School of Policy Planning and Development



Keck School of Medicine, Department of Preventive Medicine

University of Southern California

MPH Program

PM 508: Health Service Delivery in the United States

SPRING 2011

THURSDAYS: 9:00 AM to 12:30 PM

Class Location: HSA 8050

Instructor: Gregory D. Stevens, Ph.D., M.H.S.

Office Hours: Thursday, 1:00-2:00 PM or by appointment.

Office Location: HSA (Alhambra) Building A7, 4th Floor, Room 7411

Phone: (626) 457-4049

Email: gstevens@usc.edu

Teaching Assistant: TBD

Office Hours: By appointment.

Email: TBD

 

Blackboard:

OVERVIEW

This course is a core class for the MPH degree. The course will examine the health care delivery system broadly and explore contemporary issues affecting the institutions that provide health care and are designed to protect the health of the American public. The course will cover the historical development of the U.S. health care system, the changing roles of health care providers, major health programs, and health care financing. The course will explore the determinants of health, disparities in health and health care, and the controversial role of medical care in their remediation. Finally, the course will cover the process of health policy formation and current efforts at health care reform. The goal of the course is to provide students with the necessary skills to be effective participants in efforts to improve the U.S. health care system.

COURSE OBJECTIVES

Upon completing the course, the student will be able to:

1. Understand major trends in the history of medicine and public health and relate them to current events.

2. Identify the determinants of health, including both major protective and major risk factors, and the effects of health care services.

3. Describe the components of the health care delivery system and how they work together, or fail to work together, to address health problems.

4. Understand the functioning of major institutions and the roles of provider groups.

5. Understand the components of health care financing including insurance coverage, major public programs, and economic incentives in health care.

6. Understand where to get information and data about health and health care.

7. Understand the core elements of health policy-making including the roles of government and major stakeholders, major statutes affecting health care, and difficulties in passing health care reform.

8. Describe contemporary policy issues in health care delivery including the role of managed care, quality of care, privacy and consumer protections.

9. Understand and weigh ethical considerations in the health care field.

10. Analyze, evaluate, and design options for reform of the health care system.

REQUIRED TEXTBOOK

Anthony Kovner and James Knickman (Editors). Jonas & Kovner’s Health Care Delivery in the United States, 9th Ed. Springer Publishing Company, 2008.

RECOMMENDED TEXTBOOK

Jonathan Cohn. Sick: The Untold Story of America’s Health Care Crisis and the People Who Pay the Price. Harper Collins, 2007.

WEEKLY READINGS

Readings will be listed on the blackboard system. Links to the readings will be provided. These links will be accessible from a USC computer or by remote access to the USC server.

GRADING SCALE

A = 93-100%

A- = 90-92%

B+ = 87–89%

B = 83-86%

B- = 80-82%

C+ = 77-79%

C = 73-76%

C- = 70-72%

D+ = 67-69%

D = 63-66%

D- = 60-62%

F = 59% or less

DISABILITY SERVICES AND PROGRAMS

Any student requesting academic accommodations based on a disability is required to register with Disability Services and Programs (DSP) each semester. A letter of verification for approved accommodations can be obtained from DSP. Please be sure that the letter is delivered as early in the semester as possible. DSP is located in STU 301 (213-740-0776).

INTEGRITY

As everyone was informed in your initial orientation to USC, academic integrity is of paramount importance. Please take this responsibility seriously. Cheating or plagiarism will not be tolerated. Do not simply cut and paste information from the web, but rather use information from online sources as you would information from published materials. You may consult with other students in completing take home assignments but do not copy or use anything from another student’s assignment. Papers will be carefully read and verified. The instructor reserves the right to use outside vendors to screen and verify the originality of submissions. In-class exams will be monitored. When someone cheats, that person is damaging the credibility of each student’s achievements and the reputation of the University. For further information, such as the precise definition of plagiarism, please read the Student Conduct Code material reprinted each year in SCAMPUS or the MPH student handbook. Please contact the instructor if you have any questions.

REQUIREMENTS OF THE COURSE

The success of the course depends greatly upon student preparation and involvement in all aspects of the class. Students are expected to complete all assigned readings, attend lectures and participate in discussions. Clarity in exposition is essential.

