Week #14 Consumer Involvement

In the healthcare field today, healthcare providers are constantly promoting patients to take charge of their health, however, this should not be limited to just the physical and compliance aspects. Increasing consumer participation in the health policy-making process has proven to lead to better outcomes (Coulter, 2011). It seems very counterintuitive to instruct patients to be an active member in their health care when it is not overtly encouraged that they participate in creating the policies that govern their ability to obtain healthcare. Coulter (2011) identified that this lack of involvement may be attributed to the term “patient”, which implies a relationship of inferiority to the healthcare provider. Carman et al. (2013) developed a framework to properly identify how consumers may actively participate in their own health care, as well as the policies that enable or inhibit their ability to obtain necessary services.

Carman et al. (2013) identified several factors that directly influence consumer involvement such as: “beliefs about the patient role, health literacy, culture, and social norms” (p. 225). To improve healthcare outcomes consumer involvement needs to be integrated into the healthcare field at the hands-on level, the governance level, and at the policy-making level (Carman, 2013). Several of these methods are becoming more frequently seen throughout the United States such as with hospitals issuing patients surveys at the end of their stay to evaluate their experiences so that they can make necessary improvements in the future. However, is this enough? Carman et al. 2013 recommends that policy agencies should begin conducting focus groups with consumers to discuss health care concerns. By understanding what the consumers are truly concerned about, policy-makers should be better equipped to address and correct these disparities and by doing so promoting consumers to speak up in the future.

The Lucian Leape Institute of the National Patient Safety Foundation identified that to properly ensure that healthcare is a patient focused profession the patient must be considered a full partner in every aspect of healthcare and not just the direct care component (Leape et al. 2009). This concept must be addressed before the healthcare industry can expect any promising transformation to occur. As it appears right now, the healthcare industry is truly more of a patient-directed profession where all decisions and policies are directed towards the patient; however, to be truly a “patient-centered” profession, I believe the patient must be actively participating. In conclusion of this blog I believe it is the responsibility of the healthcare provider to educate the patient so that they may make the best possible decision for their health; organizations must seek consumer advices to best determine what improvements must be done to meet the needs of patients; and finally policy-makers must involve the patient in the policy-making process because who better to discuss the needs of patients than actual patients.

Reference

Carman, K. L., Dardess, P., Maurer, M., Sofaer, S., Adams, K., Bechtel, C., & Sweeney, J. (2013). Patient and family engagement: a framework for understanding the elements and developing interventions and policies. Health Affairs, 32(2), 223-231.

Coulter, A. (2011). Engaging patients in healthcare. McGraw-Hill International.

Leape, L., Berwick, D., Clancy, C., Conway, J., Gluck, P., Guest, J., … & Isaac, T. (2009). Transforming healthcare: a safety imperative. Quality and Safety in Health Care, 18(6), 424-428.

 

Week #13 Sustaining innovative environments

Being innovative is crucial to the success of any business; however, creating an environment that promotes innovation is even more crucial, as this dictates the future growth and development potential that a business has. One might ask: “what does innovation sustainability have to do with health policy?” Although the role of innovation in health policy is not as apparent, it is no less critical for future growth and development. As mentioned in previous weeks, the Center for Medicare and Medicaid Services (CMS) changed the reimbursement model for skin grafting in an attempt to reduce excessive spending while promoting the use of evidence-based decisions among healthcare providers for the various treatment options of chronic non-healing wounds (McCurdy, 2013). Even though many interest groups and individuals question CMS’s decision and the ramifications that may result from this policy change, the decision can still be classified as innovative. Is innovation not simply just a term utilized to describe a new way of completing a task, which aims to improve practice? Disregarding whether or not this policy change will impact patient care (which should absolutely never be done when deciding on a health policy change) this new reimbursement model will save the Government a substantial amount of money (Schroeder, 2013). Yes, that is right, the financial component once again plays an incredibly important role. Financial constraints are frequently identified as the main hindering factor in innovation (Canepa & Stoneman, 2008).

