NEW YORK UNIVERSITY ROBERT F. WAGNER GRADUATE SCHOOL OF PUBLIC SERVICE INTRODUCTION TO HEALTH POLICY AND MANAGEMENT HPAM-GP

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1 1 NEW YORK UNIVERSITY ROBERT F. WAGNER GRADUATE SCHOOL OF PUBLIC SERVICE INTRODUCTION TO HEALTH POLICY AND MANAGEMENT HPAM-GP Fall 2011 Mondays 10:30 am - 12:10 pm Silver 410 Assistant Professor Lucy MacPhail Office: Puck Building, 295 Lafayette Street, 3062 Office hours: Thursdays 2:00-3:30 pm or by appointment lucy.macphail@nyu.edu COURSE SYLLABUS This core course in the NYU Wagner MPA: Health Policy and Management program explores major topics in the study of health and health care delivery. We will discuss determinants of health, the social distribution of health and disease, and health disparities; the organization and financing of the U.S. health care system, its historical context, the roles and behaviors of its key actors, and its comparison to health systems of other nations; the quality, cost and accessibility of health care services; and health care delivery system improvement and reform. We will examine these themes using a multidisciplinary approach that employs sociological, political, economic and ethical perspectives on health and disease, the health care system, and the challenges of meeting the varied (and often conflicting) needs and motivations of health care system stakeholders. The objective of this course is to build understanding of fundamental ideas, issues and problems in health policy and management and thereby to provide a strong foundation for future studies and careers in the health care field. COURSE COMPETENCIES Course Focus: The ability to assess population and community health needs from a public service perspective The ability to examine social and behavioral determinants of health and understand how health systems can address the needs of vulnerable populations The ability to understand how policy and delivery processes work, and to consider the demographic, cultural, political and regulatory factors involved in and influencing health policy and management decision-making Relevant Content for the Following Competencies is Also Included: The ability to understand and apply legal and ethical principles to managerial and leadership decisions affecting health care organizations The ability to measure, monitor and improve safety, quality, access and system/care delivery

2 2 processes in health care organizations The ability to draw implications and conclusions to develop an evolving vision that results in longterm organizational viability The ability to communicate and interact productively (via listening, speaking and writing) on matters of healthcare with a diverse and changing industry, work force and citizenry The ability to present convincingly to individuals and groups the evidence to support a point of view, position or recommendation LEARNING OBJECTIVES At the conclusion of this course, students will be prepared to: Describe the organization, financing and performance of the U.S. health care delivery system Identify determinants of health and explain their impact on the distribution of health and disease Define the roles of key stakeholders providers, government and private payers, employers, regulators, patients and describe their incentives and behavior Compare the U.S. health care system to models of health care organization and financing abroad Explain fundamental concepts of health care payment and performance measurement Define major health policy developments over the past 50 years and explain their significance Analyze strengths, weaknesses and feasibility of policy and management approaches that aim to promote health, prevent disease and improve health services delivery and assess the impact of these approaches on quality, access, cost and equity goals BOOKS AND READINGS Students should arrive to class prepared to participate in the discussion of these themes based on their critical analysis of assigned readings. Required textbook: (10 th edition). A. Kovner & J. Knickman, eds. New York, NY: Springer Press, Other required readings: Assigned readings that are not included in the required textbook will be posted on. Recommended readings: In addition to assigned readings, students are encouraged to browse recent issues of peer-reviewed journals such as Journal of the American Medical Association, New England Journal of Medicine, Health Affairs, and American Journal of Public Health. The Kaiser Family Foundation website ( is also an excellent resource on health policy issues.

3 3 WRITTEN REQUIREMENTS Students are required to complete two papers (one 4-page memo due October 4 and one 8-page final essay due December 13) and three short response exercises (no more than one page, choose 3 of 4: due September 20, October 18, November 8, and November 29). Further details on written requirements and grading are provided at the end of this syllabus. A. POPULATION HEALTH COURSE SESSIONS 9/6: Week 1. Introduction: Health, Disease and Community Overview of course Definitions of health and disease Relationship between health and medical care Knickman, J. and Kovner, T. Chapter 1: The Current U.S. Health Care System, pp Schroeder, S We Can Do Better: Improving the Health of the American People. New England Journal of Medicine 357: McKinlay, J. and McKinlay, S The Questionable Contribution of Medical Measures to the Decline of Mortality in the United States in the Twentieth Century. The Milbank Memorial Fund Quarterly. Health and Society, 55(3): Colgrove, J The McKeown Thesis: A Historical Controversy and Its Enduring Influence. American Journal of Public Health 92(5): /13: Week 2. Epidemiologic Measures and Determinants of Health Relationships between socioeconomic status, race/ethnicity, gender and health Population health inequalities and social justice implications Russo, P. Chapter 5: Population Health, pp Adler, N. and Rehkopf, D U.S. Disparities in Health: Descriptions, Causes and Mechanisms. Annual Review of Public Health 29: Marmot, M Social Determinants of Health Inequalities. The Lancet 365: Williams, D. and Jackson, P Social Sources of Racial Disparities in Health. Health Affairs 24(2):

