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.

Sunday, September 26, 2010 by Dale Lupu, PhD ·

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

by Dale Lupu, PhD ·

Let's Talk about Sex

I thought I would post on what I hope will turn out to be an occasional series on sexuality here on Pallimed. We've covered sexuality some before. A post that leaps to mind is one by Christian in 2007 about the controversy that arose over a case where the staff at the world's first hospice designed specifically for young adults openly deliberated and decided to facilitate a 22-year-old patient's request to have sex before he died.


Read more »

by Brian McMichael, M.D. ·

Tuesday, September 21, 2010

Grand Rounds Vol 6.52 The Last Edition

Seattle and Vancouver
Photo by Joan Robinson RN CHPN
Seattle WA
(from the Pallimed Photo Project)
I am not sure if Nick Genes (@blogborygmi) realized this when he approached me about a date to host, but this is the last edition of Grand Rounds for Volume 6.  A hospice blog as final chapter to a great year of medical blogging, there are things in life that are more serendipitous than this of course.  But of course here at Pallimed (@pallimed), we do cover things beyond just the last few days of life. So feel free to take a look at our 1,000 other posts.

On to the best of the medical blogosphere!  No themes here but I did ask (like GruntDoc) to include a post of  other than your submission to help broaden our reach this week.


Quilter and occasional surgeon Ramona Bates (@rlbates) goes altruistic and recommends SanDiegoNavyDoc (@SanDiegoNavyDoc) and his post "They Call Me Doc..." about all the different people that live inside him.  How many different people are inside of you?  She also highlights the always respectful Bruce Campbell 'writing about when patients feel you are giving up on them.'

One of my new favorite blogs to read is The Neurocritic, who I stumbled upon with the recent review of the NEJM Pallaitive Care article and how it can help debunk 'death panel' myths. Read to the very end for why this post is so important to The Neurocritic.

Michelle Wood shares with us a realistic look at the medical uses of the iPad from FutureDocs (@FutureDocs) Vineet Arora "Attending Rounds with the iPad: Hype or Hinderance." I just don't know if I want to buy two iPad's one for isolation rooms and one for non-isolation rooms.

Tony Chen shares a post by Nick Jacobs from the very new American Board of Integrative Holistic Medicine blog "When Healing and Science Converge."  This blog has only been around for a couple of months, let's hope they stick with it.

MD from A Medical Resident's Journey writes about the recent WSJ piece on White Coat Ceremonies.  Is empathy teachable?  And bonus sharing with a post from Dr. Wes (@doctorwes) on the same topic, "On Humanizing Medicine."

Doctor Fizzy submits a post from next week's host Dr. Grumpy on the idiocy of e-prescribing. And probably the best new blog I have seen in recent months Doctor Fizzy's own 'A Cartoon Guide to Becoming a Doctor.'  I really did enjoy the cartoon descriptions of a headache.

Dr. Rich (@DrRich1) at The Covert Rationing Blog discussed the upcoming Guideline Wars with health reform with the cleverly titled but imaginary SYNTAX trial. Dr Rich also kindly introduced me to The Road to Hellth (by Dr. Perednia) with a post about when a doctor tells his patient how the medical system looks from a doctor's point of view.

Jill of All Trades shares three great blogs that should get more attention, while submitting none of her own.  She would be popular in my kids pre-school class with sharing skills like that! Here they are:
  • Dr. Synonmous, a family practice doc, no relation to Dr. Anonymous that I can tell.
  • Lockupdoc, (@lockupdoc) a psychiatrist in corrections
  • And this was her blog post of note from WhiteCoat's Callroom: What's Fair? about writing prescriptions for OTC medicines in the ED.
How to Cope with Pain shares how some may find meaning in their pain with an Chinese tale. And just for a little light heartedness, a post from 1000 Awesome Things was shared.

