HPAM-GP 2836 Current Issues in Health Policy

Fall 2018

Instructor Information● Professor John Billings● Email: john.billings@nyu.edu ● Phone: (212-998-7455) ● Office Hours: By appointment ● Office Address: 295 Lafayette Street – 2nd Floor

Course Information Class Meeting Times: 9:00AM – 4:30PM Class Location:

‒ 9/7/18 - Room 365 - Global Center for Academic and Spiritual Life‒ 9/21/18 - Room 365 - Global Center for Academic and Spiritual Life‒ 10/5/18 - Room 566A - Waverly Building‒ 10/19/18 - Room 365 - Global Center for Academic and Spiritual Life

Course DescriptionThis course is an introduction to major health policy issues and examines the role of government in the health care system. An important focus of the course is an assessment of the role of policy analysis in the formation and implementation of national and local health policy. Because much of government health policy relates to or is implemented through payment systems, several sessions involve some discussion of the policy implications of how government pays for care, with a more detailed review of the economics of payment systems available in Health Economics: Principles (HPAM-GP4830). The role of the legal system with respect to adverse medical outcomes, economic rights, and individual rights is also discussed. Proposals for health policy reform at the national and local level are examined throughout the course, as well as Medicare and Medicaid reforms currently being implemented or considered.In an effort to accommodate a subset of students with scheduling challenges, this class will be held in four all-day Friday marathons on September 7th, September 21st, October 5th, and October 19th. There will be a morning and afternoon session on each of these days, with a

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lunch break between sessions and a brief break during the morning and afternoon sessions. This is a continuing experiment, and I have attempted to adapt the content of course to make these sessions less gruelling, but expect we may make some changes along the way.

Course Learning ObjectivesStudents completing this course should have an understanding of:

The role of government at all levels in health care and its limitations; How health care “system” is organized (or not) and the implications for health policy; How health care is financed (where the money comes from) and the implication for

health policy; How health providers are paid and the implications for controlling costs and managing

care; Variation in medical practice, its causes, and the implications for payment policy and

cost issues; How the Medicare and Medicaid programs work and issues for reform; The challenges of disparities in health care, their causes, and opportunities for reform; The challenges of rising health care costs and opportunities for reform; Issues related to the uninsured and responses at the federal, state, and local level

including the Affordable Care Act; Policy issues concerning the pharmaceutical industry; Medical errors and malpractice and opportunities for reform; and How to involve patients in medical decision-making, including end-of-life care and choice

of treatment alternatives; How to present data to policy makers and managers to effectively inform policy

decisions.

Learning Assessment Table

Program CompetencyCorresponding

Course Learning Objective

Corresponding Assignment Title

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

Variation in medical practice, its causes, and the implications for payment policy and cost issues;The challenges of disparities in health care, their causes, and opportunities for reform

Dartmouth Atlas memoClass discussion on disparities and the uninsured

3 - Advanced

The ability to examine social and behavioral

The challenges of disparities in health

Class discussion on disparities and the 3 – Advanced

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Program CompetencyCorresponding

Course Learning Objective

Corresponding Assignment Title

Level of Competency Expected to Be

Achieved via the Assignment (Basic = 1, Intermediate = 2,

Advanced = 3

determinants of health and understand how health systems can address the needs of vulnerable populations

care, their causes, and opportunities for reform;Issues related to the uninsured and responses at the federal, state, and local level including the Affordable Care Act

uninsured

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

How to present data to policy makers and managers to effectively inform policy decisions

Assignment 2 - PowerPoint Presentation on the Dartmouth Atlas Memo

2 – Intermediate

Course Requirements/GradingThere are three assignments are required for the course: two papers (one ≤ 8 pages and one ≤ 6 pages) and a PowerPoint slide assignment based on the first paper. These assignments account for 85% of the final grade (35% paper 1, 25% paper 2, 25% PowerPoint assignment). Class discussion/debate and discussion group participation are integral to the course and will account for 15% of the final grade. Papers/assignments can be submitted in class or via NYU Classes File Exchange. There is no midterm or final exam.

Students are expected to have studied the assigned readings. The readings for the course are primarily journal articles that will be posted in the Assigned Readings section of NYU Classes. There is no text book for the course (although some alternative texts are suggested in the readings for the AM Session of Day 1 for students with no prior health experience). The books required for the second paper are readily available at area bookstores or on the web (e.g., amazon.com, barnesandnoble.com, etc.). Copies of PowerPoint “handout” materials used in class will be posted in the Session Notes section on the NYU Classes site at least 24 hours in advance of the class. If you have questions about the reading materials or you need other help, please contact my administrative assistant, Christopher Harris [295 Lafayette Street - 3rd Floor - 212-998-7416 –christopher.harris@nyu.edu].