4 4 9/20: Week 3. Public Health Policy and Management Public health infrastructure Prevention and health promotion frameworks Health behavior Policy approaches to improving public health RESPONSE EXERCISE #1 DUE ON BLACKBOARD Leviton, L., Rhodes, S. and Chang, C. Chapter 6: Public Health: Policy, Practice, and Perceptions, pp Orleans, C. and Cassidy, E. Chapter 7: Health and Behavior, pp Roberts, M. and Reich, M Ethical Analysis in Public Health. The Lancet 359(9311): Robert Wood Johnson Foundation Commission to Build a Healthier America Beyond Health Care: New Directions to a Healthier America. Executive Summary and Introduction, pp B. ORGANIZATION OF THE U.S. HEALTH CARE SYSTEM 9/27: Week 4. U.S. Health Policy and Reform in 20 th Century Historical development of health care delivery system Government role in health care system Sparer, M. Chapter 2: Health Policy and Health Reform, pp Blendon, R. and Benson, J Americans Views on Health Policy: A Fifty-Year Historical Perspective. Health Affairs 20(2): Rothman, D A Century of Failure: Health Care Reform in America. Journal of Health Politics, Policy and Law 18(2): Oberlander, J Long Time Coming: Why Health Reform Finally Passed. Health Affairs 29(6): /4: Week 5. Health Care Financing Fundamental characteristics of health care markets Medicare, Medicaid/CHIP and private insurance Spending growth in the U.S. Managed care and cost containment Implications of 2010 Patient Protection and Affordable Care Act (PPACA)

5 5 PAPER 1 (MEMO) DUE TODAY Knickman, J. Chapter 3: Health Care Financing, pp White, H. Chapter 12: Health Care Costs and Value, pp Appendix: Major Provisions of the Patient Protection and Affordable Care Act of 2010, pp Bodenheimer, T High and Rising Health Care Costs, Part 1: Seeking an Explanation. Annals of Internal Medicine 142(10): Cutler, D Analysis and Commentary: How Health Care Reform Must Bend the Cost Curve. Health Affairs 29(6): /11: No Class 10/18: Week 6. U.S. Health Care System in International Perspective Guest speaker: Professor Victor Rodwin, NYU Wagner RESPONSE EXERCISE #2 DUE ON BLACKBOARD Frogner, B., Waters, H. and Anderson, G. Chapter 4: Comparative Health Systems, pp Murray, C. and Frenk, J A Framework for Assessing the Performance of Health Systems. Bulletin of the World Health Organization 78(6): Davis, K., Schoen, C. and Stremekis, K Mirror, Mirror on the Wall: How the Performance of the U.S. Health Care System Compares Internationally Update. Commonwealth Fund, Pub. No Weisz, D., Gusmano, M., Rodwin, V., and Neuberg, L Population Health and the Health System: A Comparative Analysis of Avoidable Mortality in Three Nations and Their World Cities. European Journal of Public Health 18(2): /25: Week 7. Providers and Organization of Care Acute and ambulatory care delivery Evolving organizational forms Caronna, C. and Ong, M. Chapter 9: Organization of Medical Care, pp McCarthy, D. Chapter 10: Integrative Models and Performance, pp Bodenheimer, T Coordinating Care A Perilous Journey through the Health Care System. The New England Journal of Medicine 358(10): Rittenhouse, D Primary Care and Accountable Care: Two Essential Elements of Delivery

