The heart of NYU Wagner's programs is our faculty. An amalgam of full-time, clinical/research/visiting, and adjunct professors, they are outstanding teachers, expert researchers and committed practitioners.
When organizations or businesses stumble, the search for an explanation often leads back to the quality of the evidence-gathering process. It is that process, known as Evidence-based Management (EBM), that fascinates Anthony R. Kovner, who has spent more than a decade trying to get managers to employ it when they seek ways to improve their organization’s performance and results.
Professor Kovner teaches EBM to students at the Robert F. Wagner Graduate School of Public Service, where he is a professor of public and health management and the director of the Executive MPA Program for Nurse Leaders. He is also the author of several books on healthcare management. Shortly before the publication of a chapter he recently wrote, entitled “Adventures in the Evidence-based Management Trade,” for the forthcoming Oxford Handbook of Evidence-Based Management (Oxford University Press), he sat down with NYU Research Digest (Spring 2012) to discuss Evidence-based Management.
What’s the theory behind EBM?
Evidence-based Management comes out of medicine—the idea that if you make a medical intervention, it should have a predictable and positive outcome. We said, “Why can’t we apply this in management?” Well, the truth is, it’s not a simple matter. We know a lot less about management than medicine, for which there’s a huge medical research establishment, the randomized clinical trial, and an established process for scientific review.
What professional sector does EBM most lend itself to?
To every sector. So for example, when two large health organizations decide to merge, we say, “Wouldn’t it make sense to look at the best available evidence before making a decision to merge?” Instead, a very common managerial response is: “We want to merge—let’s find the evidence that justifies it.” So these managers need to do more than just type “hospital merger” in Google? Keep in mind that all managers make decisions based on evidence. The point is, what is the quality of the evidence? It can be pretty shabby.
What’s wrong with the process as it works now?
When, for instance, two large institutions decide to merge, to what extent do they ask in advance, “What do we know about successful and unsuccessful mergers?” Generally speaking, what they do is ask the consultants, and the consultants say, “This would work in Akron.” But of course that doesn’t mean that it would work in Brooklyn. Are the merging institutions’ two geographies compatible? What about their respective cultures? It’s not that you get to a solution—these kinds of problems are too messy, too wicked, and the causation is not as clear as in randomized clinical trials. But it informs your thinking so you can see and avoid the worst consequences of what might happen.
How should the evidence gathering begin?
Three basic steps: search and locate the best available evidence, learn from best practices, and try doing your own management research. If you are studying why nurses turn over so much in your hospital, it’s important for you to understand the differences between the 12-hour day shift and the 12-hour night shift. The most important step, though, is to ask the right question, and translate your management challenge into an answerable one.
If EBM is so effective, why don’t more organizations engage in it?
That’s the $64,000 question, and it’s not an easy question to deal with. What it really is about is power and hierarchy and organizations. Let’s say an employee comes up with a better way of doing something and tells the boss about it. You’d expect the boss to say it’s a great idea, let’s do it. But in practice the boss says, “You’re insulting the way I’m managing this place,” or “If you thought of it, then how good can it be, if I didn’t think of it,” or “Go ahead and present your ideas to the higher-ups, and if they like it I’ll take credit for it, and, if they don’t we’ll blame you. “
That sounds almost insurmountable.
The trick of it is to make the politics work for you. To get it implemented, you have to get the managers to see that it’s in their political interest to practice evidence-based management. And I believe it is.”
Every year, hundreds of thousands of women die during childbirth as a result of preventable conditions, including the fact that many couldn’t afford proper care. Starting later this fall, an 18-month research initiative in Kenya will deliver, via mobile phones, a set of interventions designed in part to help pregnant women set aside enough savings to cover the cost of skilled care and delivery assistance.
The research will be conducted by James Habyarimana and Billy Jack, both of Georgetown University, Tavneet Suri of MIT, and Karen Grépin, an assistant professor of global health policy at NYU’s Robert F. Wagner Graduate School of Public Service, in collaboration with Changamka, Ltd., a Kenya micro-savings company. Financial support for the project comes from the Microsavings and Payments Innovation Initiative at Yale University, Innovations for Poverty Action, and the Bill and Melinda Gates Foundation.
Professor Grépin, whose research work focuses on the economics and politics of health service delivery in developing countries, with a focus on sub-Saharan Africa, spoke with NYU Research Digest as she prepared to launch the project, and, as it happens, as she anticipated her own delivery too, in May. (A shorter version of this interview appeared in the Spring 2012 Digest.)
What’s driving the project? Pregnant women in many developing countries, including Kenya, say that financial barriers keep them from seeking proper maternal health services, including skilled assistance at delivery. What are the barriers to increased savings needed to cover the costs associated with delivery? That is the primary question we will attempt to answer.
