Shaping Public Policy to Advance Health

reprinted from Issue 10, Spring 2010 of Frontiers of Medicine (PDF)

"These experiences helped me understand how laws are made by Congress, how regulations are made in the health care industry, and what type of information policymakers want and need."
— Neil R. Powe, MD, MPH, MBA

The Department of Medicine brings together a diverse community of innovators. We aim to transform the way that medicine is practiced — through discovering new therapies and technologies, applying these discoveries to provide our patients with the best care, training future generations of outstanding physicians, and using our knowledge to impact how health care is delivered in this country and beyond. One of our major goals is to be the most trusted and influential leaders in shaping health policy. Below are profiles of three faculty members who are already at the forefront of this effort.

Improving Quality of Care

Neil R. Powe, MD, MPH, MBA
photo by Noah Berger

With advanced degrees in medicine, public health and business, Neil R. Powe, MD, MPH, MBA, brings an impressive range of experience to his work of improving health outcomes both locally and nationally.

Powe is the Constance B. Wofsy Distinguished Professor of Medicine and chief of medical services at San Francisco General Hospital (SFGH). His training has included coursework in health policy and a fellowship working for the Department of Health and Human Services. "These experiences helped me understand how laws are made by Congress, how regulations are made in the health care industry, and what type of information policymakers want and need," says Powe.

Today, Powe helps shape policy at the highest levels. For example, as part of the American Recovery and Reinvestment Act (ARRA) — the $787 billion economic stimulus package passed a year ago — Congress appropriated $1.1 billion for comparative effectiveness research, which investigates the strengths and weaknesses of various medical treatments. Congress also charged the prestigious Institute of Medicine (IOM), an independent nonprofit organization, with developing priorities for how these funds should be used.

Powe was one of 24 experts who served on the IOM committee, which issued a report recommending 100 funding priorities. Many of these centered on health care delivery and health disparities. "The committee determined these two cross-cutting themes," says Powe. "How do we use medical technologies to make sure that patients get the care they need, and how do we effectively use treatments in low-resource settings to help individuals from vulnerable populations?"

The report is now being used to direct funding priorities in comparative effectiveness research for the National Institutes of Health, the Department of Health and Human Services and the Agency for Healthcare Research and Quality. "The report made an immediate difference, affecting how ARRA money is being doled out around the country," says Powe.

Powe has also played a key role in shaping the way patients with kidney disease receive care. In 2008, Congress passed the Medicare Improvements for Patients and Providers Act. Among other enhancements, the new law will provide Medicare coverage for patients with severe kidney disease for up to six physician visits to learn about their dialysis and transplant options.

Powe has conducted extensive research about chronic kidney disease, and demonstrated that informed patients actually live longer. He recently chaired a stakeholders group at the Agency for Healthcare Research and Quality in drafting recommendations for the content and format of these Medicare-funded education sessions. "Ultimately, we hope this will support 'shared decision-making,' in which providers fully inform and involve patients in decisions about their therapy, rather than just telling patients, 'This is what I think you should have,'" says Powe.

"There are more than 500,000 patients in this country with end-stage renal disease who qualify for Medicare," he says. "The stakeholders' group helped assure that the rules by which providers are paid actually make sense and are based on evidence."

Language Access: Found in Translation

Alice Chen, MD, MPH, has led efforts to improve language access for patients.
photo by Noah Berger

"One out of five Californians speaks limited English," says Alice Chen, MD, MPH, who directs the Adult Medical Center at SFGH. "Communicating with our patients is central to our ability to provide quality care."

Chen — who speaks Mandarin Chinese and Spanish — has been at the forefront of improving language access for patients in healthcare settings. She serves as board vice president of the California Pan-Ethnic Health Network (CPEHN), an organization working to improve health care access and eliminate health disparities. CPEHN sponsored California's Health Care Language Assistance Act, which requires private health plans and insurers to provide trained interpreters to patients.

While this is the first law of its kind in the country, passing it was just the first step. "A law is just words on paper until it is implemented," says Chen. "It's like a speed limit — its effectiveness depends on how well it's enforced."

One way Chen has worked to make language access a reality is by championing videoconferencing medical interpretation (VMI) at SFGH. This new technology gives medical providers immediate access to interpreters, and allows interpreters to see what is happening in the exam room — helping them more accurately describe diagrams and other visual information to patients. "Even though we have more than 25 full-time trained medical interpreters, it's not enough to meet demand," says Chen. "They used to spend half their time in transit, running from the Emergency Department to the clinic to the hospital wards. With the centralized VMI call center, they can serve many more patients."