Conflict with your doctor? Just switch, everyone is doing it.  Ryan Dubosar blogs at ACP Internist (@ACPInternist) about research showing patients avoid confrontation with doctors.  And Ryan was so nice he shared twice: Toni Brayer and gradydoctor.  Gradydoctor writes so well, especially in this post about dealing with crying and grief in the medical world which was a nice segue into Toni Brayer's post about the importance of touch in medicine.

Apparently Somatosphere (@Somatosphere) and blogger Kalman Applbaum are not afraid of Big Bad Pharma or the backlash from 'complicit doctors' as he reviews the book "White Coat, Black Hat  Adventures on the Dark Side of Medicine."

Ken Covinsky writes at GeriPal about Humility in medicne, something that should be talked about more often.  By the way GeriPal (@GeriPalBlog) is an excellent team geriatrics/palliative care blog if you have not seen it already.

Maria Gifford at Better Health interviews Thomas Goetz about his recent book on personalized medicine and more importantly how to make good medical decisions.  Maria also wanted to share a guest blog post from Gary Schwitzer's blog Health News Review about the future of breast and ovarian cancer guidance for women with BRCA mutations.

Elaine Schattner blogs at Medical Lessons (@MedicalLessons) a classic post about how checklists (a la Gawande) may change the culture of medicine. If you ever wondered if you needed more 'poka-yoke' read this post.  Elaine also submitted a blog post from MD Whistleblower (@MDWhistleblower) (aka Dr. Michael Kirsch - he outed himself, I didn't blow any whistles!), titled Evidence-Based Medicine in Disguise: Beware the Surrogate because 'with so much emphasis and real need for greater EBM (evidence-based medicine), we should be aware of its limitations.'

John Schumann at the blog Glass Hospital (such creative names we bloggers have!) gives us a great glimpse into the skill of listening with this post Doctor Yenta. An excerpt:

As an internist, I’m trained to do things:
I listen.  I ask.
I examine, order, and test.
And then I assess.
I certainly try to treat.  All too often, this includesprescribing.
What frequently gets lost in this paradigm is that on many occasions, the listening part is often enough.
John also shares Bob Wachter's Doc on a Plane stories. Honestly we medical bloggers should get together to write a book about doctor/nurse on a plane stories.  They are always so entertaining.

Bongi at other things amanzi shares the next best stories after doctor on a plane stories, urology stories.  Bongi shares the creativity that surgeons can show when faced with a challenging problem when bullets and bladders intersect.

Laika (aka @laikas) shows how other blogs can inspire you to write.  After seeing Musings of a Dinosaur and  db's Medical Rants talk about why orthostatic vital signs should not always be considered scut work. This reminded Laika of a story about PCR and chromosome analysis.  Funny how our brains work sometimes!

Thanks so much for reading this week and thanks again to Nick Genes for organizing Grand Rounds.  Check out next week's host Dr. Grumpy and submit your posts early.

Keep In Touch With Grand Rounds:
Follow us on Twitter @grandrounds
Join our Facebook fan page
Subscribe to our RSS
See our Google Calendar for upcoming and past hosts.

Tuesday, September 21, 2010 by Christian Sinclair ·

Wednesday, September 15, 2010

Feeling Millennial - Our 1000th Post

This is our 1000th post!  Christian posted an absolutely fantastic 5 year anniversary post, including a summary and history of Pallimed, back on June 7th:  highly recommended, and I'm not going to recapitulate his summary here.   I still have a hard time believing this thing I began noodling around with as a graduating internal medicine resident in 2005 has become what Pallimed is today.  I have my collaborators to thank for that, particularly Christian, who is absolutely responsible for keeping our blog alive, and evolving, and expanding.  Thank you my friend.

I've been toying around with an idea for a lighter post the last few months, particularly with the new fresh fellow season which is upon us, and thought our 1000th post was a good opportunity to do this.  I've been thinking about this lately with the new fellows, because I've been finding myself saying these things over and over, as I do every year, as I talk with trainees about this wonderful thing we do called palliative care.

