Lawrence D Brown

Columbia University, New York City, New York, United States

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Publications (33)111.38 Total impact

  • [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. Methods: 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. Results: 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. Conclusions: 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. · 1.55 Impact Factor
  • Lawrence D Brown, Michael K Gusmano
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    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; · 1.24 Impact Factor
  • Lawrence D Brown
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    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. · 1.33 Impact Factor
  • Lawrence D Brown
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    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. · 1.24 Impact Factor
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    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; · 0.92 Impact Factor
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    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. · 1.24 Impact Factor
  • Lawrence D Brown
    Journal of Health Politics Policy and Law 06/2011; 36(3):419-27. · 1.24 Impact Factor
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    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.
    Public Administration Review 02/2011; 71(2):243 - 252. · 0.84 Impact Factor
  • Lawrence D Brown
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    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. · 1.24 Impact Factor
  • Lawrence D Brown, Kimberley R Isett, Michael Hogan
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    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. · 1.24 Impact Factor
  • M Katherine Kraft, Lawrence D Brown
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    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. · 4.24 Impact Factor
  • Michael S Sparer, Lawrence D Brown, Lawrence R Jacobs
    Journal of Health Politics Policy and Law 09/2009; 34(4):447-51. · 1.24 Impact Factor
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    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 01/2009; 21(1):28-34.
  • Lawrence D Brown, M Katherine Kraft
    Journal of Health Politics Policy and Law 07/2008; 33(3):371-86. · 1.24 Impact Factor
  • Lawrence D Brown, M Katherine Kraft
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    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. · 1.24 Impact Factor
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    Lawrence D Brown
    New England Journal of Medicine 02/2008; 358(4):325-7. · 54.42 Impact Factor
  • Katharina Janus, Lawrence D Brown
    Journal of Health Politics Policy and Law 05/2007; 32(2):293-306. · 1.24 Impact Factor
  • Lawrence D Brown
    Health Economics Policy and Law 10/2006; 1(Pt 4):409-14. · 1.33 Impact Factor
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    Lawrence D Brown
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    ABSTRACT: Most communities support their safety-net facilities, but few supply health coverage for uninsured residents. In 1991 Hillsborough County, Florida, created a health care plan that raised the sales tax by a half-cent, used the proceeds to cover about 30,000 uninsured county residents, and assured the public that this would save money. In time, however, various conflicts combined to call into question the plan's ends and means. These challenges reinvigorated advocacy by the plan's supporters, who steered the adoption of changes that seemed to have "institutionalized" it. Community-based reformers might find this local innovation instructive as they ponder how to build enduring programs.
    Health Affairs 01/2006; 25(3):w162-72. · 4.64 Impact Factor
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    Lawrence D Brown, Beth Stevens
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    ABSTRACT: The Robert Wood Johnson Foundation's Communities in Charge (CIC) program funded projects in fourteen communities that aimed to expand health insurance coverage and improve care for their uninsured residents. Our examination of seven program sites suggests that despite solid community leadership and carefully crafted plans, political, economic, and organizational obstacles precluded much expansion of coverage and constrained reforms. Redistribution of financial and organizational resources among both mainstream and safety-net institutions in these communities was hard to achieve. CIC's record offers little evidence that communities are better equipped than are other sectors of U.S. society to solve the problem of uninsurance.
    Health Affairs 01/2006; 25(3):w150-61. · 4.64 Impact Factor

Publication Stats

128 Citations
111.38 Total Impact Points

Institutions

  • 2003–2013
    • Columbia University
      • Department of Health Policy and Management
      New York City, New York, United States
    • New York Academy of Medicine
      New York City, New York, United States