Although this explains how innovation and health policy are related; how does CMS promote an environment for sustaining innovations? Well the answer truly comes from the policy-making process. During the process of policy-making there is a stage known as the modification phase where individuals, organizations and even interest groups that may be directly impacted by the policy change can deliver an argument to the formulating/implementing team in an effort to have the policy altered (Longest, 2010). This type of autonomy and freedom to express concerns is one of nine dimensions that promote an environment of creativity and innovation (Isaksen, 2007). Additionally, when CMS takes the time to listen and interact with individuals and/or organization that are impacted by these policy changes, they are promoting innovation sustainability by allowing everyone to have their voices heard (Porter-O’Grady and Malloch, 2011). The perfect example of this came when CMS took into consideration the WOCN’s complaints when they argued that this policy change would limit healthcare providers scope of practice by not allowing them to have access to all forms of wound care therapies that may be necessary for treating chronic non-healing wounds (WOCN, 2013).

Reference

Canepa, A., & Stoneman, P. (2008). Financial constraints to innovation in the UK: evidence from CIS2 and CIS3. Oxford Economic Papers, 60(4), 711-730.

Isaksen, S. G. (2007). The climate for transformation: Lessons for leaders. Creativity and Innovation Management, 16, 3-15. doi:10.1111/j.1467-8691.2007.00415.x

Longest, B.B. Jr. (2010). Health policymaking in the United States (5th ed.).            Chicago, IL: Health Administration Press.

McCurdy, D. (2013). CMS issues final medicare OPPS, ASC policies for 2014. Mondaq Business Briefing

Porter-O’Grady, T., & Malloch, K. (2011). Quantum leadership: Advancing information, transforming health care (3rd ed.). Sudbury, MA: Jones & Bartlett

Schroeder, S. & Frist, W. (2013). Phasing out fee-for-service payment. The New England Journal of Medicine, 368(21), 2029.

Wound Ostomy and Continence Nurse Society (WOCN). (2013). CMS Publishes 2014 Outpatient Prospective Payment System and Ambulatory Surgical Center Final Rule. Retrieved from: http://www.wocn.org/news/150253/CMS-Publishes-2014-Outpatient-Prospective-Payment-System-and-Ambulatory-Surgical-Center-Final-Rule.htm

 

Week #12 Financing Healthcare

In this weeks blog we will be discussing the root cause for many health policy changes, in other words the financial aspect of healthcare. In the United States of America the financing of healthcare is complicated by the existence of both public insurers, such as that seen with Medicare/Medicaid and private insurers such as Blue Cross Blue Shield. In 2010 it was estimated that 17% of the Gross Domestic Product (GDP) was spent on health care cost (CBO, 2010). Additionally, in 2010 45% of healthcare financing came from government funding (Shi and Singh, 2012). At the current projected rate of increase in health care cost compared to the national economic growth, financing the US healthcare system will consume roughly 40% of the GDP (CBO, 2010). Clearly this model is not a sustainable form of financing and changes were necessary to ensure national stability (Gruber, 2011). The government has enacted various methods for reducing the cost of healthcare over the years (i.e. the Center for Medicare and Medicaid Services switching reimbursement models to a bundle payment plan for many of the healthcare services). However, arguably one of the most radical changes implemented in an attempt to address this unsustainable financial situation was the introduction of the Affordable Care Act (Shi and Singh, 2012).

The Affordable Care Act aims to increase the number of insured citizens by creating individualized affordable national insurance plans. However, once again the financial aspect must be taken into consideration. To accomplish this tremendous undertaking the government must revert the financial burden back onto the taxpayers (Shi and Singh, 2012). The Affordable Care Act has tried to accomplish this by having the monthly healthcare insurance cost vary from citizen to citizen (not based upon health status) with some paying less while others are paying substantially more (Gruber, 2011). Interestingly enough, this same model was attempted by several states back in 1996, ultimately resulting in extremely high average monthly health insurance cost (Gruber, 2011a). These financial disparities make the future of the Affordable Care Act questionable and will likely be the cause of many future health policy changes. The juggling act between insuring that all citizens have access to health care while ensuring that the proper funding is in place to accommodate these demands will be a constant battle and the source of many arguments among politicians. Regardless, we, as healthcare providers, must insure that we forever keep the patient at the center of our focus.

