HCS 455 Future OF Health Policy Lecture Notes PDF

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HCS 455 FUTURE OF HEALTH POLICY LECTURE NOTES Government involvement in healthcare seems more prevalent today and significantly impacts the daily functions of many healthcare organizations. Therefore, healthcare leaders must be educated and informed in the process that forms policy and affect the daily functions of their operations. To remain successful in today’s competitive healthcare climate, administrators must have a clear understanding of health policies development and find ways to get involved in the legislative process to influence and shape policy. In this presentation, a description of the health policy process, factors that influence policy modification and rulemaking will be discussed, along with trends that drive change, and future changes in health policy. There are four key steps in the health policy process that administrators must be familiar with to influence and shape policy: (1) issue framing, (2) agenda setting, (3) policy formulation and (4) implementation. Knowledge of the health policy process is critical in the goal of proposing change through legislation, and healthcare leaders must be well versed in this area of policymaking to be successful. “Issue framing influences stakeholders’ ability of getting the issue on the policymakers’ agenda so that a problem is recognized and policy response is debated” (Policy Project.com, n.d.). Issue framing is an important step since healthcare leaders can share their knowledge to drive changes in policy. The second step is agenda setting which is “actually getting the problem on the formal policy agenda of issues to be addressed by presidents, cabinet members, Congress, or ministers of health” (Policy Project.com, n.d.). During this step, executive leaders could prove that their recommendations are substantive in nature and deserves to be on the agenda for consideration. Collaborating with political leaders who are responsible for the health care aspects of policy formation would be advantageous in getting an issue through the process of debate and consideration. The third step is policy formulation, and in this stage “proposed actions are articulated, debated, and drafted into language for a law or policy and written policies and laws go through many drafts before they are final” (Policy Project.com, n.d.). This phase is lengthy, and it is crucial that healthcare executives must keep abreast of where the issue is throughout this stage of the process to determine if the issue was passed or denied. The fourth step is implementation, and during this stage, administrators must collaborate with important stakeholders who will work towards the goal of implementing and monitoring the policy. “Enacted laws seldom contain enough explicit language to guide their implementation completely” (Sadler, 2014, para. 1). The implementation process begins in the agency charged with the actual operation and enforcement of the law through the process of rulemaking. The steps taken during the rulemaking process receive guidance from the Federal Register Act of 1935 and the Administrative Procedure Act of 1946 (Sadler, 2014). The rulemaking process begins with a proposal of a rule to implement the law or regulation. The proposed rule is “the official document that announces and explains the agency’s plan” (Office of Federal Register, 2011, p.4) to implement the new law. The proposed rule provides an explanation of the new law, why the law is necessary, cost-benefit analyses, the impact of the rule, and the methods considered for implementation along with the period in which the public may submit comments or concerns regarding the proposal. The proposed rule is published in the Federal Register to provide public

notification as well as an opportunity for public feedback (Office of Federal Register, 2011). The comment period typically ranges from 30 to 60 days, but agencies may allow up to 180 days for more complex rules. At the conclusion of the comment period, the feedback provided by the public, both for and against the rule, is considered along with scientific data and expert opinions to determine the final rule to be administered. The final rule is structured similar to the proposed rule but includes the effective date of the rule along with “basis and purpose” (Office of Federal Register, 2011, p. 7). The final rule includes the facts and data that were used to make the final determination and addresses the criticisms received during the proposed rule comment period. It further explains why other alternatives from law implementation were not selected. Publication of the final rule in the Federal Register with an effective date that is 30 days from the time of publication is the final step in the rulemaking process (Office of Federal Register, 2011). The Office of the Federal Register will prepare the final rule for inclusion in the Code of Federal Regulations (CFR); the CFR includes all the rules of the Federal government along with their current and future effects (Office of Federal Register, 2011). Many factors that play into the influencing of policy modification, there are a few that pertain to health care. One important factor is the access to care issue that has recently occurred in many communities. Current policies regarding access to care are ineffective and require more effort for a resolution. For instance, putting incentives in place for providers who go above and beyond in the rural areas so that people do not lack the care that they need. The quality of care that patients are receiving could also be a major cause that affects policy modification. If there are patients, who are receiving inadequate care and are not getting the best care possible then there should be changes to the policies. Changes to current policies will play into the non-effective current policies that should be looked at to see if there are possible changes that could be made to make them useful. The entire points of there being factors that influence policy modification are to create solutions where there may be problems in the current processes of a health care environment. There have been many times when there is a process in place, but the resources are not distributed equitability within an organization which would be another factor that would influence a policy modification. Research results play a significant role in policy modification as this can help in showing what is working and what may not be working with the current policies and processes. When there is a plan adjustment, there needs to be a meaningful use of the new policy in place. The CMS has implemented new policies that are involved with the meaningful use and put together a statement to show where the changes would help in making the use of EHR’s easier on providers and hospitals making the policy more realistic to workflow (Miliard, 2015). The CMS conducted research on how the EHR’s were working and found areas for modification within the current policies. Another way that an organization can see what laws may need to be modified would be to obtain patients opinions. The organization must take into consideration those who will be affected by the revised policies in the future. When looking at the factors that play a part in policy modifications, it can be a valuable tool to see if other organizations may have gone through similar circumstances, making needed changes and how the changes worked there.

