HCA531 UPENN Key Elements of Healthcare Policy in Driving Access Reading Review Instrutions and assigned reading is attached below. Please feel free to ask

HCA531 UPENN Key Elements of Healthcare Policy in Driving Access Reading Review Instrutions and assigned reading is attached below. Please feel free to ask if you have any questions. HCA_531  
 
Unit  1  additional  reading:  
 
http://www.nejm.org/doi/full/10.1056/NEJMp1204516
 
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Health Politics
and Policy
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4th edition
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A J. Litman, and Leonard S. Robins
James A. Morone, Theodor
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Australia • Brazil • Japan • Korea • Mexico • Singapore • Spain • United Kingdom • United States
9781133819202, Health Politics and Policy, Fourth Edition, Morone/Litman/Robins – © Cengage Learning. All rights reserved. No distribution allowed without express authorization.
Health Politics and Policy
Fourth Edition
James A. Morone, Theodor
J. Litman, and Leonard S. Robins
Director of Learning Solutions:
Matthew Kane
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Printed in the United States of America
1 2 3 4 5 6 7 11 10 09 08 07
9781133819202, Health Politics and Policy, Fourth Edition, Morone/Litman/Robins – © Cengage Learning. All rights reserved. No distribution allowed without express authorization.
CHAPTER 1
Values in Health Policy: Understanding
Fairness and
H Efficiency
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Deborah
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Stone
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Deborah Stone introduces us to the two most important
values in health care. We can’t have all we
want of both fairness and efficiency, so we have to
Nthink about tradeoffs between them. In the process
we learn a more fundamental lesson: how to think about values in health policy.
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Two powerful ideals—fairness and efficiency—tower U simple of the two, and more often taken for
over health policy. These ideas unite us around lofty
granted as an incontrovertible value in health
goals, only to divide us the minute we get down to A policy.
details. That’s not only because there is an inherent
tension between fairness and efficiency, but also because each has multiple meanings. Different interpretations of fairness and efficiency define different
kinds of community. They draw different boundaries, gather different memberships and offer different levels of inclusiveness. In the shadow of these
grand ideals lurk many dilemmas for those who
would use them as yardsticks for policy evaluation.
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EFFICIENCY
Let’s start with efficiency, for though it is less inspiring than fairness, it is the more deceptively
Efficiency is another word for a bargain. It is getting the most for the least, or, in slightly more economic terms, producing the most output for a given
input. All policy reformers promise to give the country a bargain. Every person with a program to peddle promises that this program will save more than
it costs. Efficiency is one of those motherhood values that everybody is for, so long as no one spells
out exactly what it means—but it papers over a lot
of conflicts.
The idea behind efficiency is engagingly simple:
First, we measure the costs and benefits of any
program, proposal, or procedure. Then, with measurements in hand, we can compare them and choose
the course of action with the highest ratio of benefits
to costs.
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9781133819202, Health Politics and Policy, Fourth Edition, Morone/Litman/Robins – © Cengage Learning. All rights reserved. No distribution allowed without express authorization.
CHAPTER 1 Values in Health Policy: Understanding Fairness and Efficiency
There are lots of problems with this vision, but
the most basic is the core assumption that efficiency
is an empirically measurable fact. I want to suggest,
instead, that efficiency is a concept that must have
and come from a point of view. Efficiency can be
judged only with reference to a vantage point, and
vantage points are particular, not universal.HWith
multiple vantage points come multiple efficiencies.
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Efficiency is not the one best way to do things for
G Effisociety as a whole (as Pareto would have it).
ciencies, like politicians, are tied to constituencies.
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Let me illustrate with five examples.
The Waiting Room
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A doctor’s waiting room is set up to be efficient.
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With long training and very expensive expertise,
doctor is a valuable resource. A doctor can’tHknow
in advance how much time each patient will need,
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so to use the resource most efficiently, the receptionist schedules patients so that there are always
N several waiting in the waiting room. The doctor never
has an unused minute. The patients kill aI lot of
time. You know the drill—how much time have
C you
killed in doctors’ waiting rooms in your life? (I venQ
ture to say it is more time than you have bought
yourself by reducing your cholesterol.)
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The waiting room game is efficient only if we reA
gard it from the doctor’s point of view. The doctor,
as a resource, is being used to the max. His or her
time is never wasted. Now look at it from the pa1
tients’ point of view. Some of their time is always
1 syswasted. In order to say that the waiting room
tem produces the most medical care for the
0 least
amount of time, we have to ignore all the patients’
5 time
wasted time. Or we have to value patients’
much less than the doctor’s time. Or both. T
The point is simple. One person’s efficiency is
another person’s waste. Even if we think thatSorganizing medical care so that patients wait for doctors is the most efficient use of medical resources
for society as a whole, we still buy societal efficiency at the cost of lots of wasted time for lots of
people. Somebody is hurt. The doctor’s waiting
room is a good metaphor for the core notion of
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efficiency itself—every gain and every loss belongs
to somebody.
