Crossing the Policy Chasm:Crossing the Policy Chasm:How to Connect Health How to Connect Health Services Research with Services Research with

Decision-MakingDecision-Making

Andrew Bindman, MDAndrew Bindman, MD

Professor Medicine, Health Professor Medicine, Health Policy, Epidemiology & Policy, Epidemiology & BiostatisticsBiostatistics

University of California San University of California San FranciscoFrancisco

Traditional Research to Policy Traditional Research to Policy ModelModel

Problem identified with help of Problem identified with help of researchresearch

Decision making about actions Decision making about actions supported by research on optionssupported by research on options

Policy implementedPolicy implementedMonitoring and evaluation through Monitoring and evaluation through researchresearch

Research at the core of rational Research at the core of rational decision making based on decision making based on consideration of all the optionsconsideration of all the options

Traditional Model Not So Traditional Model Not So TraditionalTraditional

Real life decision making not Real life decision making not linearlinear

More iterative processMore iterative process Too complex to consider all the Too complex to consider all the options and insufficient data to options and insufficient data to do sodo so

Rather than finding ideal Rather than finding ideal solution looking for a “good solution looking for a “good enough” oneenough” one

Incremental PolicyIncremental Policy

““Good enough solutions” lead Good enough solutions” lead to small scale changesto small scale changes

Research not at the heart of Research not at the heart of assessing all the options but assessing all the options but used in selective ways by used in selective ways by competing groups that move in competing groups that move in a diffuse way toward consensusa diffuse way toward consensus

Two CommunitiesTwo Communities

Research and policy worlds Research and policy worlds culturally distinctculturally distinct

Distinct language, timing, Distinct language, timing, and valuesand values

ValuesValues

AcademicAcademic– Publish or Publish or PerishPerish

– A Mile DeepA Mile Deep– Peer ReviewPeer Review– Teaching Teaching – Research/Research/GrantsGrants

– DepartmentDepartment– Endowed ChairEndowed Chair– TenureTenure

The HillThe Hill– The Power of the The Power of the PressPress

– A Mile WideA Mile Wide– Public opinionPublic opinion– Meet and GreetMeet and Greet– FundraisingFundraising– Committees (A/B)Committees (A/B)– Committee ChairCommittee Chair– ReelectionReelection

Researchers tend to see Researchers tend to see decision making as an event-decision making as an event-they deliver their edicts to they deliver their edicts to the impenetrable cardinals’ the impenetrable cardinals’ retreat and await the puff of retreat and await the puff of smoke that signals decision smoke that signals decision while grumbling about while grumbling about irrationality within the irrationality within the conclaveconclave

Decision makers tend to see Decision makers tend to see research as a product they research as a product they can purchase from the local can purchase from the local knowledge store, but too knowledge store, but too often it is the wrong size often it is the wrong size needs some assembly, is on needs some assembly, is on back order, and comes from back order, and comes from last year’s fashion line last year’s fashion line

Knowledge BrokeringKnowledge Brokering

Conduit for two way communication Conduit for two way communication between researchers and decision-between researchers and decision-makersmakers

Informing decisions is as much Informing decisions is as much social as it is technicalsocial as it is technical

Requires re-formulated Requires re-formulated communication and social communication and social interaction to bridgeinteraction to bridge

Attributes of Knowledge Attributes of Knowledge BrokersBrokers

Understands cultures of research Understands cultures of research and decision making environments and decision making environments

Able to find and assess relevant Able to find and assess relevant research in a variety of formatsresearch in a variety of formats

Facilitates, mediates, Facilitates, mediates, negotiatesnegotiates

Trusted and credibleTrusted and credible Clear communicatorClear communicator

Who Are Knowledge Brokers Who Are Knowledge Brokers in Federal Health Policyin Federal Health Policy

• Congressional think tanksCongressional think tanks CRS, CBO, GAOCRS, CBO, GAO

• Congressional CommissionsCongressional Commissions Medpac, MACPACMedpac, MACPAC

• Institute of MedicineInstitute of Medicine• FoundationsFoundations• Universities and other Universities and other

research organizationsresearch organizations

Others Who Seek to Fill Others Who Seek to Fill the Knowledge Voidthe Knowledge Void

Washington think tanksWashington think tanks

Interest groupsInterest groups

Voluntary Health AssociationsVoluntary Health Associations

American Heart AssociationAmerican Heart Association American Cancer SocietyAmerican Cancer Society American Diabetes AssociationAmerican Diabetes Association Paralyzed Veterans of AmericaParalyzed Veterans of America National Alliance Mentally National Alliance Mentally IllIll

March of DimesMarch of Dimes

Trade AssociationsTrade Associations

America’s Health Insurance America’s Health Insurance PlansPlans

American Hospital AssociationAmerican Hospital Association Association of American Association of American Medical CollegesMedical Colleges

Federation of American Health Federation of American Health SystemsSystems

Pharmaceutical Research and Pharmaceutical Research and Manufacturers AssociationManufacturers Association