So here they are - pearls for successful palliative care consultation (in no particular order).  I make no claims that any of these are original to me even if I've lost track of where they came from.  Feel free to claim them for yourself in the comments.  Few of these, particularly the ones I came up with, are aphoristic - if any of you can aphorize them please do so, in the comments.  If we get some good additions we may try to find a more permanent home to our collected wisdom.
  1. Assume nothing, ever. 
  2. Always talk to the team first.
  3. Respond to emotion with emotion. 
  4. 75% of what we do is showing up and shutting up.  
  5. Tame the beast inside who just wants to talk, talk, talk.
  6. Don't just do something, stand there.
  7. Acute symptoms = acute meds.  (That is - don't jack around with long-acting/continuous meds for out of control symptoms without first actually making someone comfortable with bolus/immediate-acting meds.)  This is a variation of the idea behind:
  8. NO DRIPS 'TITRATED FOR COMFORT.'
  9. 'Good work' describes a process, not an outcome.
  10. Palliative care is just good medicine.
  11. And what is their bowel regimen?
  12. What is their narrative?
  13. Just because someone has less than 6 months to live doesn't mean hospice is right for them. 
  14. You should worry more about your patients who want to die, and less about those who are desperate to live.
  15. It's not about you.  (This is in reference to patients' and families' emotions.)
My absolute all time favorite, which was told to me I think by David Weissman, who was quoting a former oncology fellow of his:

    16.  You can't shine shit.

Please add your own. 

Thanks for reading, thanks for sharing Pallimed with your friends and colleagues, and thanks for commenting.

(Image from here, via Google image search.  Could not identify any copyright information.)

    Wednesday, September 15, 2010 by Drew Rosielle MD ·

    Pallimed Hosting Grand Rounds Next Week

    On the eve of our 1,000th post (this is #999) Pallimed is very excited to be hosting Grand Rounds for the fourth time (find previous editions here: 2007, 2008, 2009).  There will be no particular theme assigned this week, but I will be adding a little wrinkle to the submission process: If you submit one of your own blog posts you also have to submit a recent blog post from another blogger.    Help me find the BEST in medical blogs out there!

    I will be looking around myself and finding a few selections of my own as well.  Email your submissions to ctsinclair@gmail.com with "Grand Rounds" in the subject header. Deadline for submissions will be 5pm CT on Sunday September 19th.  Please be sure to include why you think your submissions should be included in the BEST of the blogosphere.  You could also tweet me any of your links this week to @ctsinclair with the tag #gr Fair warning: Not all submissions will be included in the final post.  I will be looking at your other blog posts too and if I find something better on your blog I might choose that one instead.

    by Christian Sinclair ·

    Monday, September 13, 2010

    Advance care planning sanity

    Annals of Internal Medicine recently had a timely discussion of advance care planning, trying to focus the discussion away from helping patients specify what what they'd want, and more towards laying the groundwork for appropriate decision making by loved ones whenever that time comes.  Good one for the teaching file.

    That is, instead of thinking of ACP as patients pre-specifying 'If X happens, then I want Y,' thinking about it more as helping patients and their loved ones prepare for the decisions they'll be faced when the time comes - e.g. helping them think about 'EOL' decision-making, about what are acceptable outcomes of therapy, etc.  My own drastic condensation of what they propose is focusing the planning on outcomes as opposed to specific individual therapies.  E.g. less 'No feeding tubes' and more helping prepare loved ones to think about the medical decisions they may be faced with in light of what an acceptable outcome, 'quality of life' would be, etc.

    Read more »

    Monday, September 13, 2010 by Drew Rosielle MD ·

    I'm the friendly person who'll stick you on a treadmill and refer you for qigong.

