress in US public policies that would expand the range of choices of medical treatments available to individuals preparing for death. Beneath this obdurate and intermittently hysterical surface, however, the diffusion across US states and communities of living wills, advanced directives, palliative care, hospice services and debates about assisted suicide is gradually strengthening not so much 'personal autonomy' as the authority, cultural and formal, of individuals and their loved ones not merely to shape but to lead the inevitably 'social' conversations on which decisions about care at the end of life depend. In short, the nation appears to be (in terms taken from John Donne's mediations on death) 'stealing on insensibly' - making incremental progress toward the replacement of clinical and other types of dogma with end-of-life options that honor the preferences of the dying.
Health Economics Policy and Law 10/2012; 7(4):467-83. DOI:10.1017/S1744133112000254 · 1.33 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: As the challenges of maintaining (or, in the US case, attaining) affordable universal coverage multiply, the debate about what constitutes "real" reform intensifies in Western health care systems. The reality of reform, however, lies in the eyes of myriad beholders who variously enshrine consumer responsibility, changes in payment systems, reorganization, and other strategies -- or some encompassing combination of all of the above -- as the essential ingredient(s). This debate, increasingly informed by the agendas of health services researchers and health policy analysts, arguably serves as much or more to becloud as to clarify the practical options policy makers face and remains severely imbalanced with respect to the institutional sectors on which it concentrates, the fields of knowledge on which it draws, and the roles it envisions for markets and the state.
Journal of Health Politics Policy and Law 03/2012; 37(4):587-609. DOI:10.1215/03616878-1597439 · 1.37 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: This paper examines the implementation of large, transformative change in the Medicaid offices in New York City to improve efficiency and consumer-friendliness. A bottom-up process was engaged to design and implement the needed changes from those who were most affected by the change. Key informant interviews and observational site visits were conducted to assess the extent to which the change efforts were successful. We found that the changes impacted both quantitative measures of success (such as client processing times and number of clients served) as well as less tangible qualitative indicators of success such as staff attitudes and office climate.
Public Management Review 01/2012; 15(1):1-17. DOI:10.1080/14719037.2012.686230 · 1.42 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: Health inequalities and user financial incentives to encourage health-related behavior change are two topical issues in the health policy discourse, and this article attempts to combine the two; namely, we try to address whether the latter can be used to reduce the former in the contexts of the United Kingdom and the United States. Payments for some aspects of medical adherence may offer a promising way to address, to some extent, inequalities in health and health care in both countries. However, payments for more sustained behavior change, such as that associated with smoking cessation and weight loss, have thus far shown little long-term effect, although more research that tests the effectiveness of different incentive mechanism designs, informed by the findings of behavioral economics, ought to be undertaken. Many practical, political, ethical, and ideological objections can be waged against user financial incentives in health, and this article reviews a number of them, but the justifiability of and limits to these incentives require more academic and public discourse so as to gain a better understanding of the circumstances in which they can legitimately be used.
Journal of Health Politics Policy and Law 12/2011; 37(2):201-26. DOI:10.1215/03616878-1538602 · 1.37 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: The 2010 Patient Protection and Affordable Care Act (P.L. 111-148), or ACA, requires that U.S. citizens either purchase health insurance or pay a fine. To offset the financial burden for lower-income households, it also provides subsidies to ensure that health insurance premiums are affordable. However, relatively little work has been done on how such affordability standards should be set. The existing literature on affordability is not grounded in social norms and has methodological and theoretical flaws. To address these issues, we developed a series of hypothetical vignettes in which individual and household sociodemographic characteristics were varied. We then convened a panel of eighteen experts with extensive experience in affordability standards to evaluate the extent to which each vignette character could afford to pay for one of two health insurance plans. The panel varied with respect to political ideology and discipline. We find that there was considerable disagreement about how affordability is defined. There was also disagreement about what might be included in an affordability standard, with substantive debate surrounding whether savings, debt, education, or single parenthood is relevant. There was also substantial variation in experts' assessed affordability scores. Nevertheless, median expert affordability assessments were not far from those of ACA.