Assignments and participation in class discussions in this course will be used to assess progress against the competencies listed above that the Wagner Health Policy and Management Program has created pursuant to its accreditation with the Commission on

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Accreditation for Health Management Education (CAHME). No student will receive a B or higher without demonstrating satisfactory progress toward mastery of each competency listed in the Learning Assessment Table above.

Course Outline

Day 1 – 9/08/17 – AM Session

Introduction – Description of course content, goals, and requirements

Square One: The role of government in health/health care

A discussion of the role of policy analysis in public policy formation and the impact of public policy on the health system

Objectives of government in health and health care, discussion of limitations of government, and some examples

Discussion of implications for policy

Required reading:

S. Schoenbaum, A. Audet, and K. Davis, “Obtaining Greater Value from Health Care: The Roles of the U.S. Government,” Health Affairs (November/December 2003): 183-190.

N. Tang, J. Eisenberg, G Meyer, “The Roles of Government in Improving Health Care Quality and Safety,” Joint Commission Journal on Quality and Safety (January, 2004): 47-54.

Problems for discussion groups

Each student will be assigned to one of four “discussion groups” – these groups will be maintained throughout the semester and will be asked to address a specific problem or take on a roll for a specific issue. Assignments are posted in the Discussion Group section of NYU Classes. For this session, each group will be asked to review one of the two problems outlined below. The discussion groups can meet during the lunch break and/or during the first 30 minutes of the Day 1 PM Session to discuss the issues related to the problem, and then each discussion group will report back to the full group. The problems are:

Problem A – More than half of emergency department use is for non-emergent conditions or for conditions that could be treated safely and effectively in a primary care setting. Many emergency rooms suffer from serious overcrowding, often resulting in long waits for care or diversion of ambulances. What can government do promote/encourage/require more optimal emergency room use?Discussion Groups 1 and 2

Problem B – It’s 2004. You are the health advisor for the newly-elected President of the Dominican Republic. The DR is in the mid-range of GDP in the western hemisphere, but

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80% of the population are uninsured and the government share of health expenditures is the lowest in the western hemisphere. Hospitals are overcrowded and there is an MD shortage. The country has high infant mortality rates, the leading cause of hospitalizations is gastroenteritis, and the country has very high rates of Type II Diabetes. Where should the president start?Discussion Group 3

Square Two: How health care is organized, financed, and paid for

Brief overview of how health care is organized, where the money comes from, and how care is paid for

A little bit about insurance and “managed” care

Required reading:

Kaiser Family Foundation: How Private Health Coverage Works: A Primer. http://www.kff.org/insurance/7766.cfm

S. Glied, “Health Insurance and Market Failure since Arrow”, Columbia University

Suggested reading on how the health care delivery system is organized:

T. Bodenheimer and K. Grumbach, Understanding Health Policy - Seventh Edition (New York: McGraw Hill, 2016) – Chapters 2, 4-6.

or --

L.Shi, D. Singh, Delivering Health Care in America - Sixth Edition – (Jones & Bartlett Publishers, 2014) – Chapters 1, 7-10.

or --

J. Knickman, A. Kovner, Health Care Delivery in the United States – 11th Edition (New York: Springer Publishing Company, 2015) – Chapters 3, 9, 11.

Problems for discussion groups

Problem C – What are the issues/concerns on public vs for-profit vs not-for profit ownership of:- Group 1 – Renal dialysis centers- Group 2 – Hospices- Group 3 – Nursing homes

Problem D - Suppose current state law prohibits investor-owned hospitals. The newly elected governor has asked your group to staff a commission to consider repealing the law. Outline the advantages and disadvantages of repeal, and what protections (if any) should be included in the case of repeal.Discussion Group 2

Problem E - There is an increasing movement for clinical practices to be acquired or more strongly affiliated with hospitals or “integrated” health care delivery “systems”.

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What are the forces that are encouraging these changes and what are the advantages and disadvantages of these developments?