    The 'palliative care extends life in NSCLCA trial' has made its way to broadcast nightly news (see embed below).    It's an interesting couple minutes, and while very positive about palliative care, I'm curious as to others' reactions to this.  Watch it - you'll see what I mean.   The patient, a middle-aged man with advanced lung cancer who is clearly living with his cancer with as much dignity and vitality as could be imagined, is also the healthiest appearing advanced lung cancer patient I've seen in a while; much of the stock footage seems to take place on a pulmonary rehab unit (e.g. on the treadmill) (?);  the palliative care clinician is called a 'guide'; and alternative medicine interventions are given as much airtime as anything else.  It sorta de-medicalizes what we do, and if I had no clue what palliative care was I'd think it was some sort of friendly person who stuck you on a treadmill and referred you for qigong.   It's kind of like watching one of those Zyprexa ads where you see that attractive middle-aged woman leading this meaning-filled, poignant life full of family and work and you say to yourself 'Gee I wish I felt like that & I don't even have bipolar disorder.'  Such are the growing pains of fame for our field, I guess.

    That aside - the piece focuses as much, or more, on quality of life and symptom improvement than the mortality benefit, and, per my post about the paper, I can't see how this is anything but a net boon to our patients and access to us.

    Our blog contributor Brian McMichael alerted us to this - thanks Brian!

    (Late edit - read Brian's comments for links to related interviews.)


    by Drew Rosielle MD ·

    Tuesday, September 7, 2010

    RCT of Oxygen vs. Room Air (Delivered by a Concentrator)

    Drawing of a nasal cannula from Wikimedia Commons
    It's a common assumption amongst both the general population as well as medical professionals that breathlessness equals some problem with oxygen delivery, and therefore, every patient with dyspnea should have at least a little bit of oxygen delivered through a nasal cannula regardless of their oxygen saturation (sometimes endlessly).  Because of the ubiquitous nature of oxygen therapy, why not?  It helps many patients, and it makes sense that the higher concentration of O2 molecules represents the critical component of the therapy.  It's been shown to palliate dyspnea, improve functional status, and prolong life in patients with COPD with hypoxemia. 
    Hypoxia isn't always the cause of dyspnea, however, and Abernethy et al. set out to test the hypothesis that room air delivered by a concentrator at 2 liters per minute might rival the efficacy of oxygen delivered at the same rate for patients with advanced disease, refractory dyspnea, and normal blood oxygen concentrations (Pa02 >55 mmHg).  The results of the double-blind, randomized control trial were published in Lancet recently. 

    Read more »

    Tuesday, September 7, 2010 by Lyle Fettig, MD ·

    Palliative Care Grand Rounds up at AAHPM Blog

    cartoon from www.weblogcartoons.com

    In case you were missing the latest edition of the best writing in the Hospice and Palliative Care blogosphere, you can hop on over to the AAHPM blog and find a smorgasbord of links to keep your brain satiated until the Fall TV premieres begin.  I know Drew can't wait for Glee to start. (That is not true I just made that up. Or maybe it is true. I doubt it. End internal conversation.)

    Check it out and go give some comment love to all the writers out there giving their all.  Don't forget to spread the good stuff to your IDT, as well as on Facebook, Twitter or LinkedIn if you find something you really enjoyed.

    And if you get to the end and click on the Geripal link, I guarantee you will laugh and anyone who doesn't live and breathe palliation and communication will not get the joke.  Everyone loves an inside joke; unless they don't get it.



    Cartoon by Dave Walker. Find more cartoons you can freely re-use on your blog at We Blog Cartoons.

    by Christian Sinclair ·

    Hospice and Palliative Medicine Tweetchat Reminder

    (Note for our email subscribers you may want to go to the actual post to see all the embedded media best.)
    For those of you who missed the announcement back in July, hospice and palliative medicine has enough people on Twitter that we started having a weekly Tweetchat every Wednesday night at 9p ET/6p PT.  We have had good turnout and support from a lot of people who think what we do is very important.  If you that last sentence confused you just watch this for a quick tutorial (over 1200 views on Slideshare so far):

    Read more »

    by Christian Sinclair ·