Historically, the citizens of the United States of America have prided themselves on their freedom and the ability to have their voices heard. President Abraham Lincoln stated in his Gettysburg Address that the United States of America would have a “government of the people, by the people, for the people …” (Lincoln, 1863). This literary work of art summarizes what a true democratic society is by emphasizing that all qualified citizens have the right to voice their opinion in regards to the policies being taken into consideration. In the United States of America this process has not drastically changed over the years since the founding fathers with the exception of the speed of information disbursement and the increasing presence of biased institutions, such as the pharmaceutical companies, leaning on politicians (Sommer, 2001).
Now the development and implementation of health policies into action is a rather complicated process and relies heavily on the various different actors, such as a concerned citizen or businesses (Longest, 2010). To start the policy-making process a problem must be identified, which is where elected representatives rely on consumers to vocalize their concerns. For example the Center for Medicare and Medicaid Services (CMS) decision to change the reimbursement model for the use of skin graft therapy came from rising concerns over the increasing costs associated with wound care therapy (Schroeder & Frist, 2013).
Once the problem has been properly identified the next stage is to formulate a potential solution and present it to congress. The proposed solution to the increased expenditures related to skin grafting therapy was the adoption of the bundled payment plan (McCurdy, 2013). If the proposed policy gets enough supporters at the congressional level it is then transitioned into an endorsement phase where the policy becomes a law.
Now that the policy is a law, a regulating body is assigned to ensure that the implementation process is successful and institutions and other actors are compliant with the final ruling. In our example, CMS is the regulating body that oversees the compliance with the change in the reimbursement model. The regulation process is extremely difficult as CMS deals with a large amount of claims on a daily basis and relies heavily on the honesty of the healthcare billers to reduce any fraudulent changes. However, to keep honest people honest random audits are completed to ensure compliance and proper billing is being performed.
Finally, the new law is evaluated using a cost-benefit analysis with the intention of determining whether this new law remains practical and cost effective. Actors in the community play a very important role in this phase, as they can begin to voice their concerns once again if the newly enacted law did not properly address the initial problem (Longest, 2010).
Although this is a very simple breakdown of what it takes to develop and successfully implement a new healthcare policy it is a very complex and daunting task especially when representatives are swayed by institutions and no longer stand “for the people” (Lincoln, 1863). However, if all qualified citizens do their part in voicing their concerns and taking an active role in making representatives aware of the problems present in the “real world” than our country “shall not perish from this earth” (Lincoln, 1863).
Reference
Lincoln, A. (1863). The Gettysburg Address. Abraham Lincoln Online. Retrieved February 5th, 2014, from: http://showcase.netins.net/web/creative/lincoln/speeches/gettysburg.htm.
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.
Sommer, A. (2001). How public health policy is created: scientific process and political reality. American journal of epidemiology, 154(12), S4-S6.
CMS Reimbursement For The Use Of Skin Grafting Therapy 
Great post Peter! I loved how you incorporated Abraham Lincoln’s Gettysburg Address. You did an excellent job summarizing the development and implementation of a new healthcare policy. I totally agree with you that the voice of the people is important. As an advocate for older adults this is an area I find the most frustrating. Older adults and those caring for them (aka caregivers) are limited in their time and resources and so I feel their voice is sometimes muted. Institutions have the money and therefore the power to exert their influences, which may not coincide with the overall needs of older adults. One example that comes to mind is lobbying for research funding for diseases such as Parkinson’s and Multiple System Atrophy. Thank you for your post!
Thank you for the great post! You mapped out the process very well.
Bundle payments have been around for awhile. In the 1990’s when I first did utilization review with an insurance company, the bundled claims were primarily for surgeries (e.g. tonsillectomy and adenoidectomy had to be billed bundled and not as separate surgeries). With the Affordable Care Act, the “Bundled Payments for Care Improvement” (BPCI) was created, starting in January 2013 as a pilot with possible expansion in 2016. (1) The program significantly expanded the concept of bundled payments to include medical conditions, not just surgeries – a total of 48. Organizations in the pilot enter into payment arrangements that include financial and performance measures. My facility elected to do the BPCI for Congestive Heart Failure and I have been participating in the monthly meetings for the last year. It has been very interesting and very productive. We have not met our goals yet for CHF readmissions, but have made great strides and improved many processes. I wouldn’t necessarily call the BPCI program a success yet, but as it does save CMS money, I expect the program will be expanded in 2016 and providers will not be given a choice to participate.
If I understand correctly, this change to bundled payment for wound care therapy is not a pilot and providers did not have a choice. Is this correct? Have organizations like the AMA been involved in the discussion? Or maybe the American Board of Wound Management or American Board of Wound Medicine and Surgery would be the voice for providers. I would think even plastic and reconstructive surgery would be impacted and they also have a board. I’m hoping there is some organization advocating for these providers! Do you see an opportunity for changes to the policy based on what you’ve been learning?
Robyn
(1) Retrieved from: http://innovation.cms.gov/initiatives/bundled-payments/