Healthcare Policy: Where It Comes From and How to Change It
January 2018 Issue
A few years ago, a surgeon affiliated with a prominent medical system in Chicago passed away. He had been a well-respected mentor to many medical students and residents, and many of his former trainees eloquently described the impact that his mentorship had on their education and careers.
The surgeon had practiced in the early decades of the 20th century, a time when healthcare practice and funding was vastly different than it is today, and it was more common for patients to pay out of pocket for medical services than to rely on medical insurance. When discussing a required surgical procedure with patients and caretakers, this surgeon would inquire about the family's income and then set the price for performing the surgery at one month of the family's income. This story was related as a way of demonstrating this surgeon's sensitivity when working with patients from diverse backgrounds.
This method seems completely foreign today, when reimbursement levels are established by the policies of governmental and private-payer organizations. The policy changes that occurred over the course of this surgeon's career were related to broad shifts in economic conditions, political philosophies, and public opinion. P&O practitioners are impacted by this system daily, yet many of us are unaware of the factors that contributed to the development of this complex system.
This article reviews concepts described in a 2008 article titled "What Are the Sources of Health Policy That Influence Nursing Practice?" by Susan Taft, PhD, MSN, BSN, RN, and Kevin Nanna, MSN, RN. Although the article is ten years old and is written from the perspective of the nursing profession, it is broad enough that the authors' "framework that identifies the sources of health policies" applies to P&O practice.1 Understanding this framework can help equip practitioners to affect policy in ways that are beneficial to our patients and profession.
What is Policy?
Appropriately, a clinician's primary focus is on direct patient care. However, the decisions and actions of clinicians are affected by policy as we strive to provide services compliant with payer guidelines. While these requirements are often described as medical policies, viewed from another perspective they define the conditions that must be met to receive payment. These policies dictate what items and services will be covered, and what steps the practitioner must go through to receive that payment. Where do these policies originate, and what factors influence their development?
According to Taft and Nanna, "health policy comprises the choices that a society makes regarding its health goals and priorities, and the ways it allocates resources or policies to attain those goals. Health policy reflects the values, beliefs, and attitudes of those designing the policy, whether on the local, national, or international stage."1 These authors make distinctions between policy at the micro level (policies within the narrow scope of a practitioner's work responsibilities) and macro level (national and international guidelines or requirements for practice). Influencing policy at the macro level requires collaboration with other individuals and organizations that extend the impact of an individual practitioner. This collaboration requires a working knowledge of which organizations are involved in the development of policy to take advantage of opportunities to influence the process.
Sources of Policy
Taft and Nanna identified key sources of policy by reviewing conceptual frameworks that were developed by other authors. At the broadest level, policy sources can be defined as either public or private. Public sources are those associated with national, state, and local government, and private sources include for-profit and not-for-profit organizations. At the most private level, individuals and caretakers make healthcare decisions based on their personal values and priorities. These values and priorities inform decisions such as whether to pursue medical treatment, how to allocate personal resources to address healthcare needs, and which insurance plans to select. These specific decisions form the patient's personal healthcare policy, and practitioners must understand that options may be significantly limited for individuals with limited resources. The high cost of medical care means that many healthcare decisions will be determined by public and private organizational policies at the macro level, well beyond the direct control of the patient.
Navigating the many decisions that must be made in complex medical situations is often much more complicated for our patients than we realize. (Occasionally, the decisions they make can be surprising. I've worked with patients who have declined advanced O&P care that they were eligible to receive, based on a personal conviction that they should not take advantage of resources that could be used by someone who needed them more.) Taft and Nanna outline three primary sources of policy that impact healthcare delivery.
Organizational sources of policy include healthcare workplaces, insurers, suppliers, philanthropies, and volunteer organizations. Employer policies may dictate that practitioners purchase a specific brand of components, or provide a specific device design for certain patient presentations. For economic reasons, companies can also decide not to provide diabetic shoes and inserts, or not offer components that require documentation of a K3 functional level, since these claims have been scrutinized by Medicare and may result in denials of coverage. These are examples of an organization directing the provision of healthcare services as a matter of company policy. Navigating insurance company policies is a daily reality for every P&O clinician, since those policies dictate which items are covered and the overall level of care a patient receives.