Journal of Health Politics Policy and Law 07/2011; 36(5):829-53. DOI:10.1215/03616878-1407640 · 1.37 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: How effective was organizational reform implemented inside one critical New York City health agency? Specifically, we examine the extent to which the reorganization of the HIV/AIDS Services Administration (HASA) into the Medical Insurance Services Administration (MICSA) achieved three goals: (1) realizing synergies among the component MICSA programs; (2) cross-fertilizing ideas among MICSA agencies; and (3) facilitating HASA operations through the lens of organization change theory. Qualitative methods including interviews, site visits, and document analysis triangulate the effects of the reorganization. Implications for organization change literature are explored, especially highlighting where more theoretical and empirical studies are needed.
[Show abstract][Hide abstract] ABSTRACT: We are at the beginning of an era in which the pressure to secure the biggest possible "bang" for the health care "buck" is perhaps higher than it ever has been, on both sides of the Atlantic, and within the health policy discourse, incentives, for both professionals and patients, are occupying an increasingly prominent position. In this article, we consider issues related to motivating the professional and the patient to perform targeted actions, drawing on some of the evidence that has thus far been reported on experiences in the United Kingdom and the United States, and we present an admittedly somewhat speculative taxonomy of hypothesized effectiveness for some of the different methods by which each of these two broad types of incentives can be offered. We go on to summarize some of the problems of, and objections to, the use of incentives in health and health care, such as those relating to motivational crowding and gaming, but we conclude by positing that, following appropriate consideration, caution, and methodological and empirical investigation, health-related incentives, at least in some contexts, may contribute positively to the social good.
Journal of Health Politics Policy and Law 02/2011; 36(1):59-87. DOI:10.1215/03616878-1191108 · 1.37 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: Path dependence, a model first advanced to explain puzzles in the diffusion of technology, has lately won allegiance among analysts of the politics of public policy, including health care policy. Though the central premise of the model--that past events and decisions shape options for innovation in the present and future--is indisputable (indeed path dependence is, so to speak, too shallow to be false), the approach, at least as applied to health policy, suffers from ambiguities that undercut its claims to illuminate policy projects such as managed care, on which this article focuses. Because path dependence adds little more than marginal value to familiar images of the politics of policy--incrementalism, for one--analysts might do well to put it on the back burner and pursue instead "thick descriptions" that help them to distinguish different degrees of openness to exogenous change among diverse policy arenas.
Journal of Health Politics Policy and Law 08/2010; 35(4):643-61. DOI:10.1215/03616878-2010-020 · 1.37 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: The venerable but amorphous concept of stewardship has lately gained prominence in discussions of public policy and management and is sometimes offered as a "strategy" with a distinctive potential to mobilize effective public leadership in the service of broad social missions. In this article we explore how stewardship may be useful to the theory and practice of mental health policy, and, reciprocally, how examples from mental health policy may elucidate the dynamics of stewardship. After examining its key political ingredients--authority, advocacy, and analysis--we discuss the practical challenges in moving stewardship from moral inspiration to institutional reality.
