On values and democratic policy making: the deceptively fragile consensus around market-oriented medical care

How exposure to patient narratives affects stereotyped choices of primary care clinicians

In this paper, we examine whether patient narratives alter the impact of stereotyping on choice of primary care clinicians: in this case, the common presumption that female doctors will be more attentive to empathic relationships with patients. 1052 individuals were selected from a nationally representative Internet panel to participate in a survey experiment. Participants were given performance data about 12 fictitious primary care physicians, including a randomized set of narrative feedback from patients. We compared the choice of clinician made by participants who value bedside manner and were exposed to narratives in the experiment, compared to those valuing bedside manner who had not had this exposure. We estimated multivariate logistic regressions to assess whether exposure to patient comments that "disrupt" stereotypes influenced choice of physicians. Participants who saw patient comments and had previously reported caring about bedside manner had a 67% higher odds of choosing a female physician than those participants that did not see a patient comments, controlling for the content of the narratives themselves. When participants were exposed to patient comments that disrupt gendered stereotypes, they had a 40% lower odds of choosing a female physician. Simple exposure to patient narratives that do not clearly disrupt gendered stereotypes increased the likelihood of choosing a female clinician by priming attention to relational aspects of care. However, when the content of a sufficient proportion of patient comments runs counter stereotypes, even a minority of narratives is sufficient to disrupt gendered-expectations and alter choices.

Towards an Explanation of the Social Value of Health Systems: An Interpretive Synthesis

BACKGROUND

Health systems are complex social systems, and values constitute a central dimension of their complexity. Values are commonly understood as key drivers of health system change, operating across all health systems components and functions. Moreover, health systems are understood to influence and generate social values, presenting an opportunity to harness health systems to build stronger, more cohesive societies. However, there is little investigation (theoretical, conceptual, or empirical) on social values in health policy and systems research (HPSR), particularly regarding the capacity of health systems to influence and generate social values. This study develops an explanatory theory for the 'social value of health systems.'

METHODS

We present the results of an interpretive synthesis of HPSR literature on social values, drawing on a qualitative systematic review, focusing on claims about the relationship between 'health systems' and 'social values.' We combined relational claims extracted from the literature under a common framework in order to generate new explanatory theory.

RESULTS

We identify four mechanisms by which health systems are considered to contribute social value to society: Health systems can: (1) offer a unifying national ideal and build social cohesion, (2) influence and legitimise popular attitudes about rights and entitlements with regard to healthcare and inform citizen's understanding of state responsibilities, (3) strengthen trust in the state and legitimise state authority, and (4) communicate the extent to which the state values various population groups.

CONCLUSION

We conclude that, using a systems-thinking and complex adaptive systems perspective, the above mechanisms can be explained as emergent properties of the dynamic network of values-based connections operating within health systems. We also demonstrate that this theory accounts for how HPSR authors write about the relationship between health systems and social values. Finally, we offer lessons for researchers and policy-makers seeking to bring about values-based change in health systems.

Social values and health systems in health policy and systems research: a mixed-method systematic review and evidence map

Because health systems are conceptualized as social systems, embedded in social contexts and shaped by human agency, values are a key factor in health system change. As such, health systems software-including values, norms, ideas and relationships-is considered a foundational focus of the field of health policy and systems research (HPSR). A substantive evidence-base exploring the influence of software factors on system functioning has developed but remains fragmented, with a lack of conceptual clarity and theoretical coherence. This is especially true for work on 'social values' within health systems-for which there is currently no substantive review available. This study reports on a systematic mixed-methods evidence mapping review on social values within HPSR. The study reaffirms the centrality of social values within HPSR and highlights significant evidence gaps. Research on social values in low- and middle-income country contexts is exceedingly rare (and mostly produced by authors in high-income countries), particularly within the limited body of empirical studies on the subject. In addition, few HPS researchers are drawing on available social science methodologies that would enable more in-depth empirical work on social values. This combination (over-representation of high-income country perspectives and little empirical work) suggests that the field of HPSR is at risk of developing theoretical foundations that are not supported by empirical evidence nor broadly generalizable. Strategies for future work on social values in HPSR are suggested, including: countering pervasive ideas about research hierarchies that prize positivist paradigms and systems hardware-focused studies as more rigorous and relevant to policy-makers; utilizing available social science theories and methodologies; conceptual development to build common framings of key concepts to guide future research, founded on quality empirical research from diverse contexts; and using empirical evidence to inform the development of operationalizable frameworks that will support rigorous future research on social values in health systems.

China's National Health Guiding Principles: a perspective worthy of healthcare reform

For countries faced with much talk but little action on healthcare reform, China's National Health Guiding Principles (CNHGP), with its 60-year history, may provide a new perspective. There are four values of CNHGP for healthcare reform. First, these principles provide an innovative strategic framework for healthcare reform with three levels, from 'One priority population' to 'Four approaches' and then to 'Two aims.' The second is the importance of mass/grassroots participation, which runs through all three levels of CNHGP. The third value is that the CNHGP used nonspecific social approaches, an innovation in healthcare delivery that addressed the social determinants of health. The fourth value is the integration between Chinese traditional medicine and Western medicine.