ADVAMEDADVAMED

Professional SocietiesProfessional Societies

American Medical AssociationAmerican Medical Association National Medical AssociationNational Medical Association American Nurses AssociationAmerican Nurses Association American Pharmacists American Pharmacists AssociationAssociation

American Trial Lawyers American Trial Lawyers AssociationAssociation

Think TanksThink Tanks

Center for American Center for American ProgressProgress

HeritageHeritage CatoCato Urban InstituteUrban Institute New America FoundationNew America Foundation Brookings InstituteBrookings Institute

UNIONSUNIONS

SEIUSEIU AFL-CIOAFL-CIO UAWUAW ILGWUILGWU

Other Major StakeholdersOther Major Stakeholders

AARPAARP Families USAFamilies USA National Governors National Governors AssociationAssociation

National Conference of State National Conference of State LegislatorsLegislators

Knowledge Broker Knowledge Broker CommunicationCommunication

Shopping ideas to sympathetic Shopping ideas to sympathetic staff in Congress, White House staff in Congress, White House and Agenciesand Agencies

Cultivating specific Cultivating specific relationshipsrelationships

Talking to other knowledge Talking to other knowledge brokersbrokers

Communicating back to leadership Communicating back to leadership of organizationof organization

What are They Talking What are They Talking AboutAbout

Updates about what new things Updates about what new things they have learned since last they have learned since last conversationconversation

Information about membership Information about membership concernsconcerns

Updates about where things are Updates about where things are in legislation cyclein legislation cycle

Updates on how other decision Updates on how other decision makers view action itemsmakers view action items

Interest Groups Will Go Beyond Interest Groups Will Go Beyond Information and Promote ActionInformation and Promote Action

Encourage introduction of Encourage introduction of billbill

Write language of billWrite language of bill Strategize politics of Strategize politics of legislation with legislation with Congressional leadershipCongressional leadership

Bring members to hearingsBring members to hearings Liaison with executive branchLiaison with executive branch

Why Do Policy Makers/Staff Why Do Policy Makers/Staff Want to Meet with Knowledge Want to Meet with Knowledge BrokersBrokers

To hear about the latest research To hear about the latest research findingsfindings

To learn about stakeholder To learn about stakeholder positions and prioritiespositions and priorities

To learn what knowledge brokers To learn what knowledge brokers have learned from other decision have learned from other decision makersmakers

To test ideas for solutionsTo test ideas for solutions To activate political pressureTo activate political pressure

Limitations of Knowledge Limitations of Knowledge Broker Model for ResearchersBroker Model for Researchers

Time demanding to be an Time demanding to be an available resource for available resource for decision-makersdecision-makers

Value of objective research Value of objective research evidence can be diminished in a evidence can be diminished in a sea of competing messages from sea of competing messages from biased knowledge brokersbiased knowledge brokers

Promotes style over substancePromotes style over substance

Where Does Research End Where Does Research End and Advocacy Beginand Advocacy Begin

Some researchers never cross the Some researchers never cross the policy chasmpolicy chasm

Others engage policymakers without Others engage policymakers without engaging the communities affected by engaging the communities affected by the policiesthe policies

Increasingly researchers are working Increasingly researchers are working in a collaborative and interactive way in a collaborative and interactive way throughout the research process with throughout the research process with stakeholders to influence policystakeholders to influence policy

Community Based Community Based Participatory ResearchParticipatory Research

““Research subjects become more than Research subjects become more than research objects. They give more than research objects. They give more than informed consent; they give their informed consent; they give their knowledge and experience to the knowledge and experience to the formulation of research questions and formulation of research questions and methods applied…they become active methods applied…they become active partners in identifying key problems partners in identifying key problems and in using the research findings to and in using the research findings to advocate policies and programs and in advocate policies and programs and in program development, monitoring and program development, monitoring and evaluation.”evaluation.”

Green and Mercer, AJPH, 2001Green and Mercer, AJPH, 2001

Who is the Community in Who is the Community in Participatory ResearchParticipatory Research

Those affected by issue being Those affected by issue being studiedstudied– Individuals living in a Individuals living in a geographic areageographic area

– Community based organizationsCommunity based organizations– Government agencies that Government agencies that provide/manage resources provide/manage resources targeting at- risk targeting at- risk individuals/communitiesindividuals/communities

Traditional Research vs Traditional Research vs CBPRCBPR

Formative StageFormative Stage Traditional Traditional ApproachApproach– Researchers Researchers plan projectplan project

– Form teamForm team

CBPR ApproachCBPR Approach– Policymakers Policymakers and academic and academic partners form partners form teamteam

– Develop shared Develop shared mission and mission and decision-decision-making making structurestructure

Traditional Research vs Traditional Research vs CBPRCBPR

Study SelectionStudy Selection Traditional Traditional ApproachApproach– Researchers Researchers choose topic and choose topic and design based on design based on scientific scientific theory, academic theory, academic interest, data, interest, data, feasibilityfeasibility

CBPR ApproachCBPR Approach– Policymakers Policymakers and academic and academic partners also partners also incorporate incorporate community community priorities priorities insights and insights and assets; assets; scientific scientific rigor and rigor and community community feasibilityfeasibility