Discussion Group 1: Midtown Medical Group

Discussion Group 3: NYU Langone Medical Center

Day 1 – 9/08/17 – PM Session

Square 2 (continued): How health care is organized, financed, and paid for Finishing-up of how money changes hands Discussion of the implications for policy Quick look at English National Health Services (by way of comparison) and current

proposals for reform

Medical practice and health policy Review of the enormous variation in medical practice Discussion of causes of variation – Discussion Group Problem F:

‒ Group 1 - Tonsillectomy rates among areas in Northern New England‒ Group 2 - Caesarean section rates among hospitals for low risk deliveries ‒ Group 3 - Resource use rates among hospitals for end-of-life care

Further discussion of causes of variation Discussion of the implications for policy

Required reading:

E. Fisher, D. Wennberg, T. Stukel, et al., “The Implications of Regional Variation in Medicare Spending - Part 2: Health Outcomes and Satisfaction with Care,” Annals of Internal Medicine 138, No. 4 (2003): 288-299

J. Wennberg, E. Fisher, T. Stukel, et al., “Use of Hospitals, Physician Visits, and Hospice During the Last Six Mnths of Life among Cohorts Loyal to Highly Respected Hospitals in the United States,” British Medical Journal 328, No. 7440 (March 13, 2004): 607-610.

K. Kozhimannil, M. Law, and B. Virnig, “Caesarean Delivery Rates Vary Tenfold Among US Hospitals; Reducing Variation May Address Quality and Cost Issues,” Health Affairs (March, 2013): 527-535

D. Eddy, “Evidence-Based Medicine: A Unified Approach,” Health Affairs (January/February, 2005): 9-17.

D. Jones, “Visions of a Cure,” Isis (September 2000):91:504-541 – Visions of a Cure https://www.jstor.org/stable/237906?seq=1#page_scan_tab_contents

Gawande, “The Cost Conundrum,” New Yorker, June 1, 2009

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Day 2 –9/22/17 – AM Session

Obesity and Public Policy

Guest lecturer:

Brian Elbel – NYU Wagner School and NYU School of Medicine o Recent policy initiative to combat obesityo What is working and not working?

Required Reading:

J. Cantor, A Torres, C. Abrams, et al., “Five Year Later: Awareness of New York City’s Calories Labels, with No Changes in Policy,” Health Affairs, (November 2015), 1893-1900.

T. Frieden, W. Dietz, and J. Collins, “Reducing Childhood Obesity through Policy Change: Acting Now to Prevent Obesity,” Health Affairs, (March, 2010), 357-363

Day 2 –9/22/17 – AM/PM Session

Medicare: The basics and Issues for reform A discussion of the role and objectives of government in health Description of who and what is covered by Medicare Review of how Medicare pays for health care Description of the recent expansion Medicare to provide coverage for prescription drugs Issues for reform

Required reading:

C. Eibner, D. Goldman, J. Sullivan et al., “Three Large-Scale Changes to the Medicare Program Could Curb Its Costs but Also Reduce Enrollment,” Health Affairs (May, 2013): 891-899.

K. Davis, C. Shoen, S. Guterman, “Medicare Essential: An Option to Promote Better Care and Curb Spending Growth,” Health Affairs (May, 2013)” 900-909.

Henry J. Kaiser Family Foundation, Prescription Drug Coverage for Medicare Beneficiaries: A Summary of the Medicare Prescription Drug, Improvement, and Modernization Act of 2003 (December 10, 2003) Kaiser Family Foundation (http://kff.org/medicaid/report/prescription-drug-coverage-for-medicare-beneficiaries-a-3/)Also take a look at:

‒ Medicare and You: 2017 - https://www.medicare.gov/pubs/pdf/10050-Medicare-and-You.pdf

‒ Henry J. Kaiser Family Foundation, Policy Options to Sustain Medicare for the Future, http://kaiserfamilyfoundation.files.wordpress.com/2013/02/8402.pdf

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Issue for discussion groups:

Problem A – Should federal policy promote participation of Medicare recipients in private plans (managed care and/or fee for service)? If yes, why and how should such participation be promoted? Discussion groups will be assigned one of the following roles:

Lefty – government can/should solve most of society’s problems types – Discussion Group 1

Republican right (whatever that might be) – Discussion Group 2 NYU Langone Medical Center – Discussion Group 3

Day 2 – 9/22/17 – PM Session

Medicaid: The basics History and financing of Medicaid Description of who and what is covered by Medicaid

Required reading:

S. Decker, “In 2011 Nearly One-Third of Physicians Said They Would Not Accept New Medicaid Patients but Rising Fees May Help,” Health Affairs (August, 2012) 1673-1679.