Public values, health inequality, and alternative notions of a "fair" response

The fact that disadvantaged people generally die younger and suffer more disease than those with more resources is gaining ground as a major policy concern in the United States. Yet we know little about how public values inform public opinion about policy interventions to address these disparities. This article presents findings from an exploratory study of the public's values and priorities as they relate to social inequalities in health. Forty-three subjects were presented with a scenario depicting health inequalities by social class and were given the opportunity to alter the distribution of health outcomes. Participants' responses fell into one of three distributive preferences: (1) prioritize the disadvantaged, (2) equalize health outcomes between advantaged and disadvantaged groups, and (3) equalize health resources between advantaged and disadvantaged groups. These equality preferences were reflected in participants' responses to a second, more complex scenario in which trade-offs with other health-related values - maximizing health and prioritizing the sickest - were introduced. In most cases, participants moderated their distributive preferences to accommodate these other health goals, particularly to prioritize the allocation of resources to the very sick regardless of their socioeconomic status.

Playing fair: fairness beliefs and health policy preferences in the United States

Conventional wisdom suggests that the best way to persuade Americans to support changes in health care policy is to appeal to their self-interest - particularly to concerns about their economic and health security. An alternative strategy, framing problems in the health care system to emphasize inequalities, could also, however, mobilize public support for policy change by activating underlying attitudes about the unfairness or injustice of these inequalities. In this article, we draw on original data from a nationally representative survey to describe Americans' beliefs about fairness in the health domain, including their perceptions of the fairness of particular inequalities in health and health care. We then assess the influence of these fairness considerations on opinions about the appropriate role of private actors versus government in providing health insurance. Respondents believe inequalities in access to and quality of health care are more unfair than unequal health outcomes. Even after taking into account self-interest considerations and the other usual suspects driving policy opinions, perceptions of the unfairness of inequalities in health care strongly influence respondents' preferences for government provision of health insurance.

The politics of public health policy

Politics, for better or worse, plays a critical role in health affairs. The purpose of this article is to articulate a role for political analysis of public health issues, ranging from injury and disease prevention to health care reform. It begins by examining how health problems make it onto the policy agenda. Perceptions regarding the severity of the problem, responsibility for the problem, and affected populations all influence governmental responses. Next, it considers how bounded rationality, fragmented political institutions, resistance from concentrated interests, and fiscal constraints usually lead political leaders to adopt incremental policy changes rather than comprehensive reforms even when faced with serious public health problems. It then identifies conditions under which larger-scale transformation of health policy can occur, focusing on critical junctures in policy development and the role of policy entrepreneurs in seizing opportunities for innovation. Finally, it reviews the challenges confronting officials and agencies who are responsible for implementing and administering health policies. Public health professionals who understand the political dimensions of health policy can conduct more realistic research and evaluation, better anticipate opportunities as well as constraints on governmental action, and design more effective policies and programs.

Profit-seeking, corporate control, and the trustworthiness of health care organizations: assessments of health plan performance by their affiliated physicians

OBJECTIVE

To compare the relative trustworthiness of nonprofit and for-profit health plans, using physician assessments to measure dimensions of plan performance that are difficult for consumers to evaluate.

DATA SOURCE

A nationally representative sample of 1,621 physicians who responded to a special topics module of the 1998 Socioeconomic Monitoring System Survey (SMS), fielded by the American Medical Association. Physicians assessed various aspects of their primary managed care plan, defined as the plan in which they had the largest number of patients.

STUDY DESIGN

Plan ownership was measured as the interaction of tax-exempt status (nonprofit versus for-profit) and corporate control (single state versus multistate health plans). Two sets of regression models are estimated. The dependent variables in the regressions are five measures of performance related to plan trustworthiness: two related to deceptive practices and three to dimensions of quality that are largely hidden from enrollees. The first set (baseline) models relate plan ownership to trustworthy practices, controlling for other characteristics of the plan, the marketplace for health insurance, and the physician respondents. The second (interactive) set of models examines how the magnitude of ownership-related differences in trustworthiness varies with the market share of nonprofit plans in each community.

DATA COLLECTION

The 1998 SMS was fielded between April and September of 1998 by Westat Inc. The average time required for a completed interview was approximately 30 minutes. The overall response rate was 52.2 percent.

PRINCIPAL FINDINGS

Compared with more local nonprofit plans, for-profit plans affiliated with multistate corporations are consistently reported by their affiliated physicians to engage in practices associated with reduced trustworthiness. Nonprofit plans affiliated with multistate corporations have more physician-reported practices associated with trustworthiness than do for-profit corporate plans on four of five outcomes, but appear less trustworthy than locally controlled nonprofits on two of the five measures. The magnitude of these ownership-related differences declines as the market share of nonprofit plans rises: for two of the five measures, ownership-related differences in practices related to trustworthiness are entirely eliminated when the nonprofits enroll more than 30 percent of the local market.

CONCLUSIONS

The combination of for-profit ownership and multistate corporate control appears to consistently and substantially reduce physician-reported measures related to the trustworthiness of health plans. Because this is the fastest growing form of managed care, these results raise concerns about further erosion of trust in American health care. Preserving a substantial market niche for nonprofit plans appears to reduce this erosion and should be considered by policymakers as a strategy for restoring trust in the health care system.

Why can't we do what they do? National health reform abroad

Even Americans who have only a vague knowledge of health policy know that the U.S. is different. We do not have “socialized medicine,” like our European or Canadian neighbors. We believe that health care is not rationed here, and that, unlike citizens of other nations, we do not have to wait in long queues when we need medical care. We believe that U.S. health care is the best in the world.

At the same time, the U.S. spends more on health care - both per capita and as percentage of gross domestic product (GDP) - than other nations do. One in six non-elderly Americans has no health insurance, and voluminous studies show that lack of health insurance has a dramatic effect on both access to care and on health status. Furthermore, on many of the most important indicators of population health, such as infant mortality and life expectancy, the U.S. scores worse than do other nations.