 

Reference

Congressional Budget Office, 2010. The Long-Term Budget Outlook. Congressional Budget Office, Washington, DC.

Gruber, J. (2011). The Impacts of the Affordable Care Act: How Reasonable Are the Projections? (No. w17168). National Bureau of Economic Research.

Gruber, Jonathan, 2011a. Massachusetts Points the Way to Successful Health Care Reform. Journal of Policy Analysis and Management 30 (1), 184–192.

Shi, L., & Singh, D. A. (2012). Essentials of the US health care system. Jones & Bartlett Publishers.

 

 

 

Week #11 Change Agents in the Healthcare Sector

In this weeks blog we will be focusing on change agents in the healthcare sector. A Change agent is person, business, or organization that advocates and assists in implementing change. These change agents come in various different forms but for this particular discussion we will be focusing on a particular society that acts as a change agent for wound care related health policies. This week we will be focusing on the Wound, Ostomy and Continence Nurses Society (WOCN), which is an international nursing society founded in 1968 (WOCN, 2014). This particular society has made it their mission not only to improve clinical nursing skills through clinical, research and educational means to advance practice but also through policy advocacy (WOCN, 2014). This week I had the chance to speak with a few representatives from the health policy division of the WOCN to discuss their perspectives on the policy change that CMS has finalized in regards to the reimbursement for the use of skin substitutes. This is the conversation I had with the WOCN:

Question #1 – What is the WOCN’s opinion on the newly changed policy addressing the CMS reimbursement model for the use of biologicals (Fee-for-service vs. bundled payment)

Answer #1 – The organization has concerns about CMS’s approach to reimbursement for “skin substitutes.”  CMS’s initial proposal to restructure its reimbursement model, which was included in the CY 2014 Payment System Update for Hospital Outpatient and Ambulatory Surgical Centers, would have unconditionally packaged all drugs and biologicals that function as supplies or devices in a surgical procedure beginning in the CY 2014.  WOCN was opposed to this proposed rule and suggested in comments that CMS recognize that there are a wide variety of products available within the “skin substitute” category and that each has a different clinical function and treatment protocol.  Thus, lumping all products into the same payment methodology would discourage use of those products that were more expensive even if they were clinically appropriate.

Question #2 – The goal of this policy change was to encourage healthcare providers to use high quality evidence-based care to increase healing time and decrease overall cost. Does the WOCN believe that this policy change will accomplish this goal?

Answer #2 – The policy will almost certainly decrease costs, but could do so at the expense of quality evidence-based care.  CMS has based their bundling premise on the theory that “skin substitutes” function as wound dressings as opposed to skin grafts; we disagree with this basic premise and argue that advanced biologic products used for wound treatment act more like human grafts than simple wound dressings.  However, these advanced products do not function as a substitute for skin, rather as a wound treatment effectively creating three separate categories.   It is reasonable to think that advanced biologic products which require FDA 510(k) approval and substantial research and investment, not to mention advanced handling and storage requirements in the clinical setting, would have a higher cost than typical wound dressings.  We do not believe that bundling all products in a widely varied category such as wound treatment is high quality evidenced-based care.

Question #3 – The WOCN argued against CMS’s initial decision to lump all products into the same bundled reimbursement category, which resulted in the division of skin substitutes into two tiers. Was the WOCN satisfied with this outcome? If not, what modification to the policy would the WOCN like to see?

Answer #3 – While we were happy to see that CMS did ultimately recognize that not all wound treatment products are created equally and created a two-tier system, we remain concerned about the unintended consequences of this system.  Most notably, even within the tiers you will have products that vary widely on cost yet are reimbursed on one of two reimbursement rates.  WOCN is currently evaluating the impact of the two-tiered model and will be working with CMS to reevaluate its proposals for FY 2015.

