The strategic defense of physician autonomy: State public health agencies as countervailing powers

Abstract

Advances in genetic testing and the aggressive marketing of genetic tests by commercial diagnostic laboratories have driven both consumer demand and the need for unbiased information about how tests should guide healthcare delivery. This paper uses the countervailing powers framework to explore the role of state public health agencies as arbiters of quality and safety, specifically through their efforts to encourage physicians to follow evidence-based recommendations for screening for hereditary cancers. Social scientists have often viewed actions by the state to regulate cost, quality, or safety as a threat to physician autonomy. This paper draws on case studies from two US states—Michigan and Connecticut—to better understand the specific role of state public health agencies, and especially whether their activities to encourage adherence to evidence-based recommendations bolster or subvert the interests of other parties in the healthcare arena. We find that lacking authority to compel provider to follow evidence-based recommendations, they improvised ways to foster compliance voluntarily, for example, by emphasizing the role of the physician as gatekeeper, thus affirming the importance of physician autonomy and clinical judgment. Both states also used public health surveillance data to make rare diseases visible and illustrate gaps between recommendations and practice. Finally, they both showed that following evidence-based recommendations could align the professional and market interests of healthcare stakeholders. Both states employed similar strategies with similar effects, despite substantial differences in the regulatory climate and organizational capacity. Taken as a whole, their activities orchestrated a countervailing response that checked the profit-seeking motives of commercial laboratories. Our findings demonstrate that rather than eroding physician autonomy, state action to monitor healthcare quality and encourage adherence to evidence-based recommendations can actually reinforce physician authority.

Understanding the potential of state-based public health genomics programs to mitigate disparities in access to clinical genetic services

“…The SHAs embraced a remarkably similar set of goals in their PHG programs: using surveillance data to estimate the public health burden of hereditary conditions; educating healthcare providers and the public about genetic bases of chronic disease; promoting policies to increase access to clinical genetic services; and collaborating with internal colleagues and external partners to increase capacity. 2 , 21 , 22 However, as we will show, their execution of program objectives varied by state.…”

Navigating the evidentiary turn in public health: Sensemaking strategies to integrate genomics into state-level chronic disease prevention programs

“…We selected Michigan’s Genomics Program because it is nationally recognized for its leadership and innovation (Association of State and Territorial Health Outcomes 2010). While the Michigan Genomics Program is not representative of all state genomics programs (it is older and has more robust funding and staffing resources than those in other states), many other states have replicated elements of their program (Senier, Lee and Nicoll 2017). Our findings therefore provide insight into how other state health agencies may respond to the shifting epistemological demands of EBPH as they relate to innovations in chronic disease prevention.…”

Evaluating the role of public health in implementation of genomics-related recommendations: a case study of hereditary cancers using the CDC Science Impact Framework

“…While bidirectional reporting might not change clinical outcomes, in part due to the time elapsed between cancer diagnosis and reporting back of risk, state health departments used it as an educational tool to promote compliance with the EGAPP, USPSTF, and other recommendations. 35 The MDHHS cancer genomics program reported back 10,340 colorectal cancer cases, 3,025 breast cancers in women <age 50, 1,985 people with multiple -related or LS-related primary cancers, 459 endometrial cancer cases <age 50, 127 ovarian cancers, and 147 male breast cancers to 145 reporting institutions (D. Duquette, personal communication). The Connecticut DPH reported back >3,700 cancer cases for possible HBOC evaluation and received requests from 70% of participating hospitals for Grand Rounds presentations on prevention, early detection, and genetic counseling and testing for hereditary cancers.…”

“…The Connecticut DPH reported back >3,700 cancer cases for possible HBOC evaluation and received requests from 70% of participating hospitals for Grand Rounds presentations on prevention, early detection, and genetic counseling and testing for hereditary cancers. 35 A 2009 project in Colorado 36 reported back hereditary colorectal cancer information on 575 cases to 412 health care providers and 181 patients. HBOC bidirectional reporting programs are described further in Trivers et al 27…”