Sunday, September 26, 2010

What is health policy? Part 1: The view from the mountaintop

A Perfect Morning at Glacier National Park
Photo by Flickr user: Trey Ratcliff
**Editor's Note: We would like to welcome Dale Lupu to the growing number of Pallimed bloggers.  Dale has considerable experience in working with palliative medicine professionals.  Dale will be working on an occasional series of posts to help all of us learn why health policy matters to all of us. Please welcome Dale warmly!**

This inaugural post in a new Pallimed series on health policy for palliative care groupies has taken longer to write than I expected. Why? I expected to start in the clich├ęd manner: by defining the term “health policy.” But I was stopped short when I could not find a definition for health policy. The websites, textbooks and articles that I consulted all take for granted that we know health policy when we see it. Many sources discuss topics covered under health policy (such as access, quality, financing, delivery systems, workforce), but none that I could find offered what I considered a useful, concise definition that set clear boundaries for the field.

Since it is impossible to prove the negative, and feeling very uncertain about the thoroughness of my research (maybe I had just missed some great definition out there that EVERYBODY but me knows about), I consulted with Dr. Gerard Anderson, my professor from doctoral student days in health policy and management at Johns Hopkins School of Public Health. Gerry confirmed in an email, “there is no uniformly agreed upon definition.” There you have it. So I am left to my own devices in trying to paint for you readers the major concerns, techniques, and boundaries of the field of health policy.

So what is health policy?  For me, a key defining aspect of health policy is that it takes a 30,000 foot view of the health of a population and of the systemic factors (political systems, health financing, cultural norms) that contribute or detract from a population’s health. Contrast this to the clinical view, which put the needs and concerns of a particular individual (and possibly that individual’s family) first and foremost.

Rosa Passione
Photo by Flick user Bruno C
To compare the clinician’s usual view with the health policy view, consider looking at a garden. One can look up close at a single rose bush in the garden and work on pruning it, fertilizing it, removing pests, watering it. This is the clinical view.  In contrast, the health policy view is like an aerial view of the garden that reveals the overall plan for the whole. Taking this big view, one can see if there is an irrigation system for the entire garden, if the rose bed is in a sunny enough site, or if retaining walls are sited appropriately to stop soil erosion. In this “policy level” view, the health of one particular rose bush is not the focus of concern, and may even be obscured.

A second defining aspect of health policy is the “policy” part – the general rules (often expressed in laws and regulations at the governmental level) that are used to guide organizational and system behavior, particularly allocation of resources. Although we may be able to read the words of the laws and regulations, it can often be difficult to understand the policy goal and the policy assumptions that motivated them. In the words of Eugene Bardach (more on his policy analysis guide in the next post):

In real life, policy problems appear as a confusing welter of details: personalities, interest groups, rhetorical demands, budget figures, legal rules and interpretations, bureaucratic routines, citizen attitudes, and so on. ..You therefore need to learn to “see” the analytic concepts in the concrete manifestations of everyday life.[1]

To get a feel for the types of questions and the approaches to analysis that are typical of the health policy world, I suggest you explore these notable sites that track and digest health policy issues:

§  The Henry J. Kaiser Family Foundation (not associated with Kaiser Foundation of managed health care fame) is widely respected for its analysis and reporting on health policy issues. In particular, they are a source for cogent and succinct summaries explaining Medicare issues. Although they have a big focus on chronic care and on disparities between different subpopulations, Kaiser has yet to do much work on palliative care or hospice issues.

§  The Englelberg Center For Health Care Reform at the Brookings Institute does its own research as well as presenting analysis of others’  research.

§  While there are several journals that cover health policy in the US and internationally, Health Affairs is the preeminent source. They have covered palliative care and hospice sporadically in the past, but seem to be paying closer attention recently.  The January 2010 issue carried several coordinated articles addressing policy issues about delivery, quality and financing of palliative care in the nursing home setting.

§  Finally, a personal favorite of mine is a website that serves as a portal to a host of information sources, US Health Policy Gateway.  This is a good starting point when you are looking for information. It’s thin on the palliative care info, and hit or miss in some other areas, but its simple, straight-forward presentation makes it an excellent starting point.

My goal in this column and those to come is to give my palliative care clinical colleagues an introduction to health policy as it impacts palliative and hospice care. In the coming months I will cover analysis methods, data sources, issues, governmental and non-governmental players, all with a focus on their relevance to palliative and hospice care.  I am planning to write about the standard format for a health policy analysis, large scale data sources that are used to understand palliative care, options for financing and promoting palliative care in the long-term care setting, and the mysterious “U-shaped curve” that Medpac proposes for hospice reimbursement reform. If you have other topics you would like me to cover,  please leave a suggestion!

[1] A practical guide for policy analysis : the eightfold path to more effective problem solving.  3rd edition. Eugene Bardach. Washington, D.C. : CQ Press, c2009.

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