Another common obstacle for limited English speakers is deciphering prescription label instructions. Chen is working with Dean Schillinger, MD, Urmimala Sarkar, MD, MPH, and colleagues at Northwestern University to test the effectiveness of instructions translated into Chinese, Korean, Russian, Spanish and Vietnamese. "Once they've been translated and validated, there's little excuse for pharmacies not to use them," says Chen. "We are partnering with the California Board of Pharmacy to upload these translations to its website in the hopes that it will assist pharmacists in doing the right thing for their patients."

Chen is also helping the next generation of physicians become effective advocates. She and colleagues at SFGH and CPEHN received a grant from the Institute on Medicine as a Profession to design a new curriculum that teaches medicine and pediatrics residents skills such as writing opinion pieces, media advocacy, making legislative visits and using survey data to effect change.

Chen sees her work in advocacy and policy as a natural outgrowth of her role as a general internist. "Primary care is premised on a whole-person orientation," she says. "You not only examine patients' biologic systems, but also think about how their social milieu affects their disease processes. As physicians, we advocate every day for individual patients to access resources such as housing, disability and transit. We also need to create resources and local policies to improve the health of the community, and to advocate for legislative and administrative action to change large-scale policy that then filters back to the individual patient."

She feels SFGH is a natural place for physicians drawn to policy work. "The marriage between San Francisco General and UCSF is a very powerful one, because you have thoughtful, smart, energetic people who are constantly thinking about developing and evaluating programs and policies that impact underserved communities," says Chen.

Andrew Bindman, MD, with Congressman Henry Waxman
photo by Noah Berger

Helping Make History

"I had the thrill of watching the debate and vote on the floor of the House of Representatives on the final health care reform legislation," says Andrew Bindman, MD, chief of the Division of General Internal Medicine at SFGH.

This year, Bindman is in Washington, DC, as a Robert Wood Johnson Health Policy Fellow. He serves as a full-time staff member to Representative Henry Waxman (D-Calif.), who chairs the House Energy and Commerce Committee. "Congressman Waxman has been a leader for many years on health care, and I've been fortunate to work with him and his staff on proposals to expand health insurance coverage, support primary care and strengthen safety net hospitals and clinics," says Bindman.

"I'm very hopeful that this new law will lead to significant improvements in access and quality of care," says Bindman. "The legislation that passed isn't perfect, but it is a huge step forward for covering the uninsured. It's not the end of health care reform, but rather an important beginning for bringing equity and accountability to the health care system."

Bindman's experience as a primary care physician has provided invaluable skills for his work on Capitol Hill. "In my role with the Congress, I need to be familiar with a wide range of health policy issues and know how to diagnose and resolve the most common issues before referring the problem to colleagues with more specialized expertise," he says. As one of only two physicians staffing the committee, Bindman's 20 years at SFGH helped inform discussions with leadership from the House, Senate and White House on passing health care reform legislation.

One issue Bindman focused on is improving primary care payment — particularly for Medicaid, the federal-state insurance program for low-income Americans. Bindman's previous research demonstrated that only about half of California's primary care physicians accept Medicaid patients because of the low payment rates. Nationally, Medicaid reimburses primary care physicians at a rate that is only 66 percent of what they receive to care for patients with Medicare, the government insurance program that covers Americans who are 65 and older and people with permanent disabilities.

To help remedy this situation, the new law requires Medicaid to pay primary care physicians on a scale that is equal to or better than Medicare. "This is needed to increase capacity for an expected increase in the number of new Medicaid beneficiaries under health care reform," says Bindman.

Bindman also contributed to elements of the health care reform legislation that will financially support the safety net. Hospitals like SFGH and UCSF serve a disproportionately large percentage of low-income patients, whose care is often complicated by a variety of social challenges, including language barriers. "My experience as a primary care physician at San Francisco General Hospital has been persuasive with policymakers when debating the merits of things like interpretation services for safety net providers and their patients," says Bindman. "It was exciting that the work on primary care and safety net hospitals was included in the final legislation."

When Bindman returns to UCSF in the fall, he plans to teach a new course about disseminating research to decision-makers. Although publishing in peer-reviewed journals like the New England Journal of Medicine is an important first step, Bindman says it is also critical for academics to engage the media and constituency groups in communicating a consistent, clear and loud message to policymakers. "While in Washington, I'm learning how to better formulate messages to translate evidence-based work into policy," says Bindman.

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