Healthcare Policy: From Washington, D.C., to Your Practice

September 12, 2011

I believe that holistically understanding health policy - as seen through both “donkey” and “elephant” eyes - makes me a better clinician.

My plan for this blog is to write about policy. Health care policy. I promise to make it interesting, by adding seasoning to the blandness of Medicaid and Medicare, moisture to the dryness of Gross Domestic Product, and some cherries-on-top to the plain ugliness of Washington.

In coming months, I hope to come up with profound topics that you will find transcendent. Or, at least, come up with at least one topic that may simply change the way you interact with one patient in your practice, or hospital, the next day.

But first, before I can be as bold as to try and influence you, I need to know who “you” are.
For any writer, one of the most important criteria in putting together a piece is to know the audience. This, being my first blog, will be an attempt to define you.

My best assumption is that you are, in many ways, like me.

You are probably not uninsured. You have been through medical or graduate school, and have a fairly secure job that allows you to scour a Physician Practice blog site rather than Monster.com. Your employer - or, perhaps, you are self-employed - probably provides you health insurance, in some fashion.

You probably have access to care. Be it an informal chat with a medical colleague - “Hey Joe, twisted my knee skiing this weekend. What do you think? - or more formal access to quick appointments and subspecialist consultation, you probably can reach doctors and other in-the-know people in the medical field.

You are, probably, somewhere close to wealthy. Almost certainly middle class.

My interests in public health and health policy began in earnest after I completed my pediatrics residency, and not without a good stroke of serendipity. There was a public health school nearby, I happened to have many of my evenings free, and there were generous tuition benefits offered by my employer. I’d be somewhat dishonest if I didn’t admit that the latter of the three played perhaps the biggest role in my decision to get an MPH.

Three years of training and intense pediatric study, to learn techniques to fix a patient sitting in front of me, were unrecognizably blurred in the face of integrative, challenging conversations about public health and health policy. I had to recognize my minority status - privileged, socioeconomically stable - and more wholly contemplate the issues facing the majority.

For me, there were some eureka moments. I am embarrassed to admit that my understanding of Medicaid, the public program that finances the healthcare services of millions of children nationwide, was essentially nil even after completing my residency. Ditto for Head Start, the Woman and Children’s Supplemental Nutrition Program (WIC), and CHIP. Yes, I had heard of them, but I couldn’t explain them any better than I could explain how to rebuild a car engine, or the theory of quantum mechanics.

If, after three year of residency, you’d asked me to detail the differences between Medicaid and Medicare, I’d have choked on the air in my next breath.

In the talks I’ve done for medical audiences, I continue to find that the majority of people have only a superficial understanding of the public health policy issues they see every day. Policy issues are seen as tangential to the medical problem - Medicaid status in relation to a patient with pharyngitis, for example. Public health issues, such as antibiotic stewardship, are acknowledged but difficult to integrate into individualized patient care.

I’m wondering if my audience, here, is similar to the audiences I’ve faced in lecture halls. I’m guessing so.

While I will accept that the medical issues almost uniformly take priority, I believe that holistically understanding health policy - as seen through both “donkey” and “elephant” eyes - makes me a better clinician. I don’t know precisely how to measure this, and my randomized-controlled, double-blinded, prospective, multi-center study is still a long way off.

But I can say without a doubt that I’ve seen eyes light up. The interest level has been keen. I’ve been asked questions of varying complexity; some simple ones from subspecialist physicians, and complex ones from undergraduate economics majors. You’d be surprised, perhaps, that my talks to these audiences are not all that different, that the core understanding and interest is less related to educational background and more related to where-I-grew-up, or whether Mom ever used food stamps.

I assume nothing. For example, I may find it important to remind you that most insurance companies are for-profit - a seemingly obvious statement - because with this fact you can argue both sides of President Obama’s mandate, or you can better appreciate the challenges of Medicaid manage care.

My hypothesis is that you are an audience who is interested in a non-partisan, entertaining, easy-to-follow exploration of these questions. That you will reach out, at times, and teach me as well. I hope I am right. Feel free to leave me feedback in the comments section below.

Bryan R. Fine, MD, MPH, is a practicing pediatric hospitalist in Norfolk, Va. He received his Masters in Public Health at George Washington University in Washington, D.C., and has spoken to national and regional audiences on public health and policy issues. He currently is an assistant professor at Eastern Virginia Medical School, and teaches health policy for the EVMS School of Public Health. E-mail him here.