P11.0036 Topics in Health Policy
New York University
Robert F. Wagner Graduate School of Public Service
P11.0036 - Topics in Health Policy: Policy, Politics, and Power
Spring, 2009 – Version 1.1
Professor John Billings
Mondays and Wednesdays: 3:30-4:45
Room: 414 Silver Center
Course Description
This course is an introduction for undergraduate students to the major policy issues affecting health and health care and examines the role of government in the health care system. An important focus of the course is an assessment of the role of policy analysis in the formation and implementation of national, state, and local health policy. Because much of government health policy relates to or is implemented through payment systems, there is substantial discussion of the policy implications of how government finances and pays for health care. The role of the legal system with respect to adverse medical outcomes, economic rights, and individual rights is also discussed. Proposals for health policy reform at the national and local level are examined throughout the course, with an emphasis on Medicare and Medicaid reforms currently being implemented or considered, as well efforts to respond to disparities in health outcomes for vulnerable populations.
Course Requirements/Grading
Two brief papers (4-5 pages) are required, and there is a mid-term and final exam. Each of the papers is 20% of the final grade, the mid-term exam 25%, and the final 25%. Class participation and debate are integral to the course and will account for 10% of the final grade.
Students are expected to have studied require readings and be prepared to discuss them in class. The readings for the course are primarily journal articles that will be posted in the Assigned Readings section of Blackboard and are also available directly from the Bobst Library ejournal site. There is also one required text book: Thomas Bodenheimer and Kevin Grumbach - Understanding Health Policy - Fourth Edition New York: McGraw-Hill, 2005. The book is readily available from Amazon.com or BarnesandNoble.com, or can be obtained at Barnes and Noble on 18th Street and Broadway. Some readings from guest lecturers that are not copyright protected will be handed out in class or will be posted on the Blackboard® site. All reading materials will also be placed on reserve at Bobst Library. Copies of PowerPoint/overhead materials used in class will be posted on the Blackboard® site at least 24 hours in advance of the class.
Office Hours
By appointment (212-998-7455) -
295 Lafayette Street – 2nd Floor
Session 1 - 1/21/09 - Course introduction + Discussion of role of government in
health care
§ Description of course content, goals, and requirements
§ A discussion of the role of policy analysis in public policy formation and the impact of public policy on the health system
§ Objectives of government in health and health care
§ Brief history of federal government role in health
Required reading:
S. Schoenbaum S, A. Audet, and K. Davis, “Obtaining Greater Value from Health Care: The Roles of the U.S. Government,” Health Affairs (November/December 2003): 183-190.
G Anderson, P Hussey, B Frogner, et al., “Health Spending in the United States and the Rest of the World,” Health Affairs (July/August, 2005): 903-914.
Sessions 2-3 - 1/26/09, 1/28/09 - How health care is organized, financed and paid
for in the U.S.
§ Brief overview of how health care is organized, financed, and paid for
§ “Managed” care
§ Discussion of the implications for policy
Required reading:
T. Bodenheimer and K. Grumbach, Understanding Health Policy - Fourth Edition (New York: McGraw Hill, 2005) – Chapters 4-7.
Session 4 - 2/02/09 - Economics 101 - Market Failure
Guest Lecturer: Brian Elbel - Wagner School/NYU School of Medicine
§ Introduction of the concept of “market failure”
§ Discussion of the implications for health care and health care policy
Required reading:
http://william-king.www.drexel.edu/top/prin/txt/SDch/Ch3ToC.html
http://woodrow.mpls.frb.fed.us/pubs/fedgaz/02-05/supply.cfm?js=0
Sessions 5-6 - 2/04/09, 2/9/09 - Medical practice and health policy
§ Review of the enormous variation in medical practice
§ Discussion of causes of variation
§ Discussion of the implications for policy
Required reading:
E. Fisher, D. Wennberg, T. Stukel, et al., “The Implications of Regional Variation in Medicare Spending - Part 2: Health Outcomes and Satisfaction with Care,” Annals of Internal Medicine 138, No. 4 (2003): 288-299
J. Wennberg, E. Fisher, T. Stukel, et al., “Use of Hospitals, Physician Visits, and Hospice During the Last Six Months of Life among Cohorts Loyal to Highly Respected Hospitals in the United States,” British Medical Journal 328, No. 7440 (March 13, 2004): 607-610.