B. Sommers, K. Baicker, and A. Epstein, Mortality and Access to Care among Adults after State Medicaid Expansions,” NEJM 2012;367:1025-34.

See also: Medicaid: A Primer - http://kff.org/medicaid/issue-brief/medicaid-a-primer/ or Medicaid

Pocket Primer - http://www.kff.org/medicaid/fact-sheet/medicaid-pocket-primer/ Medicaid and Long-Term Services and Supports: A Primer -

http://kff.org/medicaid/report/medicaid-and-long-term-services-and-supports-a-primer/

Issue for discussion groups:

Problem B – It’s 1965 and Congress is designing a health coverage program for low income populations. What are your views on: i) who should be covered, ii) what should be covered, iii) federal/state/local roles, and iv) the role of private plans? Discussion group assignments:

Lefty – government can/should solve most of society’s problems types - Discussion Group 2

Republican right (whatever that might be) - Discussion Group 3 Health care providers - Discussion Group 1

Medicaid: Issues for reform What needs to be fixed/Issues for reform Responding to the needs of high cost/high risk patients

Required reading:

J. Billings, T. Mijanovich, “Improving The Management of Care for High-Cost Medicaid Patients” Health Affairs no 6 (2007) 1643-1655.

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Issues for discussion in Day 2 PM Session

Problem C – A large number of uninsured children and adults are eligible but not enrolled in Medicaid. Why? What can government/not-for-profit groups do to get more eligible enrolled? What are the barriers? Who should do what?Discussion Group 3

Problem D – It is possible to identify Medicaid patients from claims data who are at very high risk of future hospital admissions. These patients have high rates of chronic disease, mental health conditions, and substance abuse problems, and these patients are often homeless or precariously housed and socially isolated.

‒ What are the critical components of a program to respond the needs of these patients (reducing future hospital admissions)?

‒ How can it be implemented (assuming there is no new money and the initiative would have to break even with savings from reduced hospital admissions covering the costs of the intervention)?

‒ What are the barriers to implementation? Discussion Groups 1 and 2

Day 3 – 10/06/17 – AM Session

The major challenges confronting the health “system”: Disparities, Uninsurance, and Costs

Overview of disparities in health services, utilization, and outcomes Discussion of the factors that are contributing to these disparities Description of the size and characteristics of the uninsured population Review of the causes of uninsurance Description of the dynamics of current cost increases Review of the causes and implications of cost increase Discussion of the implications of these challenges for policy makers and providers and

for the current health reform initiative

Required Reading:

J. Billings, L. Zeitel, J. Lukomnik, et al., “Impact of Socioeconomic Status on Hospital Use in New York City” Health Affairs (Spring 1993): 162-173.

J. Billings, “Management Matters: Strengthening the Research Base to Help Improve Performance of Safety Net Providers,” Health Care Management Review 28, No 4 2003): 323-334.

Jha, E, Orav, Low-Quality, High-Cost Hospitals, Mainly in the South, Care for Sharply Higher Shares of Elderly Black, Hispanic, and Medicaid Patients, Health Affairs (October 2011): 1904-1911.

Kaiser Family Foundation, Primer-The Uninsured and Key Facts about Health Insurance and the Uninsured in the Era of Health Reform – November, 2015

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D. Altman and L. Levitt, “The Sad History of Health Care Cost Containment as Told in One Chart,” Health Affairs – Web Exclusive (23 January 2002): W83-4.

Phillipson T, Eber M, Lakdawalla DN, “An Analysis of Whether Higher Health Care Spending in the United States Versus Europe is “Worth It” in the Case of Cancer,” Health Affairs (April, 2012): 667-675.

P. Cunningham, “The Growing Financial Burden of Health Care,” Health Affairs (May 2010): 1037-1044.

W Hsiao, A Knight, S Kappel, et al., “What Other States Can Learn from Vermont’s Bold Experiment: Embracing A Single-Payer Health Care Financing System,” Health Affairs (July 2011): 1232-1241.

U. E. Reinhardt, Is it Time for a More Rational All-Payer System? Health Affairs (November, 2011): 2125-2133.

D. Cutler and N. Sahni, “If Slow Rate of Health Care Spending Growth Persists, Projections May Be Off by $700 Billion,” Health Affairs (May, 2013): 841-850.

Song Z, Safran DG, Landon BD et al., “The ‘Alternative Quality Contract,’ Based on a Global Budget, Lowered Medical Spending and Improved Quality” Health Affairs (August, 2012): 1885-1894.

