WEEK 5 The Historical and Contemporary Role of Institutions and Actors & The Relevant Statutory and Regulatory Mechanisms
The Role of Institutions and Actors in Developing Healthcare Policy
Policymaking is a cyclical and highly political process (Longest, 2010). It is influenced by external factors. These external factors are: preferences of individuals, organizations, and interest groups, along with biological, cultural, demographic, ecological, economic, ethical, legal, psychological, social, and technological inputs (Longest, 2010). The policymaking process includes the three following components which are interactive and interdependent: policy formulation, policy implementation, and policy modification (Longest, 2010). Health policies are made within the context of the pollical marketplace and the federal and state governments have important health policy roles (Longest, 2010). Interest groups is one of the main external factors that affects policy making process since interest group pressure has positive impact on the government’s agenda (Kingdon, 2010). Academics, researchers, and consultants’ impacts are also very important (Kingdon, 2010).
A Model of the Public Policymaking Process in the United States
The Relevant Statutory and Regulatory Mechanisms
Using emergency department (ED) for non-urgent condition has led to excessive healthcare spending (Uscher-Pines et al., 2013). Department of Health and Human Services, Centers for Medicare & Medicaid Services (CMS) is the main political actor in reducing the inappropriate used of ED visits. CMS has partnered with states, plans, providers, and consumers to implement reforms that can appropriately address the unnecessary hospital ED usage (Mann, 2014). CMS identified the three strategies to reduce inappropriate ED use:
- Broaden access to primary care services which includes developing more urgent care clinics, provide same day appointment, extended hours, and 24/7 nurse advice lines.
- Focus on frequent ED users.
- Target needs of people with behavioral health problems
(Mann, 2014)
On another hand, the Medicaid statute and implementing regulations permits cost sharing for non-emergency use of the ED (Mann, 2014). When an ED visit is determined as non-urgent and does not need ED services then cost sharing can be charged (Mann, 2014). Regardless of the state laws or Medicaid health care delivery programs, all hospital providers must bound by Emergency Medical Treatment & Labor Act (EMTALA) (Mann, 2014). EMTALA, enacted in 1986, is a federal law that requires anyone coming to an emergency department to be stabilized and treated, regardless of their insurance status or ability to pay (CMS , 2012).
References
Centers for Medicare & Medicaid Services. (2012). Emergency Medical Treatment & Labor Act (EMTALA). Retrieved from https://www.cms.gov/Regulations-and-Guidance/Legislation/EMTALA
Chou, S., Gondi, S., & Baker O. (2018). Analysis of a commercial insurance policy to deny coverage for emergency department visits with nonemergent diagnoses. JAMA Netw Open, 1 (6):e183731. doi:10.1001/jamanetworkopen.2018.3731
Kingdon, J.W. (2010). Agendas, Alternatives, and Public Policies, Update Edition (2nd ed.). London: Longman Publishing Group.
Longest, B.B. Jr. (2010). Health policymaking in the United States (5th ed.). Chicago, IL: Health Administration Press.
Mann, C. (2014). Reducing nonurgent use of emergency department and improving appropriate care in appropriate settings. Retrieved from https://www.medicaid.gov/sites/default/files/Federal-Policy-Guidance/downloads/CIB-01-16-14.pdf
Uscher-Pines, L. et al. (2013). Deciding to visit the emergency department for non-urgent conditions: A systematic review of the literature. Am J Manag Care, 19 (1): 47-59. Retrieved from https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4156292/
DNP 711 Blog 
Ha,
As a former Emergency Room (ER) Registered Nurse (RN), I feel strongly against the Avoidable ER Policy. I will admit there were times the ER seemed overly crowded with patients presenting with non-life-threatening chief complaints; however, I do not believe the answer is penalizing them for seeking care. A 2013 study found that there is nearly 90 percent overlap in symptoms between non-emergencies and emergencies (Raven, Lower, Maselli, & Hsia, 2013). If this is the case, it would ultimately be the patient’s experience of the symptoms dictating whether or not they believe it is a true emergency. Perhaps the issue goes beyond overabundance of the ER visits, but the lack of access patients have to quality primary care. Policymakers should instead focus on improving preventive care, including the expansion of health coverage for it.
Reference
Raven, M.C., Lowe, R.A., Maselli, J., & Hsia, R.Y. (2013). Comparison of presenting complaint vs discharge diagnosis for identifying “nonemergency” emergency department visits. The Journal of the American Medical Association, 309(11), 1145-1153. doi: 10.1001/jama.2013/1948
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According to the Centers for Disease Control and Prevention (CDC), an annual sample survey completed in 2016 by the National Hospital Ambulatory Medical Care (NHAMC) found that out of 145.6 million emergency department (ED) visits in the United States, only 7.8% resulted in hospital admissions (2017).
