HPAM-GP 1830

Introduction to Health Policy and Management

Fall 2018

Instructor and Course Information

Prof. Victor Rodwin

Class meets Tuesdays 4:55-6:35 pm, Silver Center, Room 208

Email: victor.rodwin@nyu.edu

Assistant: christopher.harris@nyu.edu

This Introduction to Health Policy and Management (HPAM) will help you analyze key issues related

to the distribution of health and illness in society, the organization of the healthcare system, and the

relationship of one to the other. In our first session, you will learn about the evolution of the U.S. healthcare

system and the roles of health policy and management (HPAM) and public health in current debates. We will

then go on to view the U.S. healthcare system from a telescope (an international perspective), consider the

relative power of stakeholders in the policymaking process and the roles of government in the health system.

We conclude the introduction to this class with a glimpse into the future by focusing on the evolution of

patient roles, demography and technology. This is the context in which you will find yourselves tackling

problems as your careers evolve.

In the second part of the course, we explore divergent perspectives for analyzing population health

and health care: clinical; epidemiologic; sociological, geographic and cultural; economic; and ethical. We

focus on social determinants of health, racial, ethnic and income disparities among population groups, and

how health policymakers and managers can work collaboratively with leaders in housing, education,

transportation, and other sectors to promote public health.

In the third part, we focus on selected issues that leaders in the field of HPAM will have to confront:

population health and how to improve it; the quality of care (how to measure and assess it); the opioid

epidemic; and the challenge of assuring access to healthcare services while simultaneously rationing them. In

covering these topics, we emphasize the value of understanding diverse disciplinary perspectives, the

challenges of meeting the varied (and often conflicting) needs and motivations of healthcare system

stakeholders, and the ways in which the United States healthcare system differs from those of other

wealthy nations.

2

Class Calendar

Introduction

Date Class Topic

Sept. 4 1 HPAM, Public Health and the Healthcare System

Sept. 11 2 The U.S. Healthcare System Viewed from a Telescope

Sept. 18 3 Stakeholders in the Healthcare Policymaking Process

Sept. 25 4 The Roles of Government in Health Systems and Health Policy

Oct. 2 5 Patients, Technology and the Future of Healthcare Systems

Oct. 9 No Class

Divergent Perspectives on HPAM

Date Class Topic

Oct. 16 6 Clinical

Oct. 23 7 Epidemiologic

Oct. 30 8 Sociological, Geographic and Cultural

Nov. 6 9 Economic

Nov. 13 10 Ethical

Selected Issues in Health Policy and Management

Date Class Topic

Nov. 20 11 Population Health: The Healthcare System and Social Determinants of Health

Nov. 27 12 The Opioid Epidemic

Dec. 4 13 Quality of Health Services

Dec. 11 14 Access and Rationing; and Final Presentations

3

Class Readings Every week, I expect students to read all the assigned articles and/or textbook chapters and view the

films noted on this syllabus. The textbook, edited by Kovner and Knickman, focuses on the organization

and financing of health care delivery in the United States. In addition, there are two books to read (one by J.

Groopman, a physician); the other by Lynne Payer, a medical journalist. Groopman’s book provides a

clinical perspective on health care, often not appreciated by managers and policy analysts. Payer’s book,

however dated, provides an analysis of the less scientific aspects of medicine among selected Western

nations.

Textbook Kovner, A. and Knickman, J., ed. (2015) Health Care Delivery in the United States (11th Edition). New York:

Springer Press.

Additional Books and Journals

I encourage students to browse recent issues of well-respected journals, e.g., American Journal of

Public Health; Journal of the American Medical Association; New England Journal of Medicine; The

Journal of Health Politics, Policy and Law, and Health Affairs. Kovner and Knickman’s book also contains

helpful websites and references.

Groopman, J. How Doctors Think. New York: Mariner (2008).

Payer, L. Medicine and Culture. New York: Henry Holt (1988)

Optional Reading: Reid, T.R. The Healing of America: A Global Quest for Better, Cheaper, and

Fairer Health Care. Penguin (2010).