Question #4 – An argument has been made in the past emphasizing that the cost of biologicals outweighs the benefits gained from the use of this therapy. What position does the WOCN take on the efficacy of skin graft therapy? Does the WOCN believe that healthcare providers will be swayed to use other less expensive therapies due to this policy change?

Answer #4 – The concern of the WOCN has always been the availability of alternative therapies for patients who have large defect wounds that cannot heal without an advanced therapy. Split thickness skin grafts are an ideal method for closure for some of these wounds, but there are some situations that make skin grafting difficult. The true biologic skin substitutes meet a unique need for those patients who are not candidates for “surgery” to harvest and place a split thickness graft, or who have limited tissue options to provide the donor graft or who simply cannot afford a surgical procedure (even if the cost to them is only their co-pay or deductible).

We have maintained that the two recognized biologic skin substitutes (re: actually harvested human cells that have been rigorously processed) have been shown to be quite effective in healing many such wounds. Although there is not a preponderance of research to supporting this, the case studies are numerous. And in the current health care environment, they are cost effective. Surgery is expensive, even outpatient surgeries.

Our belief is that the policy change, with its 2 tiers of products, is misleading and potentially can lead to use of less effective therapy. It is our hope that healthcare providers will review this policy change critically and recognize that not all “high” level products really meet the definition of biologic skin substitutes. Many of these describe themselves as “dermal or acellular” scaffolding for wound healing but only two really address the inclusion of fibroblast and live cells to “grow” the tissue needed to cover the wound.

As mentioned earlier in this blog, the WOCN took an active role as a change agent by acting upon their concerns and advocating for a revision of the new reimbursement model imposed by CMS (WOCN, 2013). Change agents, such as the WOCN, play a vital role in advancing health policies to ensure that evidence-based practice may be maintained within the clinical setting so that patients may continue to receive the best possible care from their health care provider. In conclusion of this weeks blog I wan to say thank you to the WOCN for continuing to fight for the patients best interest and for taking the time to answer my questions.

Reference

Wound Ostomy and Continence Nurse Society (WOCN). (2014). About US. Retrieved from: http://www.wocn.org/?page=about_us

Wound Ostomy and Continence Nurse Society (WOCN). (2013). CMS Publishes 2014 Outpatient Prospective Payment System and Ambulatory Surgical Center Final Rule. Retrieved from: http://www.wocn.org/news/150253/CMS-Publishes-2014-Outpatient-Prospective-Payment-System-and-Ambulatory-Surgical-Center-Final-Rule.htm

 

Week #10 Change Theory

In week 8 I briefly touched on the topic of “change” when I quoted Heraclitus of Ephesus when he stated that the only constant thing in life is change itself (Kirk, 1951). Change of any kind may potentially be disruptive and elicit a state of chaos or if embraced may promote growth and development. My first realization of the impact of change came at the end of my last semester of my undergraduate studies. I was in a class with twenty-five other nursing students and we were scheduled to study the theory of change (although no one knew that at the time). When we walked into class that day and sat down in the seats we had been in since the beginning of the semester, our professor suddenly (in a stern voice) stated that we were going to be reassigned new seats because of the excessive talking going on between students. Every single student was assigned a new seat in a different part of the classroom. No one understood why the professor had done this and for the first 10-15 minutes of class no one could concentrate on what was being said and several students were visibly upset. Shortly thereafter, our professor stated “and that is the power of change”. Change is powerful and even the smallest amount of it, such as a change in seat assignment, may disrupt the equilibrium that we were accustom to. But I am not here to discuss seat assignments; instead I would like to discuss how the theory of change applies to CMS reimbursement for the use of biologicals.