Problems for discussion in Day 3 AM/PM Session

Problem A – There are differences by race, ethnicity, and income in prevalence of diabetes, and these vulnerable populations have much higher rates of hospitalization for diabetic ketoacidosis/hyperosmolar syndrome and for amputations related to diabetes. You are advising a major local foundation that wants to create a program to help address this problem. Describe the range of initiatives the foundation should support – be specific about that activities supported and who the grants should go to. They’ve got about $10 million/year to spend on this program.All Discussion Groups

Problem B - For the assigned strategy for controlling costs discuss i) whether is it likely to actually work, ii) will it address the underlying "structural" factors described earlier, iii) is it politically feasible, and iv) who would do what to whom?

‒ Group 1 - Continue to tinker - pick three examples from slide above on tinkering‒ Group 2 - Implement command and control regulation‒ Group 3 - Promote competing health plans

Day 3 – 10/06/17 – PM Session

Prior efforts to respond to these challenges:The role of the states, the Clinton Health Plan, and other federal initiatives

Overview of policies/programs at the federal, state, and local level to reduce disparities, expand coverage, and control costs

Discussion of the strengths and limits of state/local initiatives

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Discussion of the Clinton health plan, what problems it might have solved or created, and why it failed

Implications for current reform initiatives

Required Reading:

J. Holahan, L. Blumberg, A. Weil, et al, “Roadmap to Coverage – Report for the Blue Cross Blue Shield of Massachusetts Foundation,” October, 2005

S. Long and K Stockey, “Sustaining Health Reform in a Recession: An Update on Massachusetts as of Fall 2009,” Health Affairs (June 2010): 1234-1241.

W. Zelman, “The Rationale behind the Clinton Health Care Reform Plan,” Health Affairs (Spring 1994): 9-29.

D. Yankelovich, “The Debate That Wasn’t: The Public and the Clinton Health Plan,” Health Affairs (Spring 1995): 7-23.

R. Blendon, M. Brodie, and J. Benson, “What Happened to America’s Support for the Clinton Health Plan,” Health Affairs (Summer 1995): 7-23.

National Health Reform 2010 Overview of Affordable Care Act (ACA) Discussion policy, politics, and power

Required Reading:

Kaiser Family Foundation: “Summary of the Affordable Care Act” – http://kaiserfamilyfoundation.files.wordpress.com/2011/04/8061-021.pdf

Kaiser Family Foundation: “Health Reform Implementation Timeline” – http://kff.org/interactive/implementation-timeline/

J. Morone, “Presidents and Health Reform: From Franklin D. Roosevelt to Barack Obama,” Health Affairs (June 2010): 1096-1100.

J. Oberlander, “Long Time Coming: Why Health Reform Finally Passed,” Health Affairs (June 2010): 1112-1116.

S. Shortell, L Casalino, and E. Fisher, “How CMS Innovation Should Test Accountable Care Organizations,” Health Affairs (July 2010): 1293-1298.

C. Price and C. Eibner, “For States That Opt Out of Medicaid Expansion: 3.6 Million Fewer Insured and $8.4 Billion Less in Federal Payments,” Health Affairs (June, 2013): 1030-1036.

National Health Reform 2017 Overview of proposals to repeal and replace the Affordable Care Act Discussion policy, politics, and power – What happened?

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Required Reading:

Compare Proposals to Replace the Affordable Care Act - Proposals to Replace ACA (http://www.kff.org/interactive/proposals-to-replace-the-affordable-care-act/) [Note: These documents are also available on NYU Classes Assigned Readings tab.

Problem for discussion in Day 3 PM Session

Problem C – Suppose Donald Trump goes rogue on health care and decides to actually try to deliver on what he has promised on reform of ObamaCare (“insurance for everybody”, “nobody will be worse off financially”, and “everyone will be taken care of”), and he tweeted at 4:00 AM this morning his support for a “single payer system”. So what might it look like?

Where would the money come from (employers, employees, individuals, Medicare trust fund, general tax revenue, etc.)?

How would it be structured? Like Medicare Part A, Part B, or Part D, or something else altogether different?

Any role for private plans like Medicare Part C or Paul Ryan’s “Path to Prosperity”/ “A Better Way” proposals from 2011 and 2016?

If Trump says: “Yeah, let’s do the Paul Ryan thing and have everyone enrolled in a private plan” – would Bernie go along?