Course Learning Objectives

This class is designed to improve your ability to:

1. Discuss major controversies in the field of Health Policy & Management (HPAM) and learn to identify and

analyze the positions of major stakeholders in the healthcare system – insurers, providers, producers of

pharmaceuticals and equipment/devices, governments and patients.

2. Assess the strengths and weaknesses of divergent perspectives for analyzing population health and

health care and articulate your own position with respect to major controversies in the field of HPAM.

3. Make arguments that distinguish individual from population and community health needs, particularly

with respect to vulnerable populations.

4. Examine social and behavioral determinants of health and understand how health systems can address

them or collaborate with other actors in a better position to do so.

5. Analyze healthcare policymaking processes and how they rely on a combination of ideas, evidence, and

negotiation with powerful stakeholders who stand to lose or gain from different policies.

6. Apply ethical principles to resource allocation decisions in the health sector.

7. Communicate and interact productively (by listening, speaking and writing) and present convincingly (to

individuals and groups) evidence to support a position on matters of health care with a diverse and

changing industry, work force and citizenry.

4

Learning Assessment Table

Class Topics and Readings

I. INTRODUCTION

Class 1. September 4. HPAM, Public Health and the Healthcare System

Brief history of healthcare system and health policy over 20th century

Views of leaders on HPAM and public health

Required reading

Articles:

1. Brown, L. (2008) The Amazing Noncollapsing U.S. Health Care System — Is Reform Finally at Hand? NEJM. 358, 325-327.

2. Chinitz, D. and Rodwin, V. (2014). On health policy and management (HPAM): mind the theory-policy-practice gap. International J. of Health Policy and Management.3(7), 361-363.

3. Hemenway, D. (2010). Why we don’t spend enough on public health. NEJM 362(18), 1657-1658.

Film: Escape Fire: The Fight to Rescue American Healthcare

Class 2. September 11. The U.S. Healthcare System Viewed from a Telescope

Overview of healthcare financing and organization

Differences among the United States patchwork healthcare system and models of National Health Insurance (NHI) and National Health Service (NHS) systems in other wealthy nations

The role of social and behavioral factors in influencing population health

Program Competency Corresponding Course

Learning Objective Corresponding Assignments

Level of Competency Expected to Be

Achieved via the Assignment (Basic = 1,

Intermediate = 2, Advanced = 3

The ability to assess population and community health needs from a public service perspective

Understand the strengths and weaknesses of divergent perspectives for analyzing population health and health care

Multiple choice quizzes based on relevant required readings and/or research dossier

2 - Intermediate

The ability to examine social and behavioral determinants of health and understand how health systems can address the needs of vulnerable populations

Distinguish individual from community health needs and understand how healthcare systems can address social and behavioral determinants of health

Multiple choice quizzes based on relevant required readings and/or research dossier

2 – Intermediate

The ability to present convincingly to individuals and groups the evidence to support a point of view, position or recommendation

Present an argument, based on relevant concepts and evidence, to your boss and/or managers and policymakers in the health sector

Final Individual and/or Group Presentation

2 – Intermediate

5

Required reading

Articles:

1. Schroeder, S. (2007) We Can Do Better—Improving the Health of the American People. NEJM. 357, 1221-8.

2. Papanicolas, I. Woskie, L. Jha, A. (2018). Health care spending in the United States and other high-income countries. JAMA 319(10), 1024-1029.

Book (Optional):

Reid T.R. (2010). The Healing of America. Chapters 1, 4, 7, and 13

Film: T.R. Reid: Sick Around the World

Class 3. September 18. Stakeholders in the Healthcare Policymaking Process

How is health policy made?

Formal vs. informal processes

The roles of policy analysis, hospitals, insurers, physicians, Big Pharma

Required reading

Articles:

1. Longest, B. (2007). The process of public policymaking: A conceptual model. In Lee PR & Estes, CL. The

nation’s health. Sudbury, MA: Jones & Bartlett

2. Navarro, V. (2007). What is a National Health Policy? International J. of Health Services 37(1), 1-14.

3. Sharfstein, J. (2016). Banishing “Stakeholders.” Milbank Quarterly 94(3), 476-479.

Class 4. September 25. The Roles of Government in Health Systems and Health Policy

Trends and characteristics of government health policy and regulation

What are 3 key roles of government in U.S. health care?