Kurt Lewin (1952) created what is known as the change theory to help educate and prepare individuals in hope that it may lessen the chaos that could potentially follow. This theory is based upon three main concepts, which are the driving forces, restraining forces, and than finally the equilibrium (Lewin, 1952). These concepts help navigate an individual through the three specific stages (Unfreezing, Change and Refreezing) that makeup the change process (Lewin, 1952). Applying this theory to the reimbursement issue, we can see that the driving forces consist of increased financial cost due to the use of non-evidence-based practice, as well as excessive billing through the fee-for-service model. The restraining forces that accompany the topic are related to the high cost of wound care supplies and the difficulty associated with healing complex wounds. However, if policy-makers can create a policy that balances these two forces than the system reaches equilibrium where the healthcare providers are happy because they are able to provide the indicated evidence-based therapy to their patients without having to assume the cost of the product and CMS is happy because the overall cost would be kept within a reasonable range. This point is known as the refreezing point, which is the stage this policy change is in due to CMS issuing it’s final ruling on this topic (McCurdy, 2013). However, if this policy change does not meet the intended need, we may see this policy enter what Longest (2010) described as the “modification phase” and start the whole process all over again.

Reference

Kirk, G. S. (1951). Natural change in Heraclitus. Mind, 35-42.

Lewin, K. (1952). Field theory in social science: Selected theoretical papers. D. Cartwright (Ed.). London: Tavistock

Longest, B.B. Jr. (2010).  Health policymaking in the United States (5th ed.).             Chicago, IL:  Health Administration Press.

McCurdy, D. (2013). CMS issues final medicare OPPS, ASC policies for 2014. Mondaq Business Briefing

Week #9 Privacy Protection

Privacy protection of sensitive patient information has been a goal in the medical field since the first recorded administration of the Hippocratic Oath at a university in Germany in 1508 (Markel, 2004). This concept was later carried forward into the realm of nursing when Lystra Gretter and colleagues created what is known as the Nightingale Pledge in 1893 (Gretter, 1893). This pledge was a modification of the Hippocratic Oath and than named after Florence Nightingale for her pioneering role in nursing (Gretter, 1893). As healthcare technology has advanced over the years so has the risk for a privacy breach. The risk became so great that in 1996 the United States Government under the Department of Health and Human Services passed the Public Law 104-191, or more commonly known as the Health Insurance Portability and Accountability Act (HIPAA) (Murray, Calhoun, and Philipsen, 2011).

HIPAA is divided into two different titles. The lesser-known function that HIPAA provides falls under Title I, which focuses on ensuring that individuals have access to health insurance policies, in between employment, under the Consolidated Omnibus Budget and Reconciliation Act (COBRA) (Murray, Calhoun, and Philipsen, 2011). The more commonly known function of HIPAA falls under Title II, which focuses on electronic health records (EHR) and the protection of individuals’ health information (Murray, Calhoun, and Philipsen, 2011). Although the functionality of Title I under HIPAA may seem to have less of an impact on individuals that receive their healthcare coverage from the Center for Medicare and Medicaid Services (CMS), Title II is exceptionally pertinent. The medical and nursing fields were built upon a foundation of trust between the patient and provider. Abiding by Title II is one of the many ways that a healthcare provider may convey trustworthiness to his/her patients. The right to privacy is not a concept that is solely found in healthcare rather this concept can be found in several United States Amendments including both the 5^th and 14^th (Murray, Calhoun, and Philipsen, 2011).

So how does this apply to CMS’s reimbursement for the use of skin graft therapy? Well for a healthcare provider to be reimbursed appropriately they must charge the insurance company (CMS in this case). However, to charge an insurance company the healthcare provider must have proper documentation to support the charges in case of an audit, which is where the EHR come into play. EHR’s help the healthcare provider eliminate charting and patient care error, which improves his/her ability to justify financial charges (Murray, Calhoun, and Philipsen, 2011).

Reference

Gretter, L. (1893). The Florence Nightingale Pledge. ANA Nursing World, http://www. nursingworld. org/about/pledge. htm (accessed 11 March 2014).

Markel, H. (2004). “I swear by Apollo”—on taking the Hippocratic oath. N Engl J Med, 350(20), 2026-2029.