6 6 System Reform. New England Journal of Medicine 361(24): /1: Week 8. Medical Professionals and the Health Care Workforce Historical and emerging roles for physicians and health professionals Health care labor markets Professionalization and power in organized medicine Scheffler, R. and Spetz, J. Chapter 12: Health Workforce, pp Goodman, C. and Fisher, E Physician Workforce Crisis? Wrong Diagnosis, Wrong Prescription. New England Journal of Medicine 358(16): Peterson, M From Trust to Political Power: Interest Groups, Public Choice, and Health Care. Journal of Health Politics, Policy and Law 26(5): Weisz, G. et al The Emergence of Clinical Guidelines. The Milbank Quarterly 85(4): /8: Week 9. Patient Decision-Making and the Provider Patient Relationship Role of the patient in the health care system Patient preferences and informed patient decision-making Provider patient relationship Consumer-directed care and patient demand for and use of information RESPONSE EXERCISE #3 DUE ON BLACKBOARD Hibbard, J. and Cunningham, P How Engaged Are Consumers in Their Health and Health Care, and Why Does It Matter? Center for Studying Health System Change, Research Brief No. 8 (October). Mechanic, D The Functions and Limitations of Trust in the Provision of Medical Care. Journal of Health Politics, Policy and Law 23(4): Sepucha, K. and Mulley, A A Perspective on the Patient s Role in Treatment Decisions. Medical Care Research and Review 66(1 suppl): 53S-74S. Arnold, S. and Scanlon, D Realizing True Consumer-Directed Health Care: What the Policy Community Needs. Medicare Care Research and Review 66 (1 suppl): 3S-8S. C. HEALTH CARE SYSTEM PERFORMANCE, CHALLENGES AND DEBATES 11/15: Week 10. Meeting Changing Population Needs Chronic disease management Long-term care End-of-life issues

7 7 Bodenheimer, T., Wagner, E., Grumbach, K Improving Primary Care for Patients with Chronic Illness: The Chronic Care Model, Part 2. Journal of the American Medical Association 288: Gawande, A Letting Go: What Should Medicine Do When It Can t Save Your Life? The New Yorker August 2 issue. Kane, R. and Kane, R What Older People Want from Long-Term Care, and How They Can Get It. Health Affairs 20(6): Grabowski, D. et al Supporting Home- and Community-Based Care: Views of Long- Term Care Specialists. Medical Care Research and Review Suppl. to 67(4): 82S-101S. 11/22: Week 11. Managing New Medical Technology Expanding use of pharmaceutical and medical devices in health care Treatment benefits versus monetary costs associated with medical innovation Role of pharmaceutical/biotech industry in health care system Satvat, A. and Leight, J. Chapter 13: Comparative Effectiveness, pp Cutler, D. and McClellan, M Is Technological Change in Medicine Worth It? Health Affairs 20(5): Gilsdorf, J As Drug Marketing Pays Off, My Mother Pays Up. Health Affairs 23(1): Lo, B Perspectives: Serving Two Masters Conflicts of Interest in Academic Medicine. New England Journal of Medicine 362(8): /29: Week 12. Improving Quality of Care Safety and quality of U.S. health care delivery Measuring, regulating and improving quality and patient safety Challenges of quality improvement and adverse event reduction in health care Quality improvement frameworks and interventions RESPONSE EXERCISE #4 DUE ON BLACKBOARD Clancy, C. and Lloyd, R. Chapter 11: High Quality Health Care, pp Kropf, R. Chapter 16: Health Information Technology, pp Landrigan, C. et al Temporal Trends in Rates of Patient Harm Resulting from Medical Care. New England Journal of Medicine 363: Mello, M., Kelly, C. and Brennan, T Fostering Rational Regulation of Patient Safety. Journal of Health Politics, Policy and Law 30(3):

8 8 12/6: Week 13. Expanding Access and Reducing Disparities in Access and Treatment Barriers to care for vulnerable patient populations The uninsured and underinsured in the U.S. Implications of 2010 Patient Protection and Affordable Care Act Billings, J., Cantor, J. and Clinton, C. Chapter 8: Access to Care, pp Ayanian, J. et al Unmet Health Needs of Uninsured Adults in the United States. Journal of the American Medical Association 284(16): Hurley, R. et al Community Health Centers Tackle Rising Demands and Expectations. Center for Studying Health System Change, Issue Brief No. 116 (December). Marmor, T Health Reform 2010: The Missing Philosophical Premises in the Long- Running Health Care Debate. Journal of Health Politics, Policy and Law 36(3): /13: Week 14. Directions for Health System Change Future of the U.S. health care delivery Competing agendas for change Course wrap-up PAPER 2 (FINAL ESSAY) DUE TODAY Fuchs, V Health Reform: Getting the Essentials Right. Health Affairs 28(2): w180-w183. Porter, M A Strategy for Health Care Reform Toward a Value-Based System. New England Journal of Medicine 361(2): Gawande, A Cowboys and Pit Crews: 2011 Commencement Address at Harvard Medical School. The New Yorker, posted May 26.