Several trends are affecting the implementation of health care policies. These trends are the signs of the time, and health care is evolving at the same pace. It is important to know where this industry is going to get an idea of what to expect. The first trend is the cost of medical care is rising, and there does not seem to be a cap. Families have to work through the increased costs daily and figure out payment plans and so forth to take care of their families (Rasmussen, 2016). Moreover, this is the first trend because it is the benefactor with the other trends. The second trend is there are not as many plan options. Plan options have decreased because there are strict mandates and policies and this has discouraged companies from introducing any new plans. The state of Texas stopped all of their relationships with each PPO, and as a result, all consumers are with HMO’s (Rasmussen, 2016). The third trend is there will be a lack of access to doctors because there will not be enough by 2025 (Rasmussen, 2016). The fourth trend is pharmacy prices are tremendously high. Pharmacy prices are a major concern across the board because the costs are continuously growing significantly. At one time medications were being migrated to generic drugs and costs were more under control. Unfortunately, this positive trend has become stagnant. The drive is “specialty drugs,” and it has brought the costs of prescription drugs to an all-time high (Rasmussen, 2016). It is quite discouraging especially for those who must take these medicines on a daily basis to maintain their health. The fifth trend is the consumer will be the one to handle expenses when it comes to health care. The user must choose which plan will work best for their needs. Therefore, with the consumer having the power to decide their health options Providers will have to be transparent and work cohesively with the expectations of the customer (Rebay, 2012). This industry is migrating in a fast pace from where it was ten years ago, and these key trends display that consumers and payers are critical as to how the future of health care will be in the future. Medicare has decided to eliminate the SRG (sustainable growth rate) and start new programs/ models for how primary care physicians receive compensation. The new Merit-based and alternative payment models will make it an all in one system. A medical practitioner will need to choose which path they will want to take with either the MISP or the APM. The APM will be a bonus program, and if they decide to go the APM route, then they will not be eligible for the MISP. Meaningful Use, PQRS, and value-based medicine will all be rolled into one program starting in 2018 (CMS, 2015). The MIPS will have percentage and criteria based which will decide if you get an increase or decrease in payment from your previous year’s performance. The APM will be designed to have the quality of care and lower cost with this the APM system.

We have seen over the past few years with insurance companies joining and merging. Aetna and Humana and Cigna participating with Anthem, are the two larger organizations which state it is necessary to combine to compete in this market. The American Medical Association said they were trying to stop the mergers as they felt it would take away the competition and not leave any room for negotiation. If we have larger companies merging, then it will lead to higher rates and less competitiveness. The insurance companies state the need to combine for financial reasons, and there is enough competition in the marketplace they don’t feel it is much of a threat.

Insurances will start to narrow their networks with provider patients can see. We have already seen this as they don’t allow new contracts for all physicians as they did before. If you are a physicians or service vendor in healthcare, you will need leverage to get an insurance contract to join an insurance network. Having a “narrow network” will help insurance companies control costs with reimbursements to providers. Insurances will be putting more out of pocket costs for patients. We have already seen this in the marketplace plans, with high deductibles plans for services other than paying for preventative care services. Telemedicine will be used much more often for services with a specialty in rural areas to help treat patients, reduce costs for them having to travel to see a specialist. Telemedicine has been around for awhile, however, it is now starting to gain ground and physicians can be paid for these services. There are also ways to train doctors and share ideas around the world with the new technology. Today’s healthcare leader must have more knowledge about many aspects outside the four walls encompassing the facility. Healthcare leaders must understand how the healthcare policy process works as well as the rulemaking process for implementation. Understanding these processes will enable leaders to become active participants in the legislation that directly affects the healthcare industry. It is also important for healthcare leaders to remain informed about factors that influence modifications to current policies; factors such as access to care and research may alter existing policies to become conform to the needs of the American population. As with factors that influence policy modification, there are also trends driving changes to current policies that must be taken into consideration to predict what a health care law may require in the future. Changes to existing policies and proposed legislation for the future will direct the healthcare industry like never before. Additional rules and regulations imposed on the sector will require healthcare leaders to have a sound knowledge of healthcare as well as legislative processes and proposals to remain viable in the current healthcare environment. CMS. (2015, November). Payment adjustment & hardship exceptions tip sheet for eligible professionals. Retrieved from https://www.cms.gov/Regulations-andGuidance/Legislation/EHRIncentivePrograms/Downloads/PaymentAdj_HardshipExcepTipSheetforEP.pdf Miliard, M. (2015, April). CMS makes meaningful use modifications. Healthcare IT News. Retrieved from http://www.healthcareitnews.com/news/cms-makes-meaningful-use-modifications Office of Federal Register. (2011). A guide to the rulemaking process. Retrieved from https://www.federalregister.gov/uploads/2011/01/the_rulemaking_process.pdf Rasmussen, R. (2016). 5 trends driving change in health care. Retrieved from http://www.benefitspro.com/2016/03/09/5-trends-driving-change-in-health-care Rebay, K. (2012). The 5 Mega-Trends That Are Changing the Faces of Health Care. Retrieved from http://www.theatlantic.com/health/archive/2012/the-5-mega-trends-that-are-changing-the-faces-ofhealth

Sadler, P. (2016). Health policy. Retrieved from http://www.guwsmedical.info/health-policy/rulemakingthe-beginning-of-implementation.html The Policy Circle - POLICY Project (n.d.). Retrieved from www.policyproject.com/policycircle/content.cfm?a0=4...