Murray, T. L., Calhoun, M., & Philipsen, N. C. (2011). Privacy, Confidentiality, HIPAA, and HITECH: Implications for the Health Care Practitioner. The Journal for Nurse Practitioners, 7(9), 747-752.

Week #8 Private Sector and Policy Advancement

The Greek philosopher, Heraclitus of Ephesus stated that the only constant thing in life is change itself (Kirk, 1951). The theory of change is one that applies to many areas in life including the far reaches of the political world, as seen with policies continually being formulated, implemented, and modified (Longest, 2010). These changes can occur as a result of many different factors including but not limited to: financial concerns, ethical dilemmas, and even private sector innovations. As long as the medical field continues to advance through innovations, policies will need to be created and/or adapted to address the use and reimbursement of these advancements. One example of private sector innovations is the development and use of biological skin equivalents (BSE), a subcategory of skin grafts.

One BSE in particular is known as Apligraf, which was created by Organogenesis, Inc. in Canton, MA (Greer et al., 2012). This product was developed utilizing sterilized neonatal foreskin and than cultured in a petri dish. Apligraf is considered a bilayer constructed skin product, meaning that it has a dermal and epidermal side, which excretes naturally forming skin growth factors that are crucial in the skin healing process (Greer et al., 2012). Unfortunately, this product must be delivered to the clinical site fresh so that it can give the patient the best chance of healing and therefore it has a very short shelf life.  As you can see, this innovative product is extremely advanced and subsequently it is rather expensive compared to other skin graft options that are currently on the market.

The dilemma between cost and treatment effectiveness has been made extremely apparent when considering the use of skin graft therapy now that the Center for Medicare and Medicaid Services (CMS) has modified the policy that dictates the reimbursement amount for the use of these products (McCurdy, 2013). On one hand CMS has to modify the current payment plan, as too many providers are financially abusing the center (Schroeder and Frist, 2013). However, on the other hand CMS cannot make the restrictions so severe that providers aren’t financially able to utilize necessary therapies (Weeks, Rauh, Wadsworth, and Weinstein, 2013). Initially, CMS had decided to lump the numerous varieties of skin grafts into the same reimbursement category, however, thanks to the Wound Ostomy and Continence Nurse Society (WOCN) and other interest groups, the final ruling for this policy included a two-tier reimbursement plan so that providers could still utilize BSEs without having to accept a financial loss (WOCN, 2013). This type scenario perfectly illustrates how a private sector innovation, such as Apligraf, assists in policy advancement.

Reference

Greer, N., Foman, N., Dorrian, J., Fitzgerald, P., MacDonald, R., Rutks, I., & Wilt, T. (2012). THERAPY DESCRIPTIONS AND REFERENCES.

Kirk, G. S. (1951). Natural change in Heraclitus. Mind, 35-42.

Longest, B.B. Jr. (2010).  Health policymaking in the United States (5th ed.).             Chicago, IL:  Health Administration Press.

McCurdy, D. (2013). CMS issues final medicare OPPS, ASC policies for 2014. Mondaq Business Briefing

Schroeder, S. & Frist, W. (2013). Phasing out fee-for-service payment. The New England Journal of Medicine, 368(21), 2029.

Weeks, W. B., Rauh, S. S., Wadsworth, E. B., & Weinstein, J. N. (2013). The unintended consequences of bundled payments. Annals of Internal Medicine, 158(1), 62-64.

Wound Ostomy and Continence Nurse Society (WOCN). (2013). CMS Publishes 2014 Outpatient Prospective Payment System and Ambulatory Surgical Center Final Rule. Retrieved from: http://www.wocn.org/news/150253/CMS-Publishes-2014-Outpatient-Prospective-Payment-System-and-Ambulatory-Surgical-Center-Final-Rule.htm

Week #7 Public Policy Implementation

The implementation of a public policy is not accomplished in one single day, rather the implementation phase is complex and often requires the assistance of additional policies to ensure proper implementation (Longest, 2010). Within the discussion of the implementation phase of public policies there also exists the discussion of both the formulation and modification phases as well, as these three phases of public policy creation are heavily interconnected (Longest, 2010).