Familiarity with Health Data Sources: Students should become familiar with the major sources of health data at the national and state levels. The National Center for Health Statistics is an invaluable source of data on health and health care at the national level, and the California Health Interview Survey site provides easy access to state health and health care access, and insurance data.

• National Center for Health Statistics: nchs

• California Health Interview Survey: chis.ucla.edu

Familiarity with Health Policy Issues: It is recommended that students sign-up for a daily or weekly email newsletter on state and national health policy activities to be conversant on health policy issues. One excellent California e-newsletter is California Healthline, which covers local, state, and national issues. Perhaps the best national e-newsletter is from the Kaiser Family Foundation.

• California Healthline:

• Kaiser Family Foundation: profile/subscriptions.cfm

COURSE ASSIGNMENTS

Assignment 1: Participation in Online Blog (5% of course grade)

After each lecture, a question or issue will be posted by the professor or T.A. on a class blog relating to the next lecture. Students are expected to contribute at least once to the online conversation. Alternately, students may propose their own questions or begin a dialogue with students on a related topic. Responses must be posted before the start of the next class (a one-week period). If the blackboard system is not accessible, students may submit a response to the T.A. by email or in writing before the beginning of class.

Assignment 2: Individual Policy Memorandum

Each student will complete an individual policy memo on a topic of choice. The purpose of the policy memo is for the student to identify a current major health care policy issue, examine the competing policy perspectives, explore and weigh the evidence available in support of the perspectives, and make a policy recommendation. There are two steps to completing the assignment:

A. Topic Selection (recommended, no grade)—Due Feb 4th at 5:00pm.

The first step in the completion of this assignment is the selection of the topic. The submission should include the proposed policy question and a description of why the topic is important and interesting to you. List 2-3 policy options and the option that you think you will be recommending. Include a brief list of possible sources or references. List any areas where you think you might need help. The assignment should be submitted using blackboard. The Professor will provide feedback on the appropriateness of the topic and policy options.

B. Completed Policy Memo (35% of course grade)—Due Feb 25th at 5:00pm

Each student will complete an individual policy memorandum on a topic of choice. The purpose of the policy memo is to concisely provide advice to a policy-maker on a current major health care policy issue or debate in the United States. Students must identify a main policy question and then offer 2-3 policy options and compare them. Evidence from the peer-reviewed literature must be used to support the selection of one option as the policy recommendation.

The memo should be concisely written (3-4 pages maximum, single-spaced, 12-point font, with one-inch margins). References should be “endnotes” numbered in the memo and listed at the bottom of the final page. The endnotes are included in the total page count. The memo is to be submitted using the blackboard system. A well-reasoned argument, a rational consideration of the options, and clear recommendation will be essential. Memos will be evaluated on the following:

1. Description of the policy question and background

2. Description and reasonableness of the policy options

3. Review of empirical evidence regarding the policy options

4. Reasoning, argument, and rationale for the recommended policy

5. Appropriateness, breadth, and use of the references

6. Grammar, spelling, clarity, and overall readability

Assignment 3: Group Policy Project

Students will work in teams of 4-5 to examine current health care reform topics existing at the state, national, and international levels. Groups will select their own teams, but will be assigned a health reform topic. The purpose of the assignment is to collectively assess a range of specific health care topics and to enable the class to be well informed on a variety of health reform issues. There are four steps to completing the assignment:

A. Project Work Plan (completed in class)

The first step is to develop a short (2-page) work plan that outlines the steps required to prepare the presentation. In preparation for the presentation, students must complete short interviews with representatives of sponsoring legislators at the national or state levels (or interview a health care provider for international projects) to obtain the most current information, ask questions about supporters and opponents, etc. In addition to a general work plan and timeline for the project, students should list the individuals to be contacted, a draft of the questions that will be asked, and a description of the overall division of labor among team members. Groups should brainstorm ways to engage the class in learning. The T.A. will provide feedback on the project work plan.