K. Baiker, A. Chandra, J. Skinner, et al., “Who You Are and Where You Live: How Race and Geography Affect the Treatment of Medicare Beneficiaries,” Health Affairs - Web Exclusive (7 October 2004): VAR33-44.
D. Eddy, “Evidence-Based Medicine: A Unified Approach,” Health Affairs (January/February, 2005): 9-17.
D. Jones, “Visions of a Cure,” Isis (September 2000):91:504-541 – [http://www.jstor.org/browse/00211753/ap010310?frame=noframe&userID=/01cc99333c3c2f10d557f64a8&dpi=3&config=jstor]
Session 7 - 2/11/09 – Racial/ethnic and socio-economic disparities in health
§ Overview of disparities in health services, utilization, and outcomes
§ Discussion of the factors that are contributing to these disparities
§ Discussion of the implications for policy makers and providers
Required Reading:
J. Billings, L. Zeitel, J. Lukomnik, et al., “Impact of Socioeconomic Status on Hospital Use in New York City” Health Affairs (Spring 1993): 162-173.
J. Billings, J. Anderson, L. Newman, “Recent Findings on Preventable Hospitalizations” Health Affairs (Fall 1996): 239-249.
J. Billings “Management Matters: Strengthening the Research Base to Help Improve Performance of Safety Net Providers,” Health Care Management Review 28, No 4 (2003): 323-334.
President’s Day - 2/16/09 – No Class
Session 8 - 2/18/09 - The Uninsured in the U.S. and what difference does
insurance coverage make?
Guest Lecturer: Michael Birnbaum - United Hospital Fund
§ Description of the size and characteristics of the uninsured population
§ Review of the causes of uninsurance
§ Discussion of the implications for health care and health care policy
Required reading:
Institute of Medicine, Committee on the Consequences of Uninsurance, Coverage Matters: Insurance and Health Care (Washington, National Academy Press, 2001) - Executive Summary (pp. 1-18). http://books.nap.edu/execsumm_pdf/10188.pdf (The executive summary is free.)
Institute of Medicine, Committee on the Consequences of Uninsurance, Care Without Coverage: Too Little Too Late (Washington, National Academy Press, 2002) - Executive Summary (pp. 3-16). http://books.nap.edu/execsumm_pdf/10367.pdf (The executive summary is free.)
Institute of Medicine, Committee on the Consequences of Uninsurance, A Shared Destiny: Community Effects of Uninsurance (Washington, National Academy Press, 2003) - Executive Summary (pp. 1-14). http://books.nap.edu/execsumm_pdf/10602.pdf (The executive summary is free.)
J Holahan, A Cook, “The U.S. Health Economy and Changes in Health Insurance Coverage,” Health Affairs – Web Exclusive (20 February 2008) W135-144
Kaiser Family Foundation, The Uninsured: A Primer, October, 2008.
Sessions 9-10 - 2/23/09, 2/25/09 – Medicare: The basics and Issues for Reform
§ Description of who and what is covered by Medicare
§ Review of how Medicare pays for health care
§ Description of the recent expansion Medicare to provide coverage for prescription drugs
§ Issues for Reform
Required reading:
M. Moon, “Medicare,” New England Journal of Medicine 344, No. 12 (March 22, 2001): 928-931.
CMS – “Medicare & You 2008” – http://www.medicare.gov/Publications/Pubs/pdf/10050.pdf
K. Davis, K. Schoen, M. Doty et al., “Medicare Versus Private Insurance: Rhetoric and Reality,” Health Affairs - Web Exclusive (9 October 2002): W311-324