Journal of Health Politics Policy and Law 06/2010; 35(3):389-405. DOI:10.1215/03616878-2010-004 · 1.37 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: s the Active Living by Design (ALbD) program envisioned them, changes in the built environ- ment (physical projects) that encouraged physi- cal activity as part of routine daily life came about because of innovations in preparation, partnership, programming, promotions, and policy.1 The articles, which represent case studies in this supplement2-16 to the American Journal of Preventive Medicine depict in enlightening detail how 15 communities moved along this strategic continuum, but say little about another "P," politics. This inattention is not surprising: Politics was not an explicit part of their formal mission. Nonetheless, the refinement and deployment of political skill is integral to attaining the goals toward which the five ALbD "P's" aim. The quest for health promoting changes in the built environment proceeds in a cultural and institutional context that can sometimes raise steep hurdles for reform- ers. Business as usual in many American communities supports zoning rules that can discourage mixed uses and density; provide powerful incentives to develop sprawling "communities"; give little priority to biking and walking; encourage school siting that presupposes students arriv- ing by bus or car; and sustain many other patterns that blend public power and private prerogatives so that built environments are at odds with active living. The cultural underpinnings of these policy patterns—for example, the quest for big houses on large lots, and the equation of automobiles with mobility and of free-wheeling develop- ment with local prosperity—run deep. Such potent forces usually change incrementally, and achieving those changes is an inescapably political project. In the case studies presented in this supplement, we find that the accomplishments of the ALbD partnerships reveal political struggles and gains at three distinct levels. The Politics of Local Coalitions Active Living by Design leaders sought to bring into coalitions such disparate but partly overlapping ingredi- ents as the cycling community; committed walkers; public health professionals who understand the importance of the built environment as a determinant of health; New Urbanists; Smart Growth advocates; environmentalists pressing to reduce pollution and preserve green space; activists who see mixed-land use as a vehicle to integrate citizens of various races, ethnicities, and classes; and voluntary associations, often small and financially shaky, that seek to protect parks, trails, and waterways. Although each pursues mainly its own agenda detached from (and sometimes in conflict with) the others, these local orga- nizations, movements, and enthusiasts have considerable untapped power that manifests itself politically in the ALbD communities that identified collective interests and constructed coherent agenda. Creating these ALbD partnerships did not happen without considerable focused attention. For organizations that lack the time, funds, and staff to concert action among their peers, the ALbD grant was a collective good of considerable value. The award supplied time, funds, and staff dedicated to canvassing the local interest groups and guiding their members toward a practical plan of action. ALbD staff helped to move beyond coalition building toward coordination by bringing forward for discussion overlapping elements of group agendas that helped cultivate a united political front. Finally, these staff complemented coalition and coordination with commu- nication, that is, working with public relations experts and local media to develop the ALbD agenda into messages that drew the attention of audiences in larger communi- ties and hence the attention of their appointed and elected officials.
American journal of preventive medicine 12/2009; 37(6 Suppl 2):S453-4. DOI:10.1016/j.amepre.2009.09.022 · 4.53 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: Technological innovation--broadly defined as the development and introduction of new drugs, devices, and procedures--has played a major role in advancing the field of cardiothoracic surgery. It has generated new forms of care for patients and improved treatment options. Innovation, however, comes at a price. Total national health care expenditures now exceed $2 trillion per year in the United States and all current estimates indicate that this number will continue to rise. As we continue to seek the most innovative medical treatments for cardiovascular disease, the spiraling cost of these technologies comes to the forefront. In this article, we address 3 challenges in managing the health and economic impact of new and emerging technologies in cardiothoracic surgery: (1) challenges associated with the dynamics of technological growth itself; (2) challenges associated with methods of analysis; and (3) the ways in which value judgments and political factors shape the translation of evidence into policy. We conclude by discussing changes in the analytical, financial, and institutional realms that can improve evidence-based decision-making in cardiac surgery.
Seminars in Thoracic and Cardiovascular Surgery 03/2009; 21(1):28-34. DOI:10.1053/j.semtcvs.2009.05.001
[Show abstract][Hide abstract] ABSTRACT: Native American youth suffer disproportionately from a range of adverse health conditions. Empowering youth leaders to work on community-based solutions has proved effective in reducing tobacco use and gun violence and is now emerging as a promising approach to improving fitness and health. This article, based on direct observation and interviews with key informants, examines the implementation of a Robert Wood Johnson Foundation-funded project that gave tribal youth councils minigrants to design and run diverse projects that encourage physical activity in their communities. The article highlights the institutional challenges that confront health-promotion strategies for disadvantaged populations. Unless they take proper account of organizational, political, environmental, and cultural forces, funders' interventions have limited chances for success and sustainability.
Journal of Health Politics Policy and Law 07/2008; 33(3):497-523. DOI:10.1215/03616878-2008-006 · 1.37 Impact Factor