B. Completed Presentation (15% of course grade)—Due as Assigned

The second step is to prepare and deliver a one-hour minimum (one-and-a-half hour maximum) presentation to help inform the class about the health care reform topic and implications for California and the U.S. The presentation should be engaging for the class (e.g., discussion, class involvement, group activity, etc.) The presentation should cover the following topics at a minimum:

7. The reform proposal or issue and its goals

8. Financing for the reform (role of government, business, individuals)

9. Stakeholder supporters and opponents (confirmed and anticipated)

10. Highlights from the required completed interview(s)

11. Analysis of the reforms for the U.S. or California

12. A recommendation for U.S. or California voters (if applicable)

C. Peer-Review of Presentation (10% of course grade)—Due as Assigned

Group presentations will also by a peer review process. The peer review forms will be distributed to students at each presentation and will be used to evaluate the clarity of the presentation, thoughtfulness and comprehensiveness of topics presented, division of labor during the presentation, organization and use of the materials, and engagement of the class in discussion. The professor reserves the option to add or subtract points from the group grade applied to an individual who does not carry his or her weight in preparing for or delivering the presentation.

D. Completion of the Peer Reviews (5% of course grade)—Due as Assigned

All students will be asked to provide reviews of the presentations of other teams. The purpose of these reviews is to provide the team with meaningful and useful feedback on their performance and ways to improve. Students who provide full reviews and constructive feedback to their classmates will receive full credit. Students who miss an opportunity to provide a given peer review for any reason may obtain full credit for the review by submitting a three-page, double-spaced review and analysis of the presentation within two weeks of the presentation date.

Assignment 4: Final Exam (30% of the course grade)—In-Class on May 5th 9:00am

There will be a two-hour, in-class final examination covering the course topics from all lectures (including guest lectures) and readings. The exam will consist of about 20 short answer questions and one short essay (1-page) testing knowledge and application of the course content. There will be a review session held in-class on April 28th.

BASIS FOR GRADING

13. Online blog participation 5%

14. Completed individual policy paper 35%

15. Completed group presentation 15%

16. Peer reviews of presentation 10%

17. Completion of the peer reviews 5%

18. Final Examination 30%

Assignments that are turned in late are subject to an automatic 10% reduction in grade.

University policy allows professors to grant an incomplete only in cases of emergency or serious illness. Plan your work throughout the entire 16 weeks so that job and family pressures can be accommodated should they occur at the end of the course.

TENTATIVE SCHEDULE, LECTURE TOPICS, AND READINGS

JAN 13: THE DETERMINANTS OF POPULATION HEALTH

Part 1: Course overview, assignments, and expectations

Part 2: The determinants of population health

Reading:

❖ Starfield B. Is U.S. health really the best in the world? JAMA. 2000 Jul 26;284(4):483-5.

❖ Breslow L. Health measurement in the third era of health. Am J Public Health. 2006 Jan;96(1):17-9.

JAN 20: OVERVIEW OF THE U.S. HEALTH CARE SYSTEM

Part 1: Development and evolution of the profession of medicine

Part 2: Synopsis of the current modern medical system in the U.S.

Reading:

❖ Kovner and Knickman (Chapter 4)

❖ Hoffman B. Health care reform and social movements in the United States. Am J Public Health. 2003; 93(1):75-85.

❖ Fuchs VR. Three “inconvenient truths” about health care. N Engl J Med. 2008; 359(17): 1749-51.

JAN 27: HEALTH CARE FINANCING AND EXPENDITURES

Part 1: Insurance coverage and public health insurance programs

Part 2: Assignment of group project teams; in class development of work plan

Reading:

❖ Kovner and Knickman (Chapter 3)

❖ Anderson GF, et al. It’s the prices, stupid: why the United States is so different from other countries. Health Aff. 2003;22(3):89-105.

❖ Anderson GF, Frogner BK. Health spending in OECD countries: obtaining value per dollar. Health Aff. 2008; 27():1718-1727.

FEB 3: THE ROLE OF GOVERNMENT IN HEALTH CARE

Part 1: The process of health policy formation and implementation

Part 2: Government organization, financing and delivering health care

Assignment Due: Topic Selection (Due Friday, Feb 4th by 5:00pm)

Reading:

❖ Kovner and Knickman (Chapter 5)

❖ Gostin LO, Power M. What does social justice require for the public's health? Public health ethics and policy imperatives. Health Aff. 2006; 25(4):1053-60.