How would providers be paid? What else needs to be decided to make it work?

All Discussion Groups

Day 4 – 10/20/17 – AM Session

More policy issues concerning the pharmaceutical industry Overview of the major policy issues concerning the pharmaceutical industry Discussion of the factors that are contributing to these emergences of these issues now Discussion of the role of government with respect to the pharmaceutical industry

Required Reading:

P. Stein and E Valery, “Competition: An Antidote to the High Price of Prescription Drugs,” Health Affairs (July/August 2004): 151-158.

K. Kaphingst and W. DeJong, “The Educational Potential of Direct-to-Consumer Prescription Drug Advertising,” Health Affairs (July/August 2004): 143-150.

J. Jeffords, “Direct-to-Consumer Drug Advertising: You Get What You Pay For,” Health Affairs - Web Exclusive (28 April 2004): W4 253-255.

P. Kelly, “DTC Advertising’s Benefits Far Outweigh Its Imperfections,” Health Affairs - Web Exclusive (28 April 2004): W4 246-248.

C. Manz, J. Ross, and D. Grande, “Marketing to Physicians in a Digital World,” NEJM (November 14, 2014) 371;20: 1857-59.

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Optional reading:

J. Weisman, D. Blumenthal, A Silk, et al., “Consumers’ Reports on the Health Effects of Direct-to-Consumer Drug Advertising,” Health Affairs - Web Exclusive (26 February 2003): W3 82-95.

J. Weisman, D. Blumenthal, A Silk, et al., “Physicians Report on Patient Encounters Involving Direct-to-Consumer Drug Advertising,” Health Affairs - Web Exclusive (28 April 2004): W4 219-233.

Medical errors – Medical malpractice Brief overview of current malpractice law Description of what is known about medical errors Analysis of the effectiveness of the legal system and malpractice law in assuring quality

and compensating victims of harm

Required reading:

Institute of Medicine, “Report Brief - To Err is Human: Building a Safer Health System” - http://www.nap.edu/catalog/9728.html

M. Hatlie and S. Sheridan, “The Medical Liability Crisis of 2003: Must We Squander the Chance to Put Patients First?” Health Affairs (July/August 2003): 37-40.

C. Landrigan, G. Parry, C. Bones et al., “Temporal Trends in Rates of Patient Harm Resulting from Medical Care,” NEJM 2010;363:2124-34.

D. Waxman, M. Greenberg, M. Ridgely, et al., “The Effect of Malpractice Reform on Emergency Department Care,” NEJM (October 16, 2014) 371;16: 1518-1525

A.J. Starmer, N.D Spector, R. Srivastave, et al., “Change in Medical Errors after Implementation of a Handoff Program,” NEJM (November 6, 2014) 371;19: 1803-12.

Problems for discussion in Day 4 AM Session

Problem A – Suggest options for responding to rapidly rising drug prices, both patent-protected (e.g., Harvoni) and off-patient (e.g., Daraprim or EpiPen) – rate any options you suggest on political feasibilityAll Discussion Groups

Problem B – Suggest some options for malpractice reform (and efforts to reduce medical errors) including government and/or private action – rate any options you suggest on political feasibilityAll Discussion Groups

Day 4 – 10/20/17 – PM Session

Role of Patients – Making informed decisions Patient’s rights to refuse/withdraw treatment What information do patients need to make health care decisions (choice of treatment,

doctor/hospital, health plan, etc.) what’s the best way to get information to patients

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Required reading:

Cruzan v. Director, Missouri Department of Health – 497 U.S. 261 (1990) Case Law (http://caselaw.lp.findlaw.com/scripts/getcase.pl?court=us&vol=497&invol=261)

M. Morgan, R Deber, H. Llewellyn-Thomas, “Randomized Controlled Trial of an Interactive Videodisc Decision Aid for Patients with Ischemic Heart Disease,” Journal of General Internal Medicine 15 No. 10 (2000): 685-693

Connor, H. Llewellyn-Thomas, and A. Flood, “Modifying Unwarranted Variations in Health Care: Shared Decision Making Using Patient Decision Aids,” Health Affairs – Web Exclusive (7 October 2004): VAR 63-72.

D. Arterburn, R Wellman, E Westbrook, et al., “Introducing Decision Aids at Group Health Was Linked to Sharply Lower Hip and Knee Surgery Rates and Costs,” Health Affairs (September, 2012): 2094-2104.