Medicare, Medicaid and other government health programs

Required reading

Textbook:

Chapter 3: Government and Health Insurance: The Policy Promise (Sparer, M. and Thompson, F.)

Articles:

1. Frieden, T. (2013) Government’s Role in Protecting Health and Safety. NEJM 368, 1857-1859.

Film: Michael Moore’s film “Sicko”

Class 5. October 2. Patients, Technology and the Future of Health Systems

Is demography destiny?

Or is technological change our destiny?

How will health care and its organization respond to these changes?

Can/Should the growth of the medical-industrial complex be regulated/contained?

6

Required reading

Articles:

1. Leonhardt, D. (2009) Making Health Care Better. The New York Times 2. Topol, Steinhubl and Torkamani (2015) Digital Medical Tools and Sensors. JAMA (313)4, 353-354. 3. Emmanuel, Z. (2018). Are hospitals obsolete? The New York Times. 4. Iglehart, J. (2015). The expansion of retail clinics – corporate titans vs. organized medicine. NEJM 373

(4), 301-303. 5. Mukherjee, S. (2017). A.I .vs. M.D. The New Yorker, April 3. 6. Obermeyer Z. and Lee, T. (2017). Lost in thought – The limits of the human mind and the future of

medicine. NEJM 377(13), 1209-1211. 7. Nochomovitz, M. and Sharma, R. (2017). Is it time for a new medical specialty? The medical virtualist.

NEJM 319(5), 437-438.

October 9 – No Class

II. DIVERGENT PERSPECTIVES ON HPAM

Class 6. October 16. Clinical

Do doctors and other clinicians think differently than managers and policymakers? How do their units of analysis compare? Decision analysis and differential diagnosis

Required reading

Book:

Groopman, J. How Doctors Think (Introduction, Chapters 1, 2 and 9).

Class 7. October 23. Epidemiologic

How to assess and measure population health status? How are health status and health care related? Descriptive vs. analytic methods

Required reading

Textbook:

Chapter 5: Russo, P. Population Health. In Kovner/Knickman, Health Care Delivery in the United

States

Articles:

1. Banks, J. Marmot, M. Oldfield, Z. and Smith, J. (2006) Disease and Disadvantage in the United

States and England. JAMA. 295(17), 2037-2045.

2. Mokdat et. al. (2004) Actual Causes of Death in the United States. JAMA. 291(10), 1238-1245.

7

Optional Recommended Article

3. Kolata, G. (2015) Death Rates Rising for Middle-Aged White Americans, Study Finds. The New

York Times.

Class 8. October 30. Sociological, Geographic and Cultural

Social and cultural factors affecting health and medical care

Class, income and use of health services

Social systems, health systems, hierarchy and control

Required reading

Book:

Payer, L. Medicine and Culture (Chapters 1-2, pp.15-34; and read two or three of four cases on France,

Germany, Great Britain and United States.

Articles:

1. Fuchs, V. (1974) A Tale of Two States. In Who Shall Live: Health Economics and Social Change. NY: Basic

Books; and update: Rodwin, V. Croce-Galis, M. (2004). Population Health in Utah and Nevada: An

Update on Victor Fuchs’ Tale of Two States. In Conrad, P. ed. Sociology of Health and Illness. NY:

Worth.

2. Isaacs S, Schroeder S.A. (2004) Class — The Ignored Determinant of the Nation’s Health. NEJM. 351, 1137-42.

3. White, K. (1961). The ecology of medical care. NEJM. (doi/pdf/10.1056/NEJM196111022651805) 4. Bradley, E. et. al. (2017).Variations in Health Outcomes: The Role of Spending on Social Services,

Public Health and Health Care. Health Affairs 35(5), 760-768.

Optional:

Green et. al. (2002). The Ecology of Medical Care Revisited. NEJM (344) 26.

Class 9. November 6. Economic

The case for and against markets in the health care sector

Financing, payment and incentives

Examples of health services research

Required reading

Articles:

1. Brooks, D. Do markets work in Health care? New York Times, Jan. 13, 2017 2. Weinstein, M. Kenneth Arrow, Nobel-winning economist whose influence spanned decades, Dies at 95.