9 9 WRITTEN ASSIGNMENTS In addition to attending and participating in classes, students are required to submit two papers and three short written exercises. Please format all written work with 1-inch margins and 12-point font. Paper 1: Public Health Memo (Due October 4) 4 double-spaced pages maximum Please write a concise, well-structured memo to the attention of the mayor, governor or other government official of a town/city or state you have inhabited (or another town/city or state of interest to you) in which you provide analysis on how to improve the health of the local population. Present evidence on factors that influence health and identify priorities and recommended actions that the municipal or state government should pursue to achieve meaningful improvements in community health over the next 10 years. In your memo, please include the following: Background on the health of the focal town/city or state population Three top-priority objectives that government and other community-based entities should aim to achieve over the next 10 years, with well-reasoned arguments for the selection of these objectives motivated by themes discussed thus far in the course Strategies to achieve these objectives, with consideration of both potential impact and feasibility Your paper should be focused and direct, consistent with the memo style, and it should not exceed four pages. Please see the Writing Center Guide to Writing Memos, posted on under the Assignments tab, for memo composition guidelines. Citations are required. Exhibits (not included in page length) are permitted but not required. Paper 2: Final Essay (Due December 13) 8 double-spaced pages maximum Please write a research paper in which you focus on one dimension of the performance of the U.S. health care delivery system explored in the course, how performance on this dimension is influenced by the organization and financing of health care in the U.S. and the behavior of its key stakeholders, what must be improved or reformed to achieve performance gains in your selected area, and implications of your analysis for health policy and management. You may focus on performance in a broadly-defined area such as quality of care, cost-effectiveness, or access to care or you may define your focus more narrowly within one of these categories (for example, quality of care for patients with chronic disease, cost-effectiveness with respect to implementation of new technologies, etc.). In your analysis, please consider all stakeholders relevant to your specified focus providers, payers and purchasers, patients, communities, policy-makers, other groups that play a role in performance in your focal area and be sure to examine performance and implications for reform at both the policy and delivery system levels. Please include references to course readings as well as any relevant outside sources that support your analysis. Citations and a references page (not included in page length) are required.

10 10 Response Exercises Complete 3 of 4: Due September 20, October 18, November 8 and November 29 One double-spaced page maximum Please write three brief responses to topics posted in the Discussion Forum on. Please post your response as a thread in the forum specified for the week s topic (can be copied and pasted directly into the body of the post or attached as a Word document). Your responses should be based on course readings and discussions and may also draw upon relevant ideas and evidence from outside sources such as journals, media or websites although no outside reading is necessary or your own experiences. Parenthetical citation of readings assigned for class is fine. In addition to posting your one-page response to the topic, please also reply to another student s response exercise with 3-5 sentences that demonstrate your engagement with the ideas and arguments presented in his or her response. Replies to another student s post should be completed by Thursday at 5 p.m. of the week that the response exercise is due. EXERCISE 1: DUE SEPTEMBER 20 Topic: If you were assessing the health of a community to determine priorities for disease prevention and health promotion, how would you measure health? What types of data would you want to collect to capture population health status? How would you collect these data? What concerns would you have about your findings on health based on your approach? EXERCISE 2: DUE OCTOBER 18 Topic: Why has health care spending risen dramatically in the U.S. over the past five decades? What are the most promising avenues for increasing value and containing cost growth in health care? EXERCISE 3: DUE NOVEMBER 8 Topic: What are the barriers to informed patient decision-making when selecting providers and determining treatments that are aligned with personal preferences? What changes are necessary to enable patients to engage with the health care system as activated consumers? EXERCISE 4: DUE NOVEMBER 29 Topic: How well does the U.S. health system perform on the dimensions of patient safety and quality of care? Why is measuring quality so challenging, and what are the implications of these challenges for quality improvement? What do you identify as the greatest priorities for achieving a safe, reliable and effective health care delivery system?

11 11 GRADING Final course grades will be calculated as follows: % Final Grade Due Date Paper 1: Memo 30% 10/4 Paper 2: Final Essay 40% 12/13 Response Exercises (3 of 4) 20% 9/20, 10/18, 11/8, 11/29 Class Participation 10% of the final course grade is determined by class participation. Evaluation will be based on student engagement in and constructive contributions to class discussions. Lateness Policy Please submit assignments on time. Assignments are due by 5:00 p.m. of the date due. Late assignments will be penalized by one-half letter grade for each day late.