Chapter 9: Policy in Public Health

What makes up the Iron Triangle?

Access, quality and cost focusing on public health policies, programs and resources

What are the two new programs provided in the Quality Payment Program of MACRA?

Advanced Alternative Payment models and the Merit-Based Incentive Payment System

What are the six general phases of the policymaking process?

1. Agenda setting is key in the policy process and pertains to getting the problem on the agenda whereby Congress, state legislators, or local public officials seek to address the identified problem. 2. Policy formulation is when policies are proposed to address the problem and then debated by policymakers. Although policymakers may agree a problem is important, inaction can occur if an acceptable policy solution is not agreed upon. 3. Policy adoption occurs through established governmental processes in which laws or ordinances are passed by lawmakers. 4. Policy implementation occurs after a policy is adopted when government units make the policy operational, which requires both human and financial resources. 5. Policy evaluation follows implementation to determine whether the policy is meet- ing its goals in addressing the identified problem. 6. Policy modification occurs after policy evaluation when results are used to determine if a policy should be continued, modified, or repealed

What are the three essential public health services associated with policy development?

1. Inform, educate, and empower people about health issues. 2. Mobilize community partnerships and action to identify and solve health problems. 3. Develop policies and plans that support individual and community health efforts.

What are the three factors ("streams of activity) of the policy "window of opportunity"?

1. Strong support among the voting public and policymakers that a problem should be resolved, consistent with the first phase of the policymaking process. Social agreement. 2. Support for the proposed policy design, consistent with the second phase. 3. Political relationships are receptive to change.

Vignette 5: Fred, a Medicare beneficiary, also had the flu and subsequently visited the ED for acute shortness of breath. The triage nurse cautioned that his wait could be long as many sick patients were waiting to be seen. Two hours later, Fred was still in the waiting room. Following multiple unanswered requests about his status in the queue, Fred notified the triage nurse that he was leaving without being seen because of their slow service. 5. Which federal policy is most relevant to Fred's experience? a. Value-based purchasing b. Medicare Access and Chip Reauthorization Act (MACRA) c. Emergency Medical Treatment & Labor Act d. All of the above

Answer: a. The scenario reflects the importance of Medicare's value-based purchasing program, which financially rewards or penalizes hospitals according to the quality of care provided to Medicare patients. Value-based purchasing was established by the ACA and implemented in 2013. Medicare has developed quality metrics that are used to create incentive payments based on how well a hospital performs or how well they improve performance relative to past performance. One ED metric is the percentage of patients who left before being seen, which is included on Medicare's Hospital Compare Web site, under the hospital's category for "Timely and Effective Care" (see Emergency Department Care).23 EMTALA is not relevant because the patient chose to leave before the screening examination. MACRA pertains to physician payments and therefore is not relevant to the scenario.

Vignette 2: The Patient Protection and Affordable Care Act (ACA) was enacted in 2010. The ACA is also known as "Obamacare" because it is health reform advanced under President Barack Obama. The law is comprehensive, and full implementation regarding private health insurance coverage was implemented on January 1, 2014. A key provision is that employers with 50 or more employees must purchase health insurance for their employees or otherwise pay a penalty. It also required noncovered individuals who do not qualify for Medicaid to purchase health insurance, with federal subsidies to those with qualifying incomes. Individual coverage can be purchased through a state or federal insurance "exchange" where insurance is purchased absent consideration of pre-existing medical conditions.6 The ACA provisions are somewhat similar to employer-sponsored health insurance in which insurance premiums are based on a group and not an individual's health status or prior use of health services. 2. The ACA legislation was passed as a result of what factor(s)? a. The policy solution was embraced by a majority of Republicans in Congress. b. The majority in Congress supported the proposed policy solution. c. The political climate between Republicans and Democrats was favorable. d. All of the above.

Answer: b. It was passed because the majority in Congress supported the proposed pol- icy solution. This occurred because the majority were Democrats, as was President Obama. Republicans in the House or Senate did not support the ACA. This subsequently resulted in contentious relationships, leading to repeated attempts by some Republicans to repeal the ACA, which did not occur until a policy solution was agreed upon by Congress and President Donald Trump in December 2017 via a tax bill. The law was changed to eliminate the penalty associated with the mandate to purchase health insurance beginning in 2019.7 This may have an impact on health insurance mar- kets and premiums if healthy individuals choose not to purchase health insurance. Nonetheless, other ACA provisions remain.

Vignette 4: Joe had the flu and weeks later was not fully recovered. As a consequence, he visited his local emergency department (ED) and reported his chief complaint as acute short- ness of breath and said he might have pneumonia. The triage nurse explained that because Joe was uninsured, it was better for him to use the hospital's urgent care center, which was a few blocks away. The nurse explained this would be less costly because an ED visit can result in a large hospital bill of $1,000 or more. 4. Which federal policy is most relevant to this scenario? a. Value-based purchasing b. Emergency Medical Treatment and Labor Act c. Health Insurance Portability and Accountability Act (HIPAA) d. Meaningful use

Answer: b. The scenario presents a violation of the federal Emergency Medical Treatment and Labor Act (EMTALA) because an ED screening examination was not provided and, therefore, it is unknown if Joe needed emergency care, such as antibiotics for pneumonia. EMTALA was passed by Congress in 1986 to ensure emergency care is accessible to all persons (including the uninsured) and not based on a patient's ability to pay. EMTALA requires hospitals with an ED to provide a medical screening examination when a patient presents to the ED, as well as to treat or stabilize any true emergency, including women in active labor. If the screening examination determines that the condition is not an emergency, EMTALA obligations have been met even if the underlying medical condition still exists.21 The other choices to this question are not correct as they relate to other policy issues including rewards or penalties for quality of care (a), privacy and security of health information (c), and meaningful use of electronic health records (EHRs; d).