The New York Times Feb. 21, 2017. 3. Deaton, A. (2016). On death and money: history, facts and explanations. JAMA 315(16), 1703-1705. 4. Baicker, K and Chandra, A. (2017). Evidence-based health policy. NEJM. 377(25), 2413-2415. 5. Stone, D. (2011). Efficiency. Ch. 3 in Political Paradox and Political Reason. Glenview: Scott Foresman &

Co.

8

Class 10. November 13. Ethical

Concepts in ethical analysis applied to public health

Ethics of health care rationing

Public health vs. medicine, and other dichotomies

Required reading

Articles:

1. Roberts, M. and Reich, M. (2002) Ethical Analysis in Public Health. The Lancet. 359, 1055-1059. 2. Brock, D. (2009). Rationing: why it is ethical. Hastings Center Blog 3. Singer, P. (2009). Why we must ration health care. The New York Times, July 19. 4. White, J. (2009). The limited ethics of rationing: A response to Dan Brock. Hastings Center Blog. 5. Bloche, M. G. (2012) Beyond the “R Word”? Medicine's New Frugality. NEJM, 366(21), 1951-1953. 6. Rosner, D. (2016) Injurious Inequalities. The Milbank Quarterly, 94(1), 47-50.

III. SELECTED ISSUES IN HEALTH POLICY AND MANAGEMENT

Class 11: November 20. Population Health: The Health Care System and Social

Determinants of Health

Approaches to measuring population health

Alternative strategies for improving dimensions of population health

The role of health care organizations in promoting population health

How should policymakers and managers respond to the evidence on social determinants of health?

Required Reading

Articles:

1. Onie et al. (2018) Population health: The ghost aim. NEJM Catalyst. 2. Fuchs, V. (2016) Social determinants of health: Caveats and nuances. JAMA.317 (1), 25-26. 3. Sequist, T. and Taveras, E. (2014) Clinic-community linkages for high-value care. NEJM. 371 (23), 2148-

2150. 4. Adler, N, Glymour, MM, Fielding, J. (2016). Addressing social determinants of health and health

inequalities. JAMA 316(16),1641-1642. 5. Marmot, M. (2006). Status syndrome. JAMA 295(11), 1304-1311. 6. McGinnis, J. M. (2016) Income, Life Expectancy, and Community Health. JAMA, 315(16), 1709.

Film: Rebecca Onie Ted Talk:

Class 12. November 27: Quality of Health Services

Do variations in medical practice matter?

Structures, processes, outcomes and CQI

The role of patients and consumerism in the health sector

9

Required Reading

Articles:

1. Huckman, R. S., & Kelley, M.A. (2013) Public Reporting, Consumerism, and Patient Empowerment. NEJM, 369(20), 1875-1877.

2. Wennberg, J. Hospital Use and Mortality Among Medicare Beneficiaries in Boston and New Haven. NEJM 321(17), 1168-1173.

3. Berwick, D. (1989) Continuous improvement as an ideal in health care. NEJM 320(1), 53-56. 4. Blumenthal D. and McGinnis, JM (2015) Measuring vital signs: An IOM report on core metrics for health

and health care progress. JAMA. 313(19) 1901-1902.

Film: Dr. Don Berwick, Youtube, My Right Knee:

Class 13: December 4. The Opioid Epidemic

Supply-side forces

Demand, need, induced demand

Regulatory challenges

Required Reading

Articles:

1. Humphreys, K et al. (2018). Opioids of the masses: stopping an American epidemic from going global. Foreign Affairs. 97(3), 118-129.

2. U.S. Senate Homeland Security & Governmental Affairs Committee (2018). Fueling an epidemic. 3. Barnett, M et al. (2017). Coupling policymaking with evaluation– The case of the opioid crisis. NEJM. 377

(24), 2306. 4. Frieden, T and Houry, D. (2016). Reducing the risks of relief – The CDD opioid-prescription guideline.

NEJM. 374, 1501-1504.

Class 14. December 11. Access and Rationing; and Final Presentations

Measures of access to health care

Are there health systems that don’t ration health care?

