Navigate 2 Scenario for Health Policy

Episode 1: Policy Analysis and Development 

Overview

In this episode, you will be in a health care policy internship program in a Senator’s office in Washington, D.C.  The Senator wants to develop policy that requires all health care organizations that receive federal funds to implement the recommendations presented in the Institute of Medicine reports on quality care. You will develop a policy, so that it can become proposed legislation. You must collect data, describe the problem, solutions and related ethical issues, examine the cost-benefit analysis, identify stakeholders (such as lobbyists from American Hospital Association, health care providers, health care corporations, pharmaceuticals, insurers, etc.), and impact.  Based on this information, you will create a policy description that will be the foundation for a bill. You will describe critical issues that would be in the bill such as requirements of hospitals to:

• Monitor and report medical errors to the Department of Health and Human Services
• Use root cause analysis on a certain percentage of errors
• Track and report patient outcomes focused on the clinical problems identified in the National Health Care Quality Report
• Integrate the 5 health care profession core competencies into staff education and track outcomes
• Establish a no-blame culture

*I suggest for you to do some research on your own, and if you use outside sources to help your compile your policy description, be sure to reference them (following an APA format) at the end of your post.

Assignment

You will post a policy description to this discussion board forum. Make sure to identify a plan that addresses legal and ethical issues in a health care policy. You must also respond to 2 of your peers’ posts and make sure to reference any outside sources you may have used in your recommendation.

Below are the characters from this LearnScapes scenario (LearnScapes for Health Policy 1):

The Student (which is you), Health Care Policy Intern for Congress

The student used to work within the Bright Road Health Care System, and had a special interest in policy. The student is thinking about moving into politics, hoping to make a difference at that level. The student has just been accepted into the internship; this is the student’s first big project.

Peter Shackley, Senior Policy Staff Member

The student’s mentor, Peter, is a young and feisty staff member. In his late 20s, Pete has been interested in politics since he was President of his high school student body. He’s especially passionate about policy-making and how the process works. Pete will help guide the student through the policy-making process.

Gretchen Wilde, Senator Chief of Staff

Gretchen is in her 30s and has been the Senator’s Chief of Staff for about 2 years now. She’s very professional, and holds high expectations for everyone in the Senator’s office, including interns. Gretchen is responsible for reviewing policy ideas and descriptions before giving the approval to create a bill.

Marian Powers, Senator

Senator Powers is a Senator in her late 40s. She’s extremely busy with legislative issues, and trusts her staff members implicitly so does not spend a lot of time working directly with the team on this policy.

However, the student and other staff members sometimes contact her for information about state issues, reaction of stakeholders, etc.

Student 1 to reply too

There is increasing concern on the part of Congress regarding healthcare quality and cost, particularly that as costs rise there are not necessarily commensurate increases in quality or outcome.  Policy is sought that would encourage healthcare providers and institutions to meet certain quality and error-reduction guidelines in order to qualify for federal (Medicare) funding. 

Medical errors, in particular, have become a significant burden to the United States Healthcare System, as they are the 3rd leading cause of death in the US, behind only heart disease and cancer (Makary & Daniel, 2016). Policy is needed that encourages systematic investments in new systems and processes that simultaneously manage risk and improve value, while not placing undue burden on rural access hospitals, health centers, or similar entities serving the underserved.  These groups often lack the resources to invest in technology, processes, and human capital than could help.  Health disparities in access to quality care are also recognized, and policy is sought to simultaneously address equalizing both access and quality. 

ERs are often overwhelmed, primary care is not sought regularly, doctors have little time for patients, and multiple electronic systems (or lack thereof) do not communicate and cause delays in information transmission when it is needed most.  The measurable, streamlining of processes, patient flow, and data sharing are also of utmost importance. 