M. Pauly, “Means Testing in Medicare,” Health Affairs - Web Exclusive (8 December 2004): W4-546-557.
Henry J. Kaiser Family Foundation, Prescription Drug Coverage for Medicare Beneficiaries: A Summary of the Medicare Prescription Drug, Improvement, and Modernization Act of 2003 (December 10, 2003) http://www.kff.org/medicare/loader.cfm?url=/commonspot/security/getfile.cfm&PageID=28710
Also take a look at: http://www.kff.org/medicare/rxdrugscalculator.cfm
Optional reading:
T. Oliver, P. Lee, and H. Lipton, “A Political History of Medicare and Prescription Drug Coverage,” The Milbank Quarterly 82, No. 2 (2004): 283-354.
Sessions 10-11 - 2/25/09, 3/02/09 - Medicaid: The basics and issues for reform
§ History and financing of Medicaid
§ Description of who and what is covered by Medicaid
§ Discussion of recent reforms/Issues for reform/Role of managed care
Required reading:
D. Boyd, “The Bursting State Fiscal Bubble and State Medicaid Budgets,” Health Affairs (January/February 2003): 44-61.
B. Vladeck, “Where the Action Really Is: Medicaid and the Disabled,” Health Affairs (January/February 2003): 90-100.
J. Hoadley, P. Cunningham, and M. McHugh, “Popular Medicaid Programs Do Battle with State Budget Pressures: The Perspective from Twelve States,” Health Affairs (March/April 2004): 143-154.
D. Draper, R. Hurley, and A. Short, “Medicaid Managed Care: The Last Bastion of the HMO?” Health Affairs (March/April 2004): 155-167.
J. Billings, T. Mijanovich, “Improving The Management of Care for High-Cost Medicaid Patients” Health Affairs no 6 (2007) 1643-1655.
See also: http://www.cms.hhs.gov/MedicaidGenInfo/Downloads/MedicaidAtAGlance2005.pdf
Session 12 - 3/04/09 – Efforts to expand coverage/reduce disparities at the federal
level and lessons from the failure of the Clinton health plan
§ Overview of policies/programs at the federal level to reduce disparities in health services, utilization, and outcomes
§ Discussion of the Clinton health plan, what problems it might have solved or created, and why it failed
§ Discussion of other proposals for reform and their limits
Required Reading:
W. Zelman, “The Rationale behind the Clinton Health Care Reform Plan,” Health Affairs (Spring 1994): 9-29.
D. Yankelovich, “The Debate That Wasn’t: The Public and the Clinton Health Plan,” Health Affairs (Spring 1995): 7-23.
R. Blendon, M. Brodie, and J. Benson, “What Happened to America’s Support for the Clinton Health Plan,” Health Affairs (Summer 1995): 7-23.
Session 13 - 3/09/09 – Expanding coverage/reducing disparities in health –
Role of the state/local governments
§ Overview of policies/programs at the state and local level to reduce disparities in health services, utilization, and outcomes
§ The Massachusetts approach/Options being considered in New York
§ Discussion of the strengths and limits of state/local initiatives
Required Reading:
Handouts
Session 14 - 3/11/09 – Mid-Term Exam
Spring Break
Session 15-16 - 3/23/09, 3/25/09 – Medical errors – Medical malpractice
§ Brief overview of current malpractice law
§ Description of what is known about medical errors
§ Analysis of the effectiveness of the legal system and malpractice law in assuring quality and compensating victims of harm
§ Discussion of current “crisis” and proposals for reform
Required reading:
Institute of Medicine, “Report Brief - To Err is Human: Building a Safer Health System” - http://www.nap.edu/catalog/9728.html
M. Mello, D. Studdert, and T. Brennan, “The New Medical Malpractice Crisis,” New England Journal of Medicine 343 No. 23 (2003): 2281-4.
