C.J. Stimson, MD, JD
There are 2 types of medical practice: retail and wholesale. Retail medicine occurs at the individual patient level in clinics, operating rooms, and hospital wards where physicians and patients work together to prevent and cure disease. Wholesale medicine, in contrast, occurs at the population and healthcare system levels, where policy makers set the rules that govern the retail practice of medicine. Physician engagement in the political process is an important mechanism for altering the trajectory of healthcare policy. This article discusses the wholesale side of medicine, exploring the why and how of physician involvement in healthcare policy.
What is Healthcare Policy?
Before we explore the how and why of physician involvement in healthcare policy, we will first define what is meant by this concept. In general, we know that a policy is a rule, or set of rules, designed to achieve a particular end by incentivizing desirable behavior. A policy aims to steer individual and collective decision making toward a predetermined goal. Based on this definition, we can conceptualize healthcare policy in terms of its goals and the means for achieving those goals.
The goals of healthcare policy are manifold. Up until the past decade, healthcare policy goals were commonly framed in terms of access, cost, and quality. Policy makers and thought leaders sought to expand access to care, minimize costs, and maximize quality. The conventional wisdom, however, was that the price for minimizing cost would always be paid either by diminished access to care or lower-quality care.
The past decade has seen an evolution in the framing of these healthcare policy goals. Borrowing from longstanding principles in management science, “value” has become the focus of healthcare policy. Defined by a direct relationship with quality and an inverse relationship with cost (value ≈ quality/ cost), this new value era in healthcare has combined the aforementioned policy goals of minimizing cost and maximizing quality into a single policy target. Framed in this way, the goal of healthcare policy is to maximize the value of healthcare such that it is worth expanding access to healthcare.
But if the goal of healthcare policy is to maximize value, the next question is, “Value for whom?” The constituents of healthcare policy makers include patients, providers, payers, and purchasers, and these highly integrated and related groups can have highly disparate perceptions of value. For example, for patients—the majority of whom are responsible for only a fraction of the total cost of their healthcare consumption—the value proposition is largely centered on maximizing quality. In contrast, payers (eg, private insurance companies) and purchasers (eg, employers that purchase healthcare services or health insurance on behalf of their employees) are more cost-sensitive.
Some providers, particularly physicians, have professional obligations to healthcare quality and patient welfare that must be balanced against the financial realities of managing a practice; however, other providers, such as hospitals, are not bound by professional obligations, but must deliver care in a manner that preserves operating margins. And while it may be appealing, often appropriate, and always politically expedient to elevate patient notions of value above all others, the answer to the question, “Value for whom?” must be an inclusive one. With this understanding of value, its multiple dimensions, and its place in the goals of healthcare policy, we now have an outstanding opportunity to explore how the next generation of physicians can engage and influence the value conversation in healthcare policy.
The means by which policy achieves its ends are rules that can influence the behavior of both individuals and the systems of which they are a part. For a rule to effectively influence behavior, it must be enforceable, and to be enforceable, it must be backed by the force of the law. This can occur in the setting of legally enforceable contracts between private parties, judicial rulings, legislative statutes, or administrative regulations. Legislation and regulation can occur at both the federal and state levels.