The department of Health, HHS, AHRQ are groups that can encourage healthcare institutions to follow IOM guidelines regarding self-disclosure of medical errors and engage them in proactive behaviors focused on quality and prevention, but policy is needed to address all of the following:

• Monitor and report medical errors to the Department of Health and Human Services
• Use root cause analysis on a certain percentage of errors
• Track and report patient outcomes focused on the clinical problems identified in the National Health Care Quality Report

The following policy solutions are offered for the above priorities:

• Legislation that supports voluntary reporting of near misses and rewards innovation following RCA to address negative trends (innovation grants or awards could be provided by HRSA, Agency for Healthcare Policy and Research, state DOH’s or others. There should be a biannual or quarterly award process.  Healthcare entities with fewer resources and serving the underserved should be held same standards, but should be eligible for grant dollars aimed at needed technology or basic reporting assistance to track outcomes.  This would avoid inequities and level the playing field.
• Center for Quality Improvement and Patient Safety (CQuIPS) has a national quality strategy (AHRQ, 2015) – incentivize organizations who align themselves with this strategy, and similarly, empower ARHQ to hold insures and others accountable for such outcomes, not just provider groups. The responsibility for outcomes should be shared, as should the reduction of health disparities, like mental health for minorities (Bussing & Gary, 2012)
• Establish a quality award system to reward consistently good outcomes that reduce health disparities and medical errors (administered by AHRQ)
• Establish a way to encourage the identification of hidden barriers to quality and safety (RCA, Gemba walks, lean six sigma approaches), like health literacy (AHRQ, 2015) and fund nonprofits through time limited grants so they can initiate such processes and then sustain them once they start seeing results
• In order to: Integrate the 5 healthcare profession core competencies into staff education and track outcomes, the following solution should be considered: Develop an organizational assessment for the quality program and leadership of various institutions – must be tailored to the type of institution and staff education with outcome evaluations in key priority areas established by AHRQ. Make federal funding contingent upon a baseline level of performance in the following areas: Team base care, 1) patient-centered care, 2) teamwork and collaboration, 3) evidence-based practice, 4) quality improvement, and 5) informatics (IOM, 2003).  Alternatively, influence all accrediting agencies to make this part of re-accreditation and avoid setting up a duplicative system if an existing one can be leveraged. 
• In order to establish a no-blame culture, I offer the following policy comment & solution: CMS can also set the stage for incentivizing the reporting of near misses and medical errors, along with root cause analysis for errors. It would be more important for policy to focus on preventive reporting (near misses) rather than simply error reporting.  There are already quality incentives for certain patient outcomes (HG AIC for diabetic control for instance) which policy should continue, but it would be sensible to add near miss and error reporting to this program.  What’s needed is simplification, however.  The way it stands now, each payor has their own quality outcome requirements and quality award structure.  There needs to be legislation that allows for a publicly available report card for payors in terms of their outcome performance (actually this is just now happening in Florida under Secretary Mayhew)

While making federal payments contingent upon compliance with reporting does not facilitate a collaborative relationship with government agencies and healthcare entities, it could be a final step after iterative warnings and opportunities are afforded.  It would be better to encourage full disclosure by participating organizations to self-disclose – allowing increased payment for self-reporting and then altering a process or identifying root cause.

Lastly, payor and provider groups need to be aligned.  Shared goals and shared savings offered back to the provider/entity should be the norm, and should be legislated as such.  Similarly, prevention needs to be paid for – so that fewer folks wind up in the hospital where medical errors are most costly.

Bussing, R. & Gary, F.A. (2012).  Eliminating mental health disparities by 2020: Everyone’s actions matter.  Journal of the American Academy of Child and Adolescent Psychiatry,  51  (7) , pp. 663-666

Institute of Medicine (IOM). (2003). Health professions education: A bridge to quality. Washington, DC:National Academies Press

Makary, M.A., & Daniel, M. (2016). Medical error: The third leading cause of death in the US.  Retrieved November 12th, 2016, from https://www.bmj.com/content/353/bmj.i2139 (Links to an external site.)

U.S. Department of Health & Human Services, Agency for Healthcare Research and Quality: Health literacy: hidden barriers and practical strategies.  Retrieved January 25th, 2019, from

http:// (Links to an external site.)www.ahrq.gov/professionals/quality-patient-safety/quality-resources/tools/literacy-toolkit/tool3a/index.html (Links to an external site.)

