This issue of the Milbank Quarterly begins with two contributions to the growing body of research concerned with the determinants of the health of populations. The principal factors lie outside the health care system and thus are beyond the reach of most matters with which health care policy has been concerned: the organization, financing, and quality of medical services. What, if any, are the policy implications of our growing understanding of these determinants?

The first article in this issue is an ambitious effort by Neal Halfon and Miles Hochstein to bring knowledge developed in disparate fields of research into an integrated framework, the Life Course Health Development (LCHD), to guide policy and further research aimed at improving the health of populations. The framework focuses on how exposure to various risk and protective factors affects humans’ biology and psychology over their lifetime. The elements that Halfon and Hochstein emphasize include (1) processes by which humans’ experiences become “embedded” in the structure and functioning of their biological systems and their behavior; (2) the important roles of both risk and protective factors; (3) the need to recognize the extended time frames across a life course, or even across generations, in which risk and protective factors may affect health; and (4) the multidimensionality of health outcomes, which adds to the complexity of understanding causation and potential interventions. In laying out the LCHD framework, Halfon and Hochstein offer a number of interesting concepts, such as the notion of “allostatic load,” or the cumulative impact of personal circumstances over the life course.

This article also addresses the health policy implications of thinking of health in the LCHD framework. Halfon and Hochstein consider four topics: how the measurement of individual and population health might be improved, how health and related services should be organized, how health care should be paid for (and how health might be thought of in investment terms), and how the research agendas of medicine and public health might converge.

“Risky Parental Behavior and Adolescent Sexual Activity at First Coitus,” by Esther Wilder and Toni Terling Watt, offers an example of one phenomenon to which Halfon and Hochstein point: the cross-generation transmission of risk factors. Wilder and Watt are interested in whether adults’ health risk behavior leads to riskier behavior by their offspring. They use data from the National Longitudinal Study of Adolescent Health to test whether adolescents are more likely to be sexually active and engage in sex before age 15 if their parents engage in such risky behaviors as smoking, drinking, and driving without wearing a seat belt. Their analysis, which tried to eliminate confounding factors like race and income, finds support for a link between parental and adolescent risk behavior. This finding suggests new targets and messages for risk reduction and health promotion efforts.

Over the past two decades, much has been written about challenges to the professional status of medicine. Most of these challenges come from the internal dynamics of the health care system, for example, its commercialism and the impact of managed care. In “Doctors in a Wired World: Can Professionalism Survive Connectivity?” David Blumenthal analyzes a challenge from outside the system: the Internet and the information revolution that it has fostered. In reviewing the factors that have led to medicine’s elevated professional status, Blumenthal identifies the asymmetry of information between doctor and patient as that element most directly challenged by the information revolution. Blumenthal systematically explores six paths by which electronic communication may take place (e.g., patients with doctors, patients with other patients, doctors with health care organizations). A special aspect of Blumenthal’s treatment of these topics is that besides synthesizing much information from trade publications and the research literature, he also draws on his own current experiences as a practicing physician. He concludes that the information revolution is likely to have “diverse and potentially contradictory effects on the cognitive, moral collegial bases of professionalism.” Much of this potential impact clearly lies ahead.

“Bargaining Health Benefits in the Workplace: An Inside View,” by “C. Montagne,” is also partly based on the author’s personal experience. Montagne is a pseudonym whose use was agreed to by the editor so that the author, a professor of economics at a large state university, would not violate his confidentiality commitments when writing about contract negotiations involving his university and the faculty union to which he belongs. Montagne served on the health benefits bargaining committee. His article contrasts the “textbook model” involving benefit-wage trade-offs with the negotiations about which he had firsthand knowledge. He also interviewed the key parties. Montagne reports that although the faculty negotiators understood that health benefits and wages constituted alternative uses of the funds in the overall benefit package and even though the increased cost-sharing was seen as addressing the moral hazard problem and therefore health care costs, no change was negotiated. He offers several explanations.

The final article in this issue is “Teaching Hospitals and Quality of Care: A Review of the Literature,” by John Ayanian and Joel Weissman. With purchasers concerned about paying higher prices at teaching hospitals, it becomes important to know whether teaching hospitals offer superior quality. Ayanian and Weissman first describe the methodological issues that research on this question should address, then summarize and assess the available research. They report that the studies that deal most adequately with the methodological challenges are the most likely to find a quality advantage in teaching hospitals. This suggests that higher payments to teaching hospitals may be justified not only by the public goods that they provide but also because of better care.

Bradford H. Gray
Editor, The Milbank Quarterly

Author(s): Bradford H. Gray

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Volume 80, Issue 3 (pages 429–431)
DOI: 10.1111/1468-0009.00183-i4
Published in 2002