❖ Lantz PM, Lichtenstein RL, Pollack HA. Health policy approaches to population health: the limits of medicalization. Health Aff. 2007; 26(5):1253-7.

FEB 10: ORGANIZATION AND DELIVERY OF HEALTH SERVICES

Part 1: How health services are organized: primary, specialty, and tertiary care

Part 2: The particular role of primary care and its contribution to health

Reading:

❖ Kovner and Knickman (Chapter 12)

❖ Bodenheimer T, Berenson RA, Rudolf P. The primary care-specialty income gap: why it matters. Ann Intern Med. 2007;19;146(12):895-6.

❖ Starfield B, Fryer GE Jr. The primary care physician workforce: ethical and policy implications. Ann Fam Med. 2007 Nov-Dec;5(6):486-91.

FEB 17: EVALUATING SYSTEM PERFORMANCE

Part 1: Approaches to measuring access, quality and outcomes of health care

Part 2: Applying performance measurement to enhance quality

Assignment Due: Completed Policy Memo (Due Friday, Feb. 25th by 5:00pm)

Reading:

❖ Leape LL, Berwick DM. Five years after To Err Is Human: what have we learned? JAMA. 2005 May 18;293(19):2384-90.

❖ McGlynn EA, Brook RH. Keeping quality on the policy agenda. Health Aff. 2001;20(3):82-90.

FEB 24: MANAGED CARE (AT L.A. CARE HEALTH PLAN)

Part 1: Managed care for vulnerable populations in L.A. (guest: TBA)

Reading:

❖ Mechanic D. The rise and fall of managed care. J Health Soc Behav. 2004;45(Suppl):76-86.

❖ Robinson JC. Reinvention of health insurance in the consumer era. JAMA. 2004;291(15):1880-6.

MAR 3: SPECIAL TOPIC: VIEWING OF THE FILM “SICKO”

Reading:

❖ Hacker JS. Healing our sicko health care system. N Engl J Med. 2007; 357(8):733-5.

MAR 10: SPECIAL TOPIC: INTERNATIONAL HEALTH SYSTEMS

Part 1: Overview of international health care systems, structures, and financing

Part 2: Implications for reforming the U.S. health care system

Reading:

❖ Woolhandler S, Himmelstein DU. Competition in a publicly funded healthcare system. BMJ. 2007; 335(7630):1126-9.

❖ Nolte E, Mckee CM. Measuring the health of nations: updating an earlier analysis. Health Aff. 2008;27(1):58-71

MAR 17: SPRING RECESS—NO CLASS

MAR 24: SPECIAL TOPIC: VULNERABLE POPULATIONS

Part 1: Definition, theories, and health consequences for vulnerable populations

Part 2: Student presentation

Reading:

❖ Fiscella K, Shin P. The inverse care law: implications for healthcare of vulnerable populations. J Ambul Care Manage. 2005;28(4):304-12.

❖ Mechanic D, Tanner J. Vulnerable people, groups, and populations: societal view. Health Aff (Millwood). 2007 Sep-Oct;26(5):1220-30.

MAR 31: SPECIAL TOPIC: HEALTH WORKFORCE DEVELOPMENT

Part 1: Training of health professionals to meet population needs (guest: TBD)

Part 2: Student presentation

Reading: None assigned

APRIL 7: SPECIAL TOPIC: SCHOOL-BASED HEALTH SERVICES

Part 1: Health care delivery systems for children in LAUSD (guest: TBD)

Part 2: Student presentation

Reading: None assigned

april 14: SPECIAL TOPIC: SAFETY-NET HEALTH CENTERS

Part 1: Health care delivery for vulnerable populations in LA (guest: TBD)

Part 2: Student presentation

Reading: None assigned

APRIL 21: SPECIAL TOPIC: HEALTH INFORMATION TECHNOLOGY

Part 1: The CAIR immunization registry in Los Angeles (guest: TBD)

Part 2: Student presentation

Reading: None assigned

APRIL 28: COURSE WRAP-UP AND FINAL EXAM REVIEW

Part 1: Course wrap-up, implications of health care reform, etc.

Part 2: Final exam review session

MAY 5: IN-CLASS FINAL EXAM: 9:00-11:30AM

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