Public sources of policy include federal, state, and local governments, each with its own version of the legislative, judicial, and executive branches. Other public sources include economic conditions, environmental factors, demographic trends, societal norms and social values, and special interest groups and lobbies. P&O companies and individual practitioners are subject to a broad range of laws related to conducting business that apply directly or indirectly to specific healthcare delivery decisions. For example, local coverage determinations (LCDs) established by the Centers for Medicare & Medicaid Services define the conditions that must be met for patients to receive specific items and services. Other laws and policies impact patient care decisions, even though they do not relate exclusively to healthcare delivery. For example, companies providing items to patients at no cost must do so in a manner that complies with laws related to inducement and anti-discrimination.
Professional sources of policy include all healthcare disciplines, educational, accrediting, and certifying organizations, volunteer professional organizations, and research facilities. Individual or corporate member organizations such as the American Academy of Orthotists and Prosthetists (the Academy) and the American Orthotic & Prosthetic Association (AOPA) help define and shape our professional identity and impact policy by offering clinical education and opportunities for advocacy. These professional organizations also represent the interests of the profession to governmental organizations and media. Organizations that fund and conduct research play a significant role in establishing healthcare delivery priorities. P&O research over the past few decades has increasingly focused not just on the development of more technologically advanced components, but on demonstrating the positive impact of that technology on function and developing assessments that help practitioners determine which patients would benefit most from this technology. Some of this research has been initiated in response to policy requirements. However, since "policy is shaped by how policymakers learn about healthcare issues and how those issues are defined as problems," research can also help to inform the development of new policy by defining clinical priorities.1
Policy impacts practice in tangible and practical ways, but the development of those policies can seem far removed from the day-to-day life of most clinicians. Understanding the sources of policy in broad terms can help clinicians focus their professional energy on areas of impact. Taft and Nanna list several ways that practitioners can influence public policy, including by becoming educated voters, joining a professional organization, writing letters to media outlets, and donating money. Of these, participation in professional organizations is one of the most effective ways to extend the influence of individual practitioners. P&O organizations work hard to promote the value they offer to their members in terms of education and networking. Maintaining a consistent professional identity and a clear voice in advocating for the profession may be an even more significant benefit. When faced with proposed revisions to the LCD for lower-limb prostheses that would have set clinical practice back decades, these organizations provided the resources and rationale that demonstrated the value of our professional education, training, and experience. Joining and supporting these organizations allows practitioners to extend their influence far beyond what would be possible through individual action. Viewed in that light, membership dues seem like a small price to pay.
An article published in 2013 presented change in political astuteness reported by nurses who participated in a legislative day.2 The authors, both researchers from the University of Washington, describe "political astuteness" as "awareness of health policy issues, an understanding of the legislative and policy process, political knowledge and skills such as knowing who policymakers are and how to communicate with them, and involvement in the political process…." They point out that most nurses (the subject of their research) do not get involved in the health policy process due to "a lack of knowledge and skill," and the authors reported on two studies related to this topic. In the first study, participants were asked after their participation in a legislative day to report the level of their political astuteness before and after the event. In the second study, participants were surveyed twice (before and after participating in a legislative day) and asked to report the level of their political astuteness. Respondents in both studies reported that their political astuteness increased after participating in a legislative day. It is encouraging, though not surprising, to see evidence that participation in events like this results in more awareness and understanding of the policy process. It is likely that P&O practitioners would report a similar increase in awareness and understanding following participation in advocacy events, such as AOPA's Policy Forum.
At a time when governmental and insurance company policies dominate the healthcare landscape, it can be difficult for us to imagine that a surgeon could determine the cost of a surgery based on his patient's income. Decades from now, practitioners may have an equally hard time imagining the convoluted system that we consider normal. No one can predict what future healthcare policy will look like, but we can play a role in how that policy develops. Joining and supporting key organizations and influencers within our profession allows us to make the type of impact that will direct policy development in ways that are most beneficial to our practices and the individuals we serve.
John T. Brinkmann, MA, CPO/L, FAAOP(D), is an assistant professor at Northwestern University Prosthetics-Orthotics Center. He has more than 20 years of experience treating a wide variety of patients.
Taft, S. H., K. M. Nanna. 2008. What are the sources
of health policy that influence nursing practice? Policy, Politics, & Nursing Practice 9(4):274-87.
Primomo, J., E. A. Björling. 2013. Changes in political astuteness following nurse legislative day. Policy, Politics, & Nursing Practice 14(2):97-108.