Prices, cost-effectiveness, medical utility in access to pharmaceuticals

Required reading

Articles:

1. DeAngelis, C. (2016). Big pharma profits and public losses. Milbank Quarterly. 94(1), 30-33. 2. Cohn, J. 2016. The drug price controversy nobody notices. Milbank Quarterly. 94(2), 260-263. 3. Fink, S. (2016) Drug shortages forcing hard decisions on rationing treatments. The New York Times.

10

Course Requirements and Grading

There are several graded components to the course for which you will be responsible, but the main

requirement is to encourage collaboration through group assignments and discussions. The purpose of your

individual and collaborative work is to help you gain a better understanding of HPAM. You will work in small

groups (never more than 3) throughout the course in preparing for short class presentations. In this context

you will face challenges from your fellow student colleagues, and share your thoughts with the class in our

weekly sessions. In addition to attending and participating in class meetings, all students are

required to complete 10 short multiple choice quizzes based on the assigned readings. In the third part of

the course, you will begin conducting your own documentary research with two objectives: 1) dig deeper

into one of the health policy issues covered in this part of the course; and 2) illustrate the strengths and

limitations of the divergent perspectives introduced in the second part of the course.

Here is a breakdown of how you will be assessed in this course:

1. Position Papers (1 page). Ten assignments posted on Class Forum (2% each for 20% of grade)

These assignments may be completed individually or by groups of 2 or 3 students. They are 1 page

summary answers to questions posed about your views/reactions to the assigned readings each week

beginning for the second class. These questions will be posted after our first session. Your responses

should be posted 24 hours before each class meeting in the appropriate forum on NYU Classes.

2. Group and/or Individual Project - 40% (10% each part) 1. Part 1: 1 page concept paper- Due on October 9 even though there is no class session

2. Part 2: Appendix due at class #8 – Due on October 30

3. Part 3: Powerpoint Presentation. Due 24 hours before you (or your group) make 5 min

presentation in class.

4. Part 4: Summary of what you learned. Due within a week of your oral presentation

3. Final posting of revised Group and/or individual Project - 5% (with revised versions, if necessary, of previous parts) - Due on Dec. 18.

4. Quizzes - 25%. These short, multiple choice, open book quizzes are taken in NYU Classes. 5. Class participation - 10%

Final grades will be calculated according to the percentages noted above. These assignments are designed

to assess understanding of course readings and progress against the course competencies noted on pp.

3-4 of the syllabus, and no student will receive a B or higher without demonstration of satisfactory

progress toward the mastery of each competency.

Lateness Policy – Please submit written assignments on time. Late assignments will be penalized by one-

half letter grade for each day late.

Class Participation – Participation performance is assessed based on preparation, engagement and quality

of contributions to in-class discussion and group work. Please do not use cell phones or go online during

class for matters other than the class discussion. We all have our reasons to miss class, on occasion. If you

cannot make it to class, there is no need to write me an e-mail explaining why.

11

Plagiarism Policy: Academic integrity is crucial to the mission of NYU Wagner. Plagiarism of any form will

not be tolerated since you have all signed an Academic Oath at NYU/Wagner and are bound by the

academic code of the school. Please review the NYU policy on plagiarism (posted on NYU Classes) prior to

submitting written work.

Guidelines for Class Assignments

General Instructions: All written assignments should be submitted in Times New Roman 12-point font,

double-spaced, with one-inch page margins. Write in full paragraphs, in the first person, and active voice

(see Strunk and White, Elements of Style, and buy yourself a copy as it will serve as the basic guide to good

writing in this class). No lists (it’s boring!). No titles of books and full authors’ names in the text (use

endnotes or footnotes or references for this). No Latin and bureaucratic writing (e.g. “as per your

request”)! Use subheadings for clarity. Please use verbs, avoid gerunds and unnecessary adverbs (e.g.

“interestingly”) and adjectives (like “very”). Be concise (when in doubt, strike it out!). Please review your

short papers and rewrite them at least twice before posting for all of us to read. Please see NYU/Wagner’s

resources for writing workshops and assistance. None of us can fail to benefit from such assistance!