Traditional Research vs Traditional Research vs CBPRCBPR

FundingFunding

Traditional Traditional ApproachApproach– Grant written Grant written by researcherby researcher

– Funds go to Funds go to researchersresearchers

CBPR ApproachCBPR Approach– Policymakers Policymakers and academic and academic partners co-partners co-develop grant develop grant with equitable with equitable distribution distribution of funds based of funds based on on contributionscontributions

Traditional Research vs Traditional Research vs CBPRCBPR

Implementation/AnalysisImplementation/Analysis Traditional Traditional ApproachApproach– Researchers Researchers solely solely responsible responsible for conducting for conducting study and study and analyzing dataanalyzing data

CBPR ApproachCBPR Approach– Policymakers Policymakers and academic and academic partners partners collaborate on collaborate on all efforts; all efforts; traditional traditional analysis analysis informed by informed by policy driven policy driven questionsquestions

Traditional Research vs Traditional Research vs CBPRCBPR

Disseminate FindingsDisseminate Findings Traditional Traditional ApproachApproach– Disseminate to Disseminate to academic academic audiencesaudiences

CBPR ApproachCBPR Approach– Policymakers and Policymakers and academic academic partners are co-partners are co-authors and co-authors and co-presenters; presenters; disseminating to disseminating to academics, academics, research research participants, participants, involved involved communities and communities and policy makerspolicy makers

Traditional Research vs Traditional Research vs CBPRCBPR

Translate Research in Translate Research in PolicyPolicy

Traditional Traditional ApproachApproach– Research often Research often ends with ends with publishing of publishing of resultsresults

CBPR ApproachCBPR Approach– Policymakers Policymakers and academic and academic partners partners mobilize the mobilize the community to community to use findings use findings to advocate to advocate for policy for policy changechange

Traditional Research vs Traditional Research vs CBPRCBPR

Sustain TeamSustain Team

Traditional Traditional ApproachApproach– When grant When grant ends, ends, researchers researchers often move to often move to new projectnew project

CBPR ApproachCBPR Approach– Sustainability Sustainability built into work built into work from inception; from inception; partners honor partners honor initial initial commitment to commitment to continue continue partnership and partnership and work beyond work beyond funding cyclesfunding cycles

Community Based Community Based Participatory Research Participatory Research (CBPR)(CBPR) BenefitsBenefits

– Direct and indirect funding Direct and indirect funding potentialpotential

– Enhanced access to dataEnhanced access to data– Greater understanding of policy Greater understanding of policy questionsquestions

– Opportunity to participate in Opportunity to participate in applied work that could have applied work that could have direct impact on policydirect impact on policy

CBPR with PolicymakersCBPR with Policymakers

ChallengesChallenges– Relationships take time Relationships take time – Sharing power, resources, Sharing power, resources, decision-makingdecision-making

– Service versus research Service versus research objectivesobjectives

– Academic independence and Academic independence and desire to learn from data desire to learn from data versus a shared mission-driven versus a shared mission-driven set of beliefsset of beliefs

Community Based Community Based Participatory Research Participatory Research with Policymakerswith Policymakers Additional ChallengesAdditional Challenges

– If too aligned with one If too aligned with one political party could be labeled political party could be labeled and isolated by the otherand isolated by the other

– Political environment can Political environment can challenge ability of challenge ability of policymakers to be consistent policymakers to be consistent partnerspartners

– Policy versus academic response Policy versus academic response timestimes

Navigating a University Navigating a University and State Government and State Government PartnershipPartnership

California Medicaid Research Institute California Medicaid Research Institute (CaMRI)(CaMRI)– University of California multi-campus University of California multi-campus research programresearch program

– Master agreement between UC and state Master agreement between UC and state that specifies expectations and that specifies expectations and responsibilities for choosing responsibilities for choosing projects, data sharing and publishingprojects, data sharing and publishing

– Cultivating relationship over time Cultivating relationship over time and deep into organizations - not just and deep into organizations - not just with leadershipwith leadership

– Pursue direct as well as independent Pursue direct as well as independent fundingfunding

CaMRI Medicaid Waiver CaMRI Medicaid Waiver Evaluation Process with Evaluation Process with StateState Formulate questions togetherFormulate questions together Agree on methodological Agree on methodological approachapproach

Approach funders togetherApproach funders together Dissemination plan includes Dissemination plan includes scientific community as well scientific community as well as Medicaid stakeholders as Medicaid stakeholders (counties, patients and (counties, patients and providers)providers)

Closing ThoughtsClosing Thoughts

Research can inform public policy and Research can inform public policy and be a powerful tool for social changebe a powerful tool for social change

To enhance your effectiveness you need To enhance your effectiveness you need to be scientifically rigorous and to be scientifically rigorous and sophisticated in how you disseminate sophisticated in how you disseminate your resultsyour results

Connecting with and forming linkages Connecting with and forming linkages among knowledge brokers is critical among knowledge brokers is critical for influencing the policy processfor influencing the policy process

Community based participatory research Community based participatory research may be a highly effective way to align may be a highly effective way to align the research process with the policy the research process with the policy decision-making processdecision-making process