D. Veroff, A. Marr, and D. Wennberg, “Enhanced Support for Shared Decision Making Reduced Costs of Care for Patients with Preference Sensitive Conditions,” Health Affairs (February, 2013): 285-293.

E.O. Lee, E.J. Emanuel, “Shared Decision Making to Improve Care and Reduce Costs,” NEJM (January 3, 2013) 368;1: 6-8.

New York State Department of Health, Adult Cardiac Surgery in New York State: 2013-2015 (February, 2018):

Problems for discussion groups

Problem C – Your state has a referendum on the November ballot to allow physician assisted suicide for patients who are terminally ill and mentally competent.

‒ Support the referendum – Discussion Group 1‒ Oppose the referendum – Discussion Group 3

Supporters should be specific about what the ground rules should be and how vulnerable patients will be protected. Opponents should provide an explanation of why assisted suicide should be prohibited, but also include alternative ideas to help assure patients can “die with dignity.”

Problem D – Patients are increasingly interested in participating in treatment choice decisions to help assure their own values and attitudes towards risk are reflected in the decision. What can be done to promote such “shared decision making”? What is the role of providers, government, insurers or other entities? Be specific about who should do what and where the money should come from to help make it happen.Discussion Group 2

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Required Assignments/Papers

Assignment 1 – Personal Resume (Pass/Fail) Provide a very brief resume/vita/something that describes who you are, employment experience (if any), and career goals (if any) and attach a recent photo of yourself (try Xeroxing you ID if you can’t do any better).

Due Date: 9/15/17 – 11:59pm (use NYU Classes File Exchange or put it in my mail box)

Note: For papers 1 and 2 and assignment 2, you may work in teams of up to 3 students, although working on team is not required. Teams must have members from at least two different programs at Wagner or NYU and two different “professions”. Player trades are allowed, and you can work on different teams for papers 1 and 2 (or no team on one or the other). For assignment 2, you may submit as a team or individually. If submitting as a team, submit only one paper/assignment per team and list all the team members.

Paper 1 – The Dartmouth Atlas Memo (35% of final grade) – ≤ 8 pages Take a look at the website for the Dartmouth Atlas of Healthcare. There is an interactive site, where you can pick out specific utilization measures for specific geographic areas or individual hospitals Dartmouth Atlas (http://www.dartmouthatlas.org/), and there is also an area of the site where you can download Excel or pdf files with the data Dartmouth Atlas 2 (http://www.dartmouthatlas.org/downloads.aspx) – this latter site much easier to navigate and I strongly recommend using it. Pick an example of variation in utilization that you believe is unwarranted and describe the range of factors that are likely to contribute to the differences among areas (or hospitals). Examples utilization rates on the site include:

Care of chronically ill patients during the last two years of life Care of Chronically Ill Patients (http://www.dartmouthatlas.org/tools/downloads.aspx?tab=40)

Selected surgical discharge rates Surgical Discharge Rates (http://www.dartmouthatlas.org/tools/downloads.aspx?tab=41)

Selected medical discharge rates Medical Discharge Rates (http://www.dartmouthatlas.org/tools/downloads.aspx?tab=41)

Children's health care in Northern New England, 2007-10 Children’s Healthcare (http://www.dartmouthatlas.org/tools/downloads.aspx?tab=35)

Prescription drug use, 2010 Prescription Drug Use (http://www.dartmouthatlas.org/tools/downloads.aspx?tab=35)

Please look at utilization levels, not variation in mortality, costs/spending/reimbursement or resource inputs that are reported in some files or tables. While you can write about some of the “quality” measures (primary care access and quality or post discharge events) if you have an abiding interest in these topics, I would much prefer you to focus on variation in rates of

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utilization – also please note that these “quality” measures will be more difficult to tie into the discussions we had in class.

After discussing the range of factors that affect variation in rates, pick one contributing factor that you think is important (or that you think something can be done about it) and make some suggestions about what might be done to reduce variation. Be specific and detailed in your suggestions, including who ought to do what to whom. Be realistic, don’t make suggestions that cannot be implemented because of technical, financial, or political considerations. This is a conceptual piece and not a research paper, but footnote sources of ideas from others that you use for the causes of variation (or the suggested solutions if the ideas come from a specific source). Please see even more detailed instructions/suggestions in the PowerPoint presentation located in the Other Material tab of NYU Classes.

Due Date: Day 2 Session or submit via NYU Classes File Exchange by 9/23/18 – 11:50PM.