Please post all written assignments on class forums to the appropriate forums set up on NYU Classes for

this course and submit two printed copies of your essays to instructor in class, as well There are three

reasons for posting all written assignments on class forum. First, because the audience to whom you should

address your papers is: the rest of us. Second, because the purpose of these assignments is to improve

communication skills and get to know one another. Third, because another purpose of these assignments is

to convince the class of your point of view.

Group or Individual Project: For presentations during sessions 10 to 14, you may either complete

the following four-part exercise as an individual or as a group of no more than 3 students (maximum). You

should address a problem related to one of the policy issues covered in Part II of the syllabus. The goal is to

prepare a research dossier that would be useful for your boss.

1. Part 1: write a one-page concept paper in which you present the specific problem related to the

policy issue you have chosen and why you think it is important.

2. Part 2: Create an Appendix on the topic you have identified. It should contain 3 of the best

refereed journal articles you have found. Highlight the most important sections you would want

your boss to read. Also attach any relevant blogs, trade journals or newspaper articles. The

Appendix can also include any charts or tables you think would be helpful to your boss.

3. Part 3: Prepare a short PowerPoint presentation (no more than 5 slides) summarizing parts 1

and 2 and use as a basis for your class presentation (no more than 4 minutes).

4. Part 4: Write a 2 page paper in which you present what you learned from this exercise and all

the materials you have provided for your boss. When relevant cite required readings from class

so that there is no need to summarize their main points.

12

Criteria for Grading Position Papers and other Writing

Element and Evaluation Criteria:

A. EXCELLENT B. GOOD C. BELOW STANDARDS

NOT ACCEPTABLE

DOES PAPER

ADDRESS

QUESTION?

Yes, precisely and has a good title

More or less No Not clear to whom paper is addressed or why it is written!

ARGUMENT OR THESIS

Strong and specific argument easily identifiable

Coherent, but no clear argument or main point

Not clear, wanders in too many directions.

No identifiable argument.

ARGUMENT OR THESIS, CONT.

Major points and citations in form of end-notes reinforce the argument throughout the piece.

Most points reinforce the argument throughout the piece

Some points reinforce the argument, but many fail to reinforce or relate to the argument

Individual points lack cohesion and fail to express a clear idea

ORGANIZATION AND STRUCTURE

Effective use of formal structure such as subheadings, a strong introductory paragraph and conclusion

Mostly effective use of formal structure. Subheadings could be more descriptive or formatting could be improved

Ideas difficult to follow

ORGANIZATION AND STRUCTURE, CONT.

Thoughts follow a clear internal logic reinforced by the formal structure

Thoughts mostly follow an internal logic reinforced by the formal structure

Lack of internal logic. Unclear formal structure

Completely illogical

ORGANIZATION AND STRUCTURE, CONT.

Overall structure is strong and contributes to effectiveness and clarity

Overall structure is acceptable.

Overall structure distracts from the meaning of the piece

Unstructured, disorganized

13

A. EXCELLENT B. GOOD C. BELOW STANDARDS

NOT ACCEPTABLE

WORD CHOICE

Use of terminology is correct in all instances. Dead and tired clichés and metaphors are avoided. Adverbs were avoided along with all unnecessary words, e.g. “very”!

Occasional use of inappropriate jargon, acronyms or imprecise terms. Minimal usage of dead and tired clichés and metaphors.

Many mistakes in terminology. Frequent use of dead and tired clichés and metaphors

Imprecise terminology and heavy usage of jargon and acronyms

WORD CHOICE, CONT.

Strong use of simple, precise and effective language easily read and understood by intended and potential audiences

Minor issues with wordiness, repetition. Easily understood by intended audience, but perhaps not by other potential audiences.

Some issues with wordiness and repetition. Mostly understandable to intended audience.

Wordy and repetitive

GRAMMAR Few if any grammatical errors. Any errors do not affect meaning

Minor errors cause momentary distraction for readers.

Errors do not cause the writing to be unclear, but weaken the effectiveness of the communication

Systemic errors that make the writing difficult to read.

ACADEMIC CONVENTION

Assigned readings to support points made are appropriate and properly cited

Some missing citations or a few improperly cited sources.

Research is inconsistently cited. Un-cited facts, figures and passages bring about questions of plagiarism in reader’s mind

No citations. Clear violations of rules of plagiarism