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
CMS Reimbursement For The Use Of Skin Grafting Therapy 
Hi Peter!
Change can be very disruptive, whether it is intended as a positive or negative change. Although, I believe the level of disruptiveness depends on the perspective. One person may perceive a change as unnecessary and bothersome, unsettling their normal routine. This reaction usually causes them to resist the change and likely not allow the change to be successful. Another person might embrace a change because they see the change as beneficial and a step along the progression of continual process improvement. Either way the change can be disruptive but then the question is, is disruption really all that bad?
Peter –
If only the actual process of change within Medicare could function as smoothly as is portrayed in your model! While increased costs may be part of the driving issue I would think that decreased provider participation and potentially compromised patient care could also be factors in driving change. Without Medicare reimbursing for these services providers may choose not to participate in Medicare and Medicare patients would be left without. Similarly if these wound services are the best evidence based care, Medicare not providing them would lead to poorer patient outcomes and then increased costs. These large government programs do have trouble seeing the big picture at times and then changing to keep up with essential needs.
Peter, your example highlights the importance of Lewin’s first stage in his three-step theory of change. When your professor had students switch seats suddenly, with no explanation given, the unfreezing stage was bypassed, and the second stage (change implementation) was immediately initiated. The unfreezing stage is when agents of change motivate and prepare stakeholders, build trust in the need for change, increase driving forces away from the status quo, and decrease restraining forces that prevent movement from the current state of affairs (Kritsonis, 2005). Part of successful unfreezing is providing rationale to individuals, as well as phasing processes in over time; both time and information can serve to reduce uncertainty and stress when undergoing change (Utley, 2011). While purposefully intended to be dramatic, your professor’s tactic is certainly an illustration of the deleterious effects of sudden, unexpected change where buy-in is not sought, and feedback is not valued.
References
Kritsonis, A. (2005). Comparison of change theories. International Journal of Management, Business, and Administration, 8, 1-7.
Utley, R. (2011). Theory and research for academic nurse educators: Application to practice. Sudbury, MA: Jones and Bartlett Publishers, LLC.