Paper 2 – Book Memo (25% of final grade) - ≤ 6 pages You are a newly hired policy staff person for some senator, the governor of any state, a health commissioner, the president of the National Association of Community Health Centers, CEO of a large health insurance plan/managed care plan, or some other health organization of your choice (domestic or international). Your boss walks by your cubicle and plops down one of the books listed below and asks you to read it and tell her/him i) what it’s about, ii) why it’s important, and iii) what ought to be done about it by your organization or boss. Select a book from the list below and write a brief memo (remembering your boss has a very short attention span and will stop reading if it goes beyond 6 pages). Make sure you identify your hypothetical employer. If there is a book relevant to the class that you are dying to read that is not on the list, let me know and, if I have read it or am willing to read it, the book can be added to the list.

Adrian Nicole LeBlanc – Random Family: Love, Drugs, Trouble, and Coming of Age in the Bronx.

Anne Fadiman – The Sprit Catches You and You Fall Down. Sherwin Nulin – How We Die. Eric Klinenberg – Heat Wave: A Social Autopsy of Disaster in Chicago; Going Solo: The

Extraordinary Rise and Surprising Appeal of Living Alone Laurie Kaye Abraham – Mama Might Be Better Off Dead: The Failure of Health Care in

Urban America. Jerry Avorn – Powerful Medicines: The Benefits, Risks, and Costs of Prescription Drugs. Andrew Solomon – The Noonday Demon. Richard Deyo and Donald Patrick – Hope or Hype: The Obsession with Medical

Advances and the High Cost of False Promises. Shannon Brownlee - Overtreated: Why Too Much Medicine Is Making Us Sicker and

Poorer Jerome Groopman – How Doctors Think

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John Abramson - Overdosed America: The Broken Promise of American Medicine Atul Gawande – Being Mortal: Medicine and What Matters in the End or The Checklist

Manifesto: How to Get Things Right. David Kessler – The End of Overeating: Taking Control of the Insatiable American

Appetite John Wennberg – Tracking Medicine Otis Brawley – How We Do Harm: A Doctor Breaks Ranks Eric Manheimer - Twelve Patients: Life and Death at Bellevue Hospital Angela Coulter – Engaging Patients in Healthcare Nina Teicholz – The Big Fat Surprise Elizabeth Bradley/Lauren Taylor – The American Health Care Paradox: Why Spending

More Is Getting Us Less Sanjeep Jauhar – Doctored: The Disillusionment of an American Physician Sherri Fink – Five Days at Memorial

Due Date: Day 3 Session or submit via NYU Classes File Exchange by 10/07/18 – 11:59PM

Assignment 2 – Dartmouth Atlas PowerPoint Slides (25% of final grade) Take your Dartmouth Atlas paper and make it into a PowerPoint presentation. As with the paper, describe the “unwarranted” variation, discuss the potential causes of the variation, and make recommendations on what might be done about it. Incorporate or address any suggestions that I made in grading the paper. While substantive content matters, you will be graded primarily on how clearly and effectively the material is presented. Look and feel matter. Don’t make slides too busy or have too much text on a slide, and avoid cute graphics. You will not actually have to present the slides, but keep the length to a presentation that would take not more than 15 minutes. If you worked on team on the paper, you may submit as a team or individually.

Due Date: Day 4 Session or submit via NYU Classes File Exchange by 10/21/18 – 11:59PM

Academic IntegrityAcademic integrity is a vital component of Wagner and NYU. All students enrolled in this class are required to read and abide by Wagner’s Academic Code. All Wagner students have already read and signed the Wagner Academic Oath. Plagiarism of any form will not be tolerated and students in this class are expected to report violations to me. If any student in this class is unsure about what is expected of you and how to abide by the academic code, you should consult with me.

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Henry and Lucy Moses Center for Students with Disabilities at NYUAcademic accommodations are available for students with disabilities. Please visit the Moses Center for Students with Disabilities (CSD) website and click on the Reasonable Accommodations and How to Register tab or call or email CSD at (212-998-4980 or mosescsd@nyu.edu) for information. Students who are requesting academic accommodations are strongly advised to reach out to the Moses Center as early as possible in the semester for assistance.

NYU’s Calendar Policy on Religious HolidaysNYU’s Calendar Policy on Religious Holidays states that members of any religious group may, without penalty, absent themselves from classes when required in compliance with their religious obligations. Please notify me in advance of religious holidays that might coincide with exams to schedule mutually acceptable alternatives.

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