Sunday, September 26, 2010

What is health policy? Part 2: the art and the science

To make an impact on health policy (and I assume that the reason you are reading this post is that you – eventually- want to influence the policies that affect you and your patients), one must deal with two different but related spheres that I will call the art and the science of policy-making. The art aspect is the political and organizational process for making, changing and implementing policy. It’s a messy process where emotions and alliances usually have more influence than information. The science portion is the rational, analytic approach practiced by the armies of policy analysts that populate think tanks and government policy offices. The science of health policy analysis – with its tools like adjusted quality of life scores and mortality risk adjustment – attempts to professionalize the otherwise very messy political process.

 Of course, the two categories are not mutually exclusive.  There is art to the science of policy analysis: how to organize information and arguments, what options to analyze. And there is science to the art:  the entire field of “Political Science.” My own practice of the art has been instinctual and uninformed by formal study of political science. Therefore, I’m going to leave an explanation of the political process to others. In this post, I’m going to try to give you a feel for the science side: rational policy analysis methods.

One guide to policy analysis that I like very much is A Practical Guide for Policy Analysis: The Eightfold Path to More Effective Problem Solving by Eugene Bardach.[1] (Nowhere in the book did I see an explanation of the title’s allusion to Buddhism’s eightfold path, but I would be surprised if it were merely a coincidental reference.) Although this guide is not specific to health policy, its common sense approach and readable style makes it a quick and useful read. 

Bardach’s 8 step method is:
§  Define the problem
§  Assemble some evidence
§  Construct the alternatives
§  Select the criteria
§  Project the outcomes
§  Confront the trade-offs
§  Decide!
§  Tell your story

These steps are common sense, but Bardach’s explanations of how to work with them is sophisticated, practical, and at least for me as a policy wonk, fun to read. He gives an array of pointers about how to conduct each of these steps in the most artful way. For instance, regarding defining the problem, he warns about the common mistake of defining a solution right into the problem statement:
Don’t say: “New schools are being built too slowly.” Simply assuming that “more schools” is the solution may inhibit you from thinking about ways to use existing facilities more efficiently.  Try instead: “There are too many schoolchildren relative to the currently available classroom space.”

Some people despair that the rational, analytic, and evidence-based realm doesn’t exert much influence on the political process. In our own field, the classic example is the Medicare Hospice Benefit. Congress passed the enabling legislation in 1982 without bothering to wait for the results of the hospice demonstration project, which had been expressly designed to determine whether a hospice benefit was useful and how best to shape it. After the law was passed, Vince Mor and the other social scientists working on the evaluation of the hospice demonstration were able to feed preliminary information from the demonstration to the regulators as they shaped the details of the Medicare hospice regulations. [2] Should congress have waited? Would we have the hospice benefit (with its strengths and its flaws) that we have today if they had?

I am a realist about this. The political aspect of policy-making proceeds at its own pace, usually without slowing to wait for the results from years-long and careful demonstrations.  (Does anyone REALLY know at this point whether medical homes or accountable care organizations work? They are in the health reform legislation anyway.)

Even though rational analysis does not usually have the upper hand in how health policy is determined, I think it nevertheless plays an essential role. It is like the rudder of a sailboat. In calm seas with favorable winds, the rudder sets the course. However, in stormy seas, strong winds and waves may work against the course set by the rudder. Even so, it is far better to have the rudder’s steadying effect than to sail without it.

I conclude with Dr. Bardach’s sage words about the relevant contribution to be made through rational, insightful policy analysis:

Finally, just as policy analysis originates in politics, so it concludes in politics.  Political life has two sides: channeling conflict and building community.  Policy analysis serves both sides.  It channels conflict by showing that some arguments, and their proponents, are in some sense superior to others and deserve to win out. But it helps to build community by marking off potential common ground as well. This common ground Is defined by the rules and conventions of rational discourse- - where opponents may employ analytical procedures to resolve disagreements, or where they may discover that at least some seemingly irreducible values conflicts can be recast as dry-as-dust technical disagreements over how much higher a probability Policy A has than Policy B for mitigating Problem P.

[1]Eugene Bardach.  A practical guide for policy analysis: the eightfold path to more effective problem solving. 3rd ed. Washington, D.C. : CQ Press, 2009.

[2] A Short History of the Medicare Hospice Cap on Total Expenditures

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