Center for Quality Improvement and Patient Safety (CQuIPS). Content last reviewed December 2015. Agency for Healthcare Research and Quality, Rockville, MD.        https://www.ahrq.gov/cpi/centers/cquips/index.html     

Student 2 Reply too

Problem Statement

Healthcare costs in the US are increasing and the quality of care is not keeping pace. According to the Institute of Medicine’s report Crossing the Quality Chasm, US health care deliver systems do not provide consistent, high-quality medical care to all people (Institute of Medicine, 2001). Health care providers have a difficult time keeping up with the ever-increasing advances in technology along with the growing population.

Background

‘Health care spending growth is expected to increase an average annual rate of 5.8 percent. By 2024, health spending is projected to account for 19.6 percent of GDP, up from 17.4 percent in 2013’ (Keehan, et al., 2015). The deaths considered preventable with timely and effective care (amenable mortality) is the worst out of ten other ranked countries (Sawyer & McDermott, 2019).

Landscape

People over 60 are projected to increase from 11% of the population to 22% of the population between 2000 and 2050, with an average life expectancy of 80 years (Jin, Simpkins, Ji, Leis, & Stambler, 2015). This will put significant impact on the health care system.

Physician burnout is a significant concern and must be considered with any new regulatory requirements. ‘Physicians have to navigate a rapidly expanding medical knowledge base, more onerous maintenance of certification requirements, increased clerical burden associated with the introduction of electronic health records (EHR’s) and patient portals, new regulatory requirements (meaningful use, e-prescribing, medication reconciliation), and an unprecedented level of scrutiny (quality metrics, patient satisfaction scores, measures of cost) (Shanafeld, MD, Dyrbye, MD, MHPE, & West, MD, PhD, 2017).

Rural hospitals are closing at an increasing rate since 2010 (Kaufman, MSPH, et al., 2015). Low profitability, patient volumes, and staffing are some of the contributing factors. Any new regulations need to be mindful of these financially fragile, yet important health care facilities.

Option

Implementation of the Institutes of Medicine’s Ten Rules for Redesign:
1. Care is based on continuous relationships.
2. Care is customized according to patient needs and values.
3. The patient is the source of control.
4. Knowledge is shared and information flows freely.
5. Decision making is evidence-based.
6. Safety is a system property.
7. Transparency is necessary.
8. Needs are anticipated.
9. Wasted is continuously decreased.
10. Cooperation among clinicians is a priority.

Recommendation

In order to receive federal funds health care organizations must abide by the following four of the ten quality recommendations from the IOM’s Crossing the Quality Chasm report:
• Implementation of evidence-based medicine. Care should be standardized based on scientific knowledge.
• Safety is a system property. Patients should be safe from injury caused by the care system.
• Transparency is necessary. Patients and their families should have information that enables them to make informed decisions related to their health care.

References

Institue of Medicine. (2001). Crossing the Quality Chasm: A New Health System for the 21st Century. Washington: National Academy Press.

Jin, K., Simpkins, J. W., Ji, X., Leis, M., & Stambler, L. (2015). The Critical Need to Promote Research of Aging and Aging-related Diseases to Improve Health and Longevity of the Elderly Population. Aging and Disease.

Kaufman, MSPH, B. G., Thomas, MPP, S. R., Randolph, MRP, R. K., Perry, J. R., Thompson, K. W., Holmes, PhD, G. M., & Pink, PhD, G. H. (2015). The Rising Rate of Rural Hospital Closures. The Journal of Rural Health.

Keehan, S. P., Cuckler, G. A., Sisko, A. M., Madison, A. J., Smith, S. D., Stone, D. A., . . . Lizonitz, J. M. (2015). National Helath Expenditure Projections, 2014-24: Spending Growth Faster Than Recent Trends. Health Affairs.

Sawyer, B., & McDermott, D. (2019, March 28). How does the qualit of the US healthcare system compare to other countries? Retrieved from Peterson-Kaiser Health System Tracker: https://www.healthsystemtracker.org/chart-collection/quality-u-s-healthcare-system-compare-countries/#item-start

Shanafeld, MD, T. D., Dyrbye, MD, MHPE, L. N., & West, MD, PhD, C. P. (2017). Addressing Physician Burnout: The Way Foward. JAMA, 901-902.