Why is it important to know how and why pregnant women in Kenya save money? It’s important that we become better able to understand all the barriers that pregnant women face to health care – informational, financial, and others. If we do, we might be able to develop savings vehicles that would help promote the capacity of women to accrue enough money to cover the cost of their baby’s delivery, both in Kenya and other settings as well. Since we will also be able to learn what care these women seek for their deliveries, we hope that this study will also contribute to our understanding of health-seeking behavior.
Your project involves mobile phones. What is their significance here? One of the big innovations in this project is that we plan to deliver all of the interventions that we are testing (financial incentives and informational incentives) via mobile phones. Mobile phones have become widely available in many developing countries. But people don’t use them just for communication; they are also used as credit cards and bank accounts, especially in Kenya. If we find that our interventions are successful, the interventions can be scaled up rapidly and inexpensively due to the availability of this technological platform.
What unique challenges do you anticipate? Our primary research site will be in densely populated urban slums in Kenya. Since we need to track and monitor women for approximately a year, this can be challenging in these communities. Fortunately, we do have their cell phone numbers, which does make continued tracking a great deal easier!
How does this research relate to other work that has been done in this vein? This work is part of a growing area of research on the potential of m-health technologies to improve health service delivery in developing countries. It also adds to the growing literature in the international health economics literature on savings and incentives for seeking care. It is one of the few m-health programs under way that will be evaluated in a rigorous randomized control trial setting.
Why do you consider the project of great importance, and to whom? The work is critically important. Although great efforts have been exerted over the past few decades to improve access to maternal health services in most developing countries, millions of women still do not seek proper care at delivery, and as a result hundreds of thousands die every year during childbirth from conditions that could be prevented if they were access the proper care. Given that financial barriers are seen as key to this challenge, we hope that this work will help develop our understanding in this area.
The April edition of the New England Journal for Medicine features an essay co-written by Jan Blustein, professor of health policy and medicine at NYU Wagner, on the prospects for success of hospital “pay for performance.” The new payment mechanism will be implemented across U.S. acute care hospitals this October under the Medicare Hospital Value-Based (VBP) program.
Paying U.S. acute care hospitals for improved performance is based on the notion that money changes behavior. “Accumulating evidence, however, raises serious doubts about whether the program will improve value in health care,” Professor Blustein writes with Andrew Ryan, a public health scholar at the Weill Cornell Medical College in the essay “Making the Best of Hospital Pay for Performance.” The piece, newly-published online and available in print April 26, explores how we can learn from the program as it unfolds, and how it can be improved, and includes an audio interview with Dr. Blustein.
Dr. Blustein’s research on this topic appears separately in the April edition of the journal Health Affairs. In this scholarly article, coauthored with Ryan and other experts in public policy and medicine, she examines the impact of the incentive’s piloted use by Massachusetts to address racial and ethnic disparities in hospital care. The research raises questions about whether "pay for performance" for hospitals is an effective method for stemming disparities.
In addition to her role as professor of health policy and medicine at Wagner, Blustein co-directs New York University’s NIH-funded TL1 PhD program in Clinical and Translational Research, and is the founding director of the IRB Initiative, a resource for issues involving federal regulation of human-subjects research. She holds an MD degree from the Yale School of Medicine and a Ph.D. from Wagner.
Rising costs and budget reductions are forcing New York City leaders to grapple with the long-term financial impact of City retirees' pension and health care benefits. At present, about 20 percent, or $13 billion, of the City's annual budget pays those expenses. This portion arises from collective bargaining agreements, the ups and downs of the stock market, the dynamics and costs of health care, demographics, and other factors.
Weaving questions of public finance and public policy, a December 12 roundtable discussion at NYU Wagner on the City's long-term liabilities drew more than 100 guests, as leading experts explained the hard numbers and difficult choices associated with the public cost of health care for city and state employees, both active and retired, in the years ahead.
The discussion was the second of three roundtables on long-term liabilities cosponsored by The Fund for Public Advocacy; the Office of Bill de Blasio, Public Advocate for the City of New York; as well as by NYU Wagner and the Wagner Economics and Finance Association.
"It's the 20 percent of the budget that we tend to talk about the least," noted De Blasio, who explained that the question of how long-term liabilities are handled is critical to sustaining the City's strengths as a major local employer and an indispensable provider of public services.
The event included a keynote address on Federal health care liabilities by Neera Tanden, president of the Center for American Progress, and a panel discussion with Carol Kellermann, president of the Citizens Budget Commission; Bruce McIver, president, the Voluntary League of Hospitals and Homes New York; Carol O'Cleireacain, senior fellow at the Brookings Institution, and New York Times columnist Michael Powell (moderator).