 For example, the first mention of a government health insurance was in the late 1930’s when Senator Capper sponsored the “Epstein bill” (Social Security Online, n.d.). After many different formulation phases, President Johnson successfully signed into law the Medicare and Medicaid programs in the summer of 1965 (Centers for Medicare and Medicaid Services, n.d.). As you can see, there was roughly a thirty-year gap between the first formulation phase and the actual implementation phase. However, the implementation process does not stop once the policy has been singed into law, rather it is just the beginning of the policy implementation process. Since the signing of Medicare and Medicaid into law, the United States Government has continued to modify these programs in an attempt to balance financial sustainability with effective patient care, as seen with the changes made by the CMS regarding the reimbursement model for the use of skin substitutes (Social Security Online, n.d.). This policy change was enacted due to the problematic financial inefficiencies that were being observed with the previous reimbursement model (Schroeder and Frist, 2013). These inefficiencies were also translating to less effective care being given to the patients. This reevaluation of the reimbursement model equates to what Longest (2010) describes as the modification phase of policy making.

During the modification phase the Center for Medicare and Medicaid services (CMS) met to discuss possible solutions to this problem, taking feedback from individuals, business’s and organizations that may experience consequences or benefits from this policy modification (Longest, 2010). The decision to change the reimbursement model beginning January 1^st 2014 to a bundle payment plan was decided on with the thought that this model would encourage providers to utilize the most evidence-based therapies to reduce to length of healing time as much as possible (McCurdy, 2013). Now the implementation phase begins again where CMS must send out notifications to all individuals and business impacted by this policy change so that all have adequate time to fully understand the change and how it may alter their current practice (Longest, 2010). The cycle of formulation, implementation, and modification for public policies is complex and heavily intertwined with each other so much so that one cannot exist without the other.

Reference

Centers for Medicare and Medicaid Services. (n.d.). Key Milestones in the CMS Programs.  Retrieved from: https://www.cms.gov/About-CMS/Agency-Information/History

Longest, B.B. Jr. (2010).  Health policymaking in the United States (5th ed.). Chicago, IL:  Health Administration Press.

McCurdy, D. (2013). CMS issues final medicare OPPS, ASC policies for 2014. Mondaq Business Briefing

Schroeder, S. & Frist, W. (2013). Phasing out fee-for-service payment. The New England Journal of Medicine, 368(21), 2029.

Social Security Online (n.d.). Social Security History. Retrieved from: http://www.ssa.gov/history/corningchap4.html

Week # 6 Public Sector Influence

With the growing awareness of the prevalence of health disparities among underserved populations such as the elderly and persons with disabilities, President Johnson successfully signed into law the Medicare and Medicaid programs in the summer of 1965 (Centers for Medicare and Medicaid Services, n.d.). These programs would later become known as the Center for Medicare and Medicaid Services (CMS). One year after the signing of this law roughly 19 million United States citizens had been enrolled into the these programs (Centers for Medicare and Medicaid Services, n.d.).

However, there have been numerous changes made to these programs over the years in an attempt to enhance the services available to the customers while considering the financial sustainability. Often times these policy revisions come during the modification phase (Longest, 2010). During this phase individuals, organizations, and even interest groups that may be directly impacted by the policy change can deliver an argument to the formulating/implementing team in an effort to have the policy altered (Longest, 2010). In the case of the CMS final ruling on the reimbursement of the use of skin substitutes, also known as “biologicals”, several organizations were involved in making necessary alterations.