Vignette 3: Medicaid expansion was passed as part of the ACA in 2010 and would require states to expand Medicaid coverage to cover all low-income adults aged 18 to 64 years who were at less than or equal to 138% of the federal poverty level. Each state's expansion was to be implemented on January 1, 2014. Initially, the Medicaid expansion would be funded solely by federal funds and later transition to federal and state matching funds. 3. Since then, what occurred with the Medicaid expansion? a. All states have expanded Medicaid consistent with the ACA. b. Some states have requested waivers to avoid the mandate to expand Medicaid. c. The US Supreme Court overturned the mandate for states to expand Medicaid. d. Some states have been given approval to delay their Medicaid expansion.

Answer: c. In 2012, the US Supreme Court overturned the mandate for states to expand Medicaid, following legal challenges from many states. The court found the mandate "unconstitutionally coercive of states" because states had insufficient notification to voluntarily agree to an expansion, and noncompliance could result in a state losing all federal Medicaid funding. As a consequence, about 18 states have not expanded Medicaid, thereby forgoing federal funds to cover low-income adults. The other answers are not correct regarding approvals and waivers and not all states expanded Medicaid coverage consistent with the ACA.

Vignette 1: Title XVIII of the Social Security Act (Medicare) was enacted in 1965 under President Lyndon Johnson. In general, Medicare provides health care coverage to persons who are 65 years and older. It was later expanded to also cover younger persons who qualify for Social Security disability benefits or have end-stage renal disease. As passed in 1965, original Medicare included Parts A and B. Parts C and D were added after and are discussed later in this chapter. Medicare Part A covers hospital inpatient care and is funded by a pay- roll tax that is paid by both employers and employees. Medicare Part B covers supplemental medical (physician and outpatient) services. Participation in Part B requires Medicare beneficiaries to pay a monthly premium that is supplemented (subsidized) by federal funds. 1. The Medicare policy "window of opportunity" in 1965 was successful with the passage of Medicare because of what factor(s)? a. The public perceived that a problem existed. b. Support existed for the policy design. c. A majority in Congress supported the plan. d. All of the above

Answer: d. All of the above factors contributed to its success. As workers retire, they typically lose access to their employer-sponsored health plan. The public and policymakers perceived an issue because older persons had problems purchasing individual private health insurance coverage because of their higher costs from increased likelihood of chronic diseases and hospitalizations. Both Democrats and Republicans supported Medicare, which was a policy solution designed to meet the interests of both political parties. Democrats sought hospital coverage, which was included in Medicare Part A, whereas Republicans sought a federal subsidy for physician coverage, which was included in Medicare Part B. Part B requires a premium, which satisfied fiscally conservative Republicans. Thus, the "window of opportunity" resulted in Medicare passing because consensus existed about the problem and the policy solution, and a favorable political climate existed.

Offices and agencies under the HHS

CDC, Food and Drug Administration (FDA), National Institutes of Health (NIH), Health Resources and Services Administration (HRSA), Agency for Healthcare Research and Quality (AHRQ), Indian Health Service (IHS), Agency for Toxic Substances and Disease Registry (ATSDR), Office of Civil Rights (OCR), Substance Abuse and Mental Health Services Administration (SAMHSA), and many other offices that are described on the HHS Web site.

Emergency Medical Treatment and Labor Act (EMTALA) definition

Cannot turn away patient's due to lack of insurance. Must provide medical screening exams, treat or stabilize any true emergency

Center for Medicare and Medicaid Innovation (CMMI) definition

Charged with designing, testing, and implementing new payment models that address enhancing quality, containing costs, and reducing inefficiencies in care delivery

What does Medicare use to assess quality for providers other than hospitals such as nursing homes and physicians?

Consumer Assessment of Healthcare Providers and Systems

State Children's Health Insurance Program (SCHIP or CHIP) of Title XXI of the Social Security Act definition

Covers children who do not qualify for original Medicaid, and whose family incomes are insufficient to afford private health insurance 70% federal/30% state

What are examples of cost-sharing provisions?

Deductibles, copayments and co-insurance

Centers for Medicare and Medicaid Services (CMS) definition

Governs Medicare, Medicaid and SCHIP Goal is to cover eligible individuals to improve quality and affordability of health care for its beneficiaries agency under the US Department of Health and Human Services (HHS)

What national survey asks hospital patients about their satisfaction with factors such as communication with docs and nurses, responsiveness of hospital staff, discharge instructions, and overall rating of the hospital?

Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS) survey

How does a bill become a law?

If it raises taxes, it begin in the House. Both the House of Reps and the Senate must each pass a version of the bill. Both bills are referred to a conference committee, which includes relevant members of the House and Senate to resolve differences. Once consensus is achieved, a conference report is sent back to the House and Senate for a vote. The president can sign bill into law or veto. If vetoed, sent back to Congress for another vote. 2/3s vote can override a President veto.

What are examples of value-based purchasing (quality) assessments?

Physician Quality Reporting System and Medicare Access and Chip Reauthorization Act (MACRA) modify the way physicians can be paid for Medicare patients

What are the three core public health functions?

Policy development, assessment and assurance

How does the CDC define policy?

a law, regulation, procedure, administrative action, incentive, or voluntary practice of governments and other institutions

Moral hazard definition

the demand for services increases, in particular unnecessary services, if they are provided at no cost to patients