W. Sage, “Medical Liability and Patient Safety,” Health Affairs (July/August 2003): 26-36.
M. Hatlie and S. Sheridan, “The Medical Liability Crisis of 2003: Must We Squander the Chance to Put Patients First?” Health Affairs (July/August 2003): 37-40.
A. Chandra, S. Nundy, S. Seabury, “The Growth of Physician Medical Malpractice Payments: Evidence from the National Practitioner Data Bank,” Health Affairs - Web Exclusive (31 May 2005): W5-240-249.
Session 17 - 3/30/09 - More policy issues concerning the pharmaceutical industry
§ Overview of the major policy issues concerning the pharmaceutical industry
§ Discussion of the factors that are contributing to these emergence of these issues now
§ Discussion of the role of government with respect to the pharmaceutical industry
Required Reading:
P. Stein and E Valery, “Competition: An Antidote to the High Price of Prescription Drugs,” Health Affairs (July/August 2004): 151-158.
K. Kaphingst and W. DeJong, “The Educational Potential of Direct-to-Consumer Prescription Drug Advertising,” Health Affairs (July/August 2004): 143-150.
J. Jeffords, “Direct-to-Consumer Drug Advertising: You Get What You Pay For,” Health Affairs - Web Exclusive (28 April 2004): W4 253-255.
P. Kelly, “DTC Advertising’s Benefits Far Outweigh Its Imperfections,” Health Affairs - Web Exclusive (28 April 2004): W4 246-248.
Optional reading:
J. Weisman, D. Blumenthal, A Silk, et al., “Consumers’ Reports on the Health Effects of Direct-to-Consumer Drug Advertising,” Health Affairs - Web Exclusive (26 February 2003): W3 82-95.
J. Weisman, D. Blumenthal, A Silk, et al., “Physicians Report on Patient Encounters Involving Direct-to-Consumer Drug Advertising,” Health Affairs - Web Exclusive (28 April 2004): W4 219-233.
Session 18 - 4/01/09 – Role of Patients – End of life decisions
§ Patient’s rights to refuse/withdraw treatment
§ Advanced directives/proxies
§ Physician assisted suicide
Required reading:
Cruzan v. Director, Missouri Department of Health – 497 U.S. 261 (1990) http://caselaw.lp.findlaw.com/scripts/getcase.pl?court=us&vol=497&invol=261
Session 19 - 4/06/09 – Role of Patients – Making other health decisions
§ Choice of treatment
§ Choice of provider
§ Choice of health plan
Required reading:
M. Morgan, R Deber, H. Llewellyn-Thomas, “Randomized Controlled Trial of an Interactive Videodisc Decision Aid for Patients with Ischemic Heart Disease,” Journal of General Internal Medicine 15 No. 10 (2000): 685-693
A. O’Connor, H. Llewellyn-Thomas, and A. Flood, “Modifying Unwarranted Variations in Health Care: Shared Decision Making Using Patient Decision Aids,” Health Affairs – Web Exclusive (7 October 2004): VAR 63-72.
J. Billings, “Promoting The Dissemination of Decision Aids: An Odyssey in a Dysfunctional Health Care Financing System,” Health Affairs – Web Exclusive (7 October 2004): VAR 128-132.
Session 20 - 4/08/09 – Long Term Care –Key Policy Issues
Guest Lecturer: James Knickman – New York State Health Foundation
§ Description of key policy issues affecting long term care
§ Examination of the expected impact of “baby boomers” on long term care
Required reading:
J. Knickman and E. Snell, “The 2030 Problem: Caring for Aging Baby Boomers,” HSR: Health Services Research 37 No. 4 (August 2002): 849-884.
T. Bodenheimer and K. Grumbach, Understanding Health Policy - Fourth Edition (New York: McGraw Hill, 2005) – Chapter 10 (Long Term Care).
Session 21 - 4/13/09 – Controlling health costs: Policy options missing in action
§ Description of the dynamics of current cost increases
§ Review of the causes and implications of cost increase
§ Discussion of policy options and current politics in Presidential campaigns