The Million-Dollar Catheter Lab
Under the headline “Doctors Say They Can Save
Lives and Still Save Money,” the New York Times ran
an article touting the Geisinger Foundation in Minnesota as the wave of the future. The Geisinger
Foundation had figured out how to increase efficiency in medical care. Among its tricks was a grand
version of the waiting room game. The health plan
avoided “duplication of costly equipment” by doing
all cardiac catheterizations at one hospital. “This
does mean,” the New York Times allowed, “that some
patients have to travel up to 100 miles for major
procedures that in a less efficient system might be
available at a community hospital.”1
It might be more efficient to have only one cardiac
catheterization lab for the entire community served
by the Geisinger Foundation, but we shouldn’t leap
to that conclusion before we tally up all the costs of
centralization. First, there are the costs of patients’
time; then the time of their spouses, friends, or
whomever accompanies the patients; then the travel
and lodging costs for all the people who have to
travel so far from home. There are the emotional
costs of making this procedure into an even bigger
deal than it already it is by embedding it in a trip
away from home. There may be still more costs associated with leaving home—paying someone else
to mind the kids, for example, or the burden to yet
another relative who comes into the home to mind
the kids. One can imagine an infinite chain of disturbance: John needs a cardiac catheterization, his
wife Janice goes with him, her sister Janeen takes
time off from work to mind their kids, Janeen’s husband Arthur eats out because Janeen’s not there to
cook, Janeen’s colleagues work harder to fill in for
her, and some of Janeen’s work doesn’t get done,
with attendant costs to her employer.
A full efficiency calculus has to take into account
all these points of view—the points of view of all the
people who are affected by the remote location of
catheterization labs. Tracing out such chains of
9781133819202, Health Politics and Policy, Fourth Edition, Morone/Litman/Robins – © Cengage Learning. All rights reserved. No distribution allowed without express authorization.
26
PART ONE Ideas and Concepts
consequences is rather like doing genealogy: We can
decide to go only so far as our great-grandparents,
but drawing those limits is an arbitrary decision.
This represents what I call the boundary problem
in efficiency measurement. How do we know where
to draw the boundaries in including the ramifications and costs of any way of organizing medical
care? There are no natural or correct or obvious
boundaries, because people live embedded in social
networks, just as they are born into unbounded genealogical trees.
The Paycheck
Every paycheck is an expenditure to a hospital and
a livelihood to an employee, and therein lies a tale.
Whether that paycheck goes on the output side or
the input side of an efficiency ratio depends on who
is doing the accounting.
We could adopt the point of view of the hospital
CEO, and say we are trying to measure efficiency
from the point of view of the hospital. How much
input does it take to produce our output? To the
CEO, the paycheck is input, and she or he wants to
write as few paychecks as possible and keep each
one of them as low as possible.
But the hospital is also a community institution
and a major local employer. To the governor, the
mayor, and even the neighbors, the hospital’s role
is not only to make sick people well but also to provide economic stability to the neighborhood. From
the point of view of the local community, each hospital payroll check is output many times over. It
means a livelihood to a hospital employee and her
family. Because employees will spend most of their
paychecks, each check means revenue to local businesses and, in turn, paychecks to those businesses’
employees.
Robert Reich, the former secretary of labor, has
made a career on the idea that economies produce
not only goods and services, but jobs. Reich has
taught us that while labor counts as “inputs” to production in classic market models, employment is also
an economic output. Societies whose economies produce more employment for their members are
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usually better off than those whose economies produce less.
Thus, President Bill Clinton was only half right
when he said in his first inaugural address that we
can’t fix our economy without doing something
about health care costs. The half he didn’t mention
is that our health care system is the strongest part
of our economy in terms of jobs. Between 1988 and
1992, in the run-up to the Clinton presidency, jobs
in health care grew 43%, while jobs elsewhere in the
private sector inched up a paltry 1%.2 Thanks
largely to a graying population, jobs in the health
sector are projected to increase almost twice as
fast as jobs in all industries—27% compared with
14%—over the next several years.3 There’s a nasty
double bind here. Health care expenditures are eating up our GNP and raising the cost of American
goods, but every health care expenditure is income
to someone employed in the health sector, or to
someone employed by someone who makes things
for the health care sector. We can’t get a handle on
health care costs unless we are willing to put a lot
of people out of work.
There’s another wrinkle to the paycheck story.