Reshma Saujani, executive director, Fund for Public Advocacy, and deputy advocate for special initiatives at the Office of the Public Advocate, delivered opening remarks, as did Neil Kleiman, special advisor to the NYU Wagner dean.
The series is being presented with the help of generous support from The New York Community Trust and the Peter G. Peterson Foundation.
Ellen Schall, Dean and Martin Cherkasky Professor of Health Policy & Management at NYU Wagner, moderated a comprehensive, in-depth panel discussion on healthcare policy and management on December 12 at the second annual "Innovations in Healthcare Symposium" at New York University.
Attended by 150 guests, the symposium was co-sponsored by NYU Wagner, the College of Nursing, and NYU Langone, and was held at the NYU Langone Medical Center's Alexandria Center, located along the East River. The gathering brought together leading minds from inside and outside the healthcare industry to offer solutions for healthcare reform and innovation.
Dean Schall's panel, "Innovation in Health Care Delivery: Making Patient-Centeredness Real," included these leading healthcare experts: Annette Diefenthaler, PhD, Design Researcher and Project Lead, IDEO; Kimberly S. Glassman, PhD, RN, Sr. Vice President of Patient Care Services and Chief Nursing Officer, NYU Langone Medical Center; Albert G. Mulley, Jr., MD, MPP, Director, Dartmouth Center for Health Care Delivery Science Professor of Medicine, Dartmouth Medical School; and Michael Meltsner, JD, Matthews Distinguished University Professor of Law, Northeastern University School of Law.
Commented Robert I. Grossman, MD, dean & CEO at NYU Langone Medical Center, "Discovering innovative ways to deliver health care cannot be accomplished if we work only in silos, and succeeding in this challenge never been more important than it is today. Providers, payers, academia and industry must collaborate to create novel methods to improve the quality, safety and effectiveness of care at a reasonable cost. This symposium was created to facilitate dialogue and drive action towards improving the healthcare delivery system."
The Robert F. Wagner Graduate School of Public Policy at NYU offers a Health Policy and Management Program that has been recognized as one of the best in the country, crossing traditional boundaries, linking management, finance and policy and providing students with the cutting-edge concepts and skills needed to shape the future of health policy and management. Students in the Wagner program receive a set of tools and experiences that allow them to understand both the delivery of health care services and the broader social, cultural and economic factors that influence health outcomes. Wagner's students experience firsthand the importance of health care delivery and health promotion in one of the most interesting, diverse, and complex cities in the world, and its graduates work in every sector of the health care system.
NYU Wagner's John Billings, associate professor of health policy, has been chosen as the 2011 recipient the Lewis and Jack Rudin New York Prize for Medicine and Health. The award was presented to him on Oct. 10, 2011 at New York Academy of Medicine (NYAM).
"Throughout his career, John has always brought into focus the inequalities and disparities in health care," said Dr. Jo Ivey Boufford, MD, president of NYAM. "In New York City, he's the ‘go-to' researcher who is able to deal with public policy issues in a practical way. He is a brilliant teacher and is always a challenging and rewarding."
Established in 2003, the prize provides a forum for a distinguished member of the research community to receive recognition from colleagues and the public at large. The award was created to promote the sharing of innovative findings from a variety of research areas with both fellow researchers and clinicians in the metropolitan New York region, with particular focus on the excellence and dedication of the men and women striving to find solutions to pressing health concerns.
Previous recipients include Dr. David Ho of the Aaron Diamond AIDS Research Center and The Rockefeller University, Dr. Harold Freeman of the National Cancer Institute, Dr. John H. Laragh of the New York Presbyterian Hospital-Weill Cornell Medical Center, Dr. Susan Band Horwitz of Albert Einstein College of Medicine, and Dr. Barbara Barlow of Harlem Hospital Center.
At the award event, Billings delivered a lecture, "Population Health: Improving the Health of Vulnerable Populations."
Professor Billings is the director of NYU Wagner's Health Policy and Management Program. He is principal investigator on numerous projects to assess the performance of the safety net for vulnerable populations and to understand the nature and extent of barriers to optimal health for vulnerable populations. Much of his work has involved analysis of patterns of hospital admission and emergency room visits as a mechanism to evaluate access barriers to outpatient care and to assess the performance of the ambulatory care delivery system. He has also examined the characteristics of high cost Medicaid patients in order to help in designing interventions to improve care and outcomes for these patients.
Parallel work in the United Kingdom has involved creating an algorithm for the National Health Service to identify patients at risk of future hospital admissions and designing interventions to improve care for these high risk patients. As a founding member of the Foundation for Informed Decision Making, Professor Billings is helping to provide patients with a clearer mechanism for understanding and making informed decisions about a variety of available treatments. Professor Billings received his J.D. from the University of California (Berkeley).