One of the most notable organizations that brought forth an argument to CMS was the Wound Ostomy and Continence Nurse Society (WOCN)(WOCN, 2013). The initial proposal for the reimbursement for the use of skin substitutes categorized all approved skin substitutes and/or biologicals into the same financial reimbursement category (WOCN, 2013). Although this may seem logical from a policy standpoint, there are many different types of skin substitutes on the market that vary drastically in both price and function. The WOCN argued that lumping all of these products into the same reimbursement category would encourage providers to utilize the least expensive and potential inappropriate skin substitute in order to assure the recoupment of their expenses (WOCN, 2013). Even with the arguments made by the WOCN CMS went forward with the implementation of the bundled payment method for the reimbursement of skin substitutes. However, the WOCN did successfully argue for the division of skin substitutes into two separate reimbursement tiers so that providers would still be encouraged to use the appropriate skin substitute

Although, the WOCN was unable to change the entire reimbursement model decided on by the CMS their argument for the incorporation of a two-tier approach for skin substitutes is the perfect example of how a public sector organization may influence the outcome of a healthcare policy.

Reference

Centers for Medicare and Medicaid Services. (n.d.). Key Milestones in the CMS Programs.  Retrieved from https://www.cms.gov/About-CMS/Agency-Information/History

Longest, B.B. Jr. (2010).  Health policymaking in the United States (5th ed.). Chicago, IL:  Health Administration Press.

Wound Ostomy and Continence Nurse Society (WOCN). (2013). CMS Publishes 2014 Outpatient Prospective Payment System and Ambulatory Surgical Center Final Rule. Retrieved from: http://www.wocn.org/news/150253/CMS-Publishes-2014-Outpatient-Prospective-Payment-System-and-Ambulatory-Surgical-Center-Final-Rule.htm

Week #5 Statutory and Regulatory Mechanisms

In week three we discussed the basics of the policy-making process. However, this week we will expand upon the policy-making process further by discussing how statutory and regulatory mechanisms function within the Center for Medicare and Medicaid Services’ (CMS) healthcare policy on the reimbursement model for the use of skin graft therapy.

To begin, CMS is the federal agency that has been overseeing both Medicare and Medicaid programs since 1977 (Longest, 2010). Title XVII and XIX of the Social Security Act was utilized as a statutory framework to help policy development within the CMS programs (Center for Medicare and Medicaid Services, n.d.). Title XVII and XIX were enacted in the United States of America in 1965 to provide health care coverage for all individuals ages 65 and older, as well as for low-income children, the blind, and individuals with disabilities (Center for Medicare and Medicaid Services, n.d.). Subsequently the Medicare program was divided into four separate parts consisting of: Part A, Part B, Part C, and Part D. These individual parts of Medicare have their own regulatory committee, which review and issue official rulings on proposed policies that fall within their sector of healthcare. In the case of reimbursement for the use of skin graft therapy, Medicare Part B would be the authoritative committee, as they oversee and manage the Hospital Outpatient Perspective Payment Services (HOPPS), which is responsible for assigning the Ambulatory Payment Classification for outpatient services (Anumula and Sanelli, 2012).

As mentioned in week #4, a health policy begins when a problem has been brought to the attention of an authoritative committee. Once the problem is acknowledged the policy-making process enters into what Longest (2010) describes as the “formulation phase”, which is where possible solutions and political circumstances are discussed. This process can take the policy through numerous revisions and regulatory actions ensuring that the policy is constitutionally sound and ultimately meets the intended need (Longest, 2010). The policy is then integrated into the “implementation phase” where the committee must disperse the latest ruling and the regulations that coincide with the new policy (Longest, 2010). The last phase in the policy-making process is that of “modification”, which involves collecting feedback on the latest ruling from individuals and organizations that were directly or even indirectly affected by the new policy (Longest, 2010). Even though there are three clear phases that a policy must go through the process is occurring simultaneously and is greatly affected by the actors, as well as the regulatory and statutory mechanisms that are employed in the policy-making process (Longest, 2010).

Reference

Anumula, N., & Sanelli, P. C. (2012). Hospital outpatient prospective payment system. American Journal of Neuroradiology, 33(4), 616-617.

Centers for Medicare and Medicaid Services. (n.d.).  Key Milestones in the CMS Programs.  Retrieved from https://www.cms.gov/About-CMS/Agency-Information/History/index.html?redirect=/history/

Longest, B.B. Jr. (2010).  Health policymaking in the United States (5th ed.).             Chicago, IL:  Health Administration Press.