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The Politics of Health Care

With the support of a new professorship, Signe Flieger assesses a changing landscape for the nation's patients

Signe Peterson Flieger, an assistant professor of public health and community medicine at Tufts, woke up on November 9, 2016, wondering what Donald Trumpís presidency would mean for U.S. health care. Candidate Trump promised to repeal Obamacare soon after he took office. Now he had the potential to deliver on that.

Besides increasing the number of Americans with health insurance, the Patient Protection and Affordable Care Act (ACA), the official name for Obamacare, set out to reform health-care delivery, access, and costs. The legislation introduced new models that incorporated prevention and care coordination and triggered a period of sweeping change.

As Aviva Must, N87, N92, J01P, A03P, the Morton A. Madoff, M.D., M.P.H., Professor of Public Health and Community Medicine, described it, "The ACA initiated a grand experiment in health care."

Trump's victory, and his subsequent nomination of six-term congressman Tom Price, a fierce opponent of the ACA, to head the Department of Health and Human Services, all but guarantee another sharp turn for U.S. health care.

Flieger has a nuanced perspective on what the health-care landscape could look like under the new administration. After the ACA became law in 2010, she dug into what happens when health-care organizations change the way they deliver care. "I focused on organizations as they implemented new initiatives," she said. "How were they transforming, and what could we learn about organizational change?" Thanks to a new professorship at Tufts University School of Medicine, Flieger, the first appointee to the Tufts Health Plan Professorship in Health Care Policy Research, will be able to continue her research about health-care policies and how they affect patients.

"Health policy has become very political," said Harris Berman, dean of the medical school. "We need people like Signe who understand the policies and their implications and whose research can help us understand what works or doesn't work based on evidence, not just politics."

Soon after the passage of the ACA, Flieger's research took her to New Hampshire to study nine primary-care practices that were implementing the patient-centered medical home model, an approach that establishes primary care practices as a "home base" for patients. Medical homes assume responsibility for tracking every aspect of a patient's care, keeping an eye out for potential complications, coordinating with other providers, and taking a population health approach to care delivery, all efforts that are aligned with the goals of the ACA.

Flieger analyzed insurance claims data and interviewed clinicians and administrators at each of the nine sites, asking what seemed to work, what did not, and whether they were interacting with patients differently than they had before. One of the themes that emerged was how long it takes to actually transform health-care delivery.

"Organizations in the medical home pilot study were getting mixed messages," she said. "They received some new incentives for delivering patient-centered care, but that only covered a portion of their services. Their other services were still being reimbursed by the old fee-for-service model [in which each treatment is paid for separately], and that affected the pace of change."

More recently, her research has shifted to palliative care, which is, by definition, patient centered. Involving patients in care decisions when they are seriously ill and aligning the delivery of care with a patient's goals, Flieger believes, will promote better care while also driving down costs.

"There's a lot of research into overutilization in patients' last weeks of life," she said. "Many times patients don't want all the expensive, invasive procedures they're given." However, she said, "palliative care is not just about end-of-life treatment."

With more hospitals adding palliative-care programs, Flieger wants to study how organizations are developing models to extend palliative care into community-based settings, such as primary-care offices, where patients might be more comfortable sharing their wishes when they are facing serious and life-limiting illness. Like many things related to health care, this will hinge on the policies of the new administration.

Regardless of who is in power in Washington, D.C., one reality remains unchanged. "We'll still have people living longer with multiple conditions," Flieger said. "People still want to have choices, and many don't want to end up in the hospital if they donít need to."

Nonetheless, she believes the concept of patient-centered care will change dramatically in the new administration. "There's a lot of attention on consumers making choices and purchasing health care with their own money. The question is, will the policies that claim to be consumer-directed put too much pressure on patients to make difficult decisions when they are sick and seeking care?"

Issues like these are of great interest to Tufts Health Plan, which has funded Flieger's professorship. "We always work to understand the challenges for our providers and our members," said Paul Kasuba, senior vice president and chief medical officer of the health plan, a network of 91 hospitals and 29,000 health providers who care for more than a million patients. "Professor Flieger's research will help us appreciate how these changes may impact our members and how we can continue to provide them access to the highest-caliber care possible."

Promoting Public Health

Tufts Health Plan and Tufts School of Medicine have a long history of working together to improve the health of communities. The health plan established the Madoff Public Health Professorship that is currently held by Must; it is named after a former dean of the medical school who established Tufts Health Plan in 1979.

The two institutions also co-founded the Tufts Health Care Institute, which for 20 years trained Tufts medical students in how to apply public health principles, such as patient-centered care and population health, to their practices.

When the institute disbanded recently, the health plan looked for another way to support the medical school. "Our goal, in part, was to continue to recognize the good work the medical school is doing to advance knowledge around population health," Kasuba said.

The new professorship is part of a fundraising strategy for the medical school as well, Berman said. "Our aim is to help young faculty accelerate their careers," said Berman, who hopes the Tufts Health Plan Professorship will be the first of several such opportunities for young faculty. "A named professorship signifies you're doing something special and helps attract additional funding," he said. "This is the ultimate recognition we can give a young professor."

Flieger said the professorship is an opportunity to refine her research agenda. "It gives me the flexibility to think about how to design my research so it can make the most meaningful contributions to the field."

With health care about to go through another period of sweeping change, Flieger has launched a health policy blog that synthesizes the intertwined perspectives of health, policy, and politics. "I've reinvigorated my policy side since the election," she said. "It's rapid-pace policy analysis for the non-wonk who wants to know whatís going to happen to Medicare or what it means if the ACA is dismantled."

It is that forward-looking perspective that made Flieger the ideal candidate for the Tufts Health Plan Professorship, Must said. "Signe thinks about health care with a 360-degree view. Her research will help us understand the drivers of health in a deeper way."