Jobs, on balance, probably contribute to people’s
health: Paychecks feed families. Jobs give people
pride, satisfaction, something to do. For the lucky
employees of large businesses, jobs provide health
insurance and access to medical care. To be sure,
not all jobs provide decent wages, stress-free
work, or even safe and healthy work, much less
health insurance. But to the extent that jobs do
provide these things, reducing the input side of
health production by reducing paychecks doesn’t
necessarily increase the ratio of output (health) to
input (dollars).
Only from the vantage point of someone whose
vision stops at the hospital walls does cutting staff
increase efficiency. From a wider community vantage point, such as the mayor’s, the efficiency calculus is much different. To extend the analogy, insofar
as health analysts look only at the efficiency of
health providers, they neglect all the important ways
health activities are outputs to the communities in
which providers provide.
9781133819202, Health Politics and Policy, Fourth Edition, Morone/Litman/Robins – © Cengage Learning. All rights reserved. No distribution allowed without express authorization.
CHAPTER 1 Values in Health Policy: Understanding Fairness and Efficiency
The Leaky Bladder
To talk about producing health care most efficiently
requires us to think that health care production can
be analyzed like widget production. The most important difference is that medicine works not by
people doing something to inert objects, H
but by
people interacting in a relationship. Trust and
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warmth in the relationship contribute to better diagnosis and more effective therapy. Without G
getting
sentimental about old fashioned doctoring,
G it is
probably fair to say that time and talk are the two
great healers. When time and talk are treatedSas inputs in a production process, to be measured
, and
minimized, medical care will suffer.
Economists traditionally measure productivity in
manufacturing as output per labor hour. In the
S service sector, this definition becomes something like
Hsince
“number of people processed per labor hour,”
handling people is what service industries do.AThus,
hospital productivity is measured in patient days.
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Extra personnel, such as more nurses or ombudspersons, no doubt add to patients’ comfort andI sense
of well-being, and maybe even to their health;
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they lower productivity statistics because now there
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are more workers spread over the same number
patients.
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If we adopt the point of view of the consumers,
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patients, and families instead of the CEOs, productivity looks very different. In choosing a hospital or
a nursing home for a relative, you would look for a
1 that
high staff-to-patient ratio. The very qualities
make hospitals and other human services more
1 attractive to consumers—more useful and helpful to
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them—make them less productive in efficiency
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statistics.
What happens when we use economic notions
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efficiency to re-shape health services and drive down
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costs? Consider New York’s effort to reduce
spending for home care during the 1990s. New York
has the most extensive and generous Medicaid
home care program. In 1991, 63 cents of every Medicaid dollar spent nationally on home care were
spent in New York.4 The state department of social
services decided to apply Scientific Taylorism to
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home care. The department devised a system of
defining precise client needs—such as feeding, toileting, and bathing—and designated an amount of
time necessary for each task. The goal was to pay
home care workers only for the time necessary to do
these instrumental tasks and to cut out the unproductive or “dead time.” The dead time is the time a
home care worker spends chatting with the client—
schmoozing, joking, just being together in a human
relationship. Under the new system, an elderly
woman whose chief problem is incontinence would
no longer be eligible for a full-time live-in attendant.
Her allotment of care would be ten-and-a-half hours
per week.That was apparently the time it took to service someone without bladder control. The department thought of paying for her care in the same way
an auto mechanic would figure out how much time
it takes service a car with a leaky gas tank. The pursuit of instrumental efficiency reduced this woman
to a leaky container that needed mopping up.5
In health care, it is hard to tell what efficiency is
because we don’t know what “output” is in the first
place. We use some crude population measures,
such as infant mortality and life expectancy, but
these are not good measures of a health system’s
output since they are influenced by lots of factors
besides medical care. Researchers in the field of
outcomes research have come up with a host of indicators about specific treatments, such as survival
rates for cardiac bypass operations or recurrence
rates for urinary tract infections. Others have
developed “report cards” to measure organizational
performance on such indicators as consumer satisfaction, delivery of preventive care, and administrative efficiency.
Most of what the health system produces is not
so easily definable and measurable—things such as
better functioning, lowered risk of future disease, reduced pain, education about caring for oneself,
and, let us not forget, reassurance, hope, and a
sense of well-being. Health researchers are going to
be hard-put to provide consumers with this kind of
outcome data.
Pain control, peace of mind, dignity, hope,
and other important features of medical care are
9781133819202, Health Politics and Policy, Fourth Edition, Morone/Litman/Robins – © Cengage Learning. All rights reserved. No distribution allowed without express authorization.
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PART ONE Ideas and Concepts
notoriously hard to measure. And when the only incentive is to score well on the measures, that whic…
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