The overuse of Emergency Department (ED) for non-urgent medical care has significantly impacted health care spending in the United States. Not only is health care in the United States expensive, but the cost of care in an emergency setting is significantly higher than care in other medical settings (Adams, 2013). While Americans are living longer and the population in the United States continues to grow, access to healthcare will be increasingly difficult unless something changes. In order to increase access to care and reduce spending, it is important for policy makers to focus on promoting alternative approaches to primary care services (Adams, 2017). For example, the development of more free-standing hospital-based care clinics, accessible walk-in clinics, and additional specialized services for the undeserved and vulnerable populations. Options such as these can help decrease ED utilization for non-emergent conditions and reduce spending while providing more options for care. Policy for reducing over use of ED services should also include incentives for offering extended hours, walk-ins, and telehealth so that access to healthcare is attainable for both the insured and uninsured. However, for this to happen, policy makers must work together with not only the health care system but also providers, patients, and advocates to create more effective ways to receive healthcare in America.
References
Adams, J. G. (2013). Emergency department overuse. JAMA, 309(11), 1173. doi:10.1001/jama.2013.2476
Centers for disease control and prevention. (2017, January). Emergency department visits. Retrieved February 8, 2020, from https://www.cdc.gov
Centers for disease control and prevention. (2017, January). Emergency department visits. Retrieved February 8, 2020, from https://www.cdc.gov
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The “Avoidable ER Policy ” is very interesting to me for several reasons, one very personal. I completely understand the burden non-emergent visits place on the department, staff and consumers. I worked in the ER for a short period and during that time I was surprised how many patients felt like 80% or more of conditions and signs and symptoms that would have been better suited for an urgent care facility or making an appointment with a primary care provider. The ER began to feel like an urgent care, but a very expensive one that did full panel labs on all admissions and standard tests. According to an article by Nicole Cohen (2019) a small number of patients, less than 10% are admitted to the hospital after being assessed in the ER.
I can understand and sympathize for the situation as the ER being utilized as a walk-in clinic, but it also brings up concern for patients who should seek treatment from the ER and may be concerned regarding if the patient’s illness is ER suitable. On a personal note my mother passed away the first semester of this school from a tooth infection. Yes, tooth infection. She had been battling gingivitis for several years and was scheduled to have several teeth extracted as well as her gums cared for. She became sick several months prior to her scheduled surgery and made over 4 visits to a local urgent care, each time sent home on an antibiotic and diagnosed with respiratory infections. Although we urged my mother several times to seek care at an ER she did not feel she was ill enough to require emergent care. My mother unfortunately did not live long enough for her surgery. She passed within 4 days of going to the ER of sepsis. I assume if she would have gone to the ER earlier, instead of the urgent care facility, her labs would have been drawn and maybe the development of the infection could have been caught and cured.
Reference
Cohen, N. (2019). Urgent care centers and virtual visits help avoid unnecessary trips to the ER.
Fairfield County Business Journal, 55(24), 13. Retrieved from
http://login.ezproxy1.lib.asu.edu/login?url=https://search-proquest-.ezproxy1.lib.asu.edu/docview/2261152877?accountid=4485
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This topic is so important to address. Thank you for sharing this information. As I was reading your blog, I found myself thinking about the three strategies that CMS has identified to reduce inappropriate emergency department use and how all three may be intertwined. Behavioral health patients tend to be a large portion of frequent utilizers of emergency departments (numbers 2 and 3 of the strategies). If these patients, perhaps, had more urgent care facilities across the valley (number 1 of the strategies) for mental health services that included immediate intake assessments, ability to prescribe bridge prescriptions, ensure appropriate follow up appointments are in place and transportation and funds are available, and follow up services this may positively impact the inappropriate utilization of the emergency departments. With the shortage of psychiatric providers, sometimes appointments for evaluations are months out and an urgent care mental health setting can get services and medications started sooner with the hopes for stabilization. I look forward to learning more about your topic in future blogs.
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Ha,
I would agree with you that electronic health record systems are a very important technological advancement when it comes to healthcare. As you mentioned electronic health records have been breached and it is important to consider adopting electronic health record systems with strong barriers to protect patient information. Because of the sensitive nature of the information stored within electronic health record systems, it is important to understand that several security safeguards have been introduced through the Health Insurance Portability and Accountability Act (HIPAA) and the Health Information Technology for Economic and Clinical Health (HITECH) Act (Kruse, Smith & Nealand, 2017). Firewalls and cryptography are important security techniques, as well as cloud computing, antivirus software and initial risk assessment programs along with a chief information security (Kruse, Smith & Nealand, 2017). Cloud computing appears to be a promising platform and according to a cyber-security checklist created by the Office of the National Coordinator for Health Information Technology, antivirus software is in the top ten listed methods for avoiding security breaches (Kruse, Smith & Nealand, 2017). Definitely something to consider when making decisions to protect private data stored in electronic health record systems.
References
Kruse, C. S., Smith, B., Vanderlinden, H., & Nealand, A. (2017). Security techniques for the electronic health records. Journal of medical systems, 41(8), 127. https://doi.org/10.1007/s10916-017-0778-4
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Hi Ha,
I had a remarkable experience last week, which was to learn a new way of framing the value of the profession I care about deeply: cancer rehabilitation therapists. I am not a therapist, but I continue to experience negative side-effects from my treatment. Most of these issues could have been avoided completely if had seen a cancer rehabilitation specialist during my treatment.
As you point out in your blogs, reducing unnecessary ED visits is a great way to generate significant cost savings for the healthcare system. But there is a second way to reduce avoidable trips to the ER, and that is to reduce trips to the ER that are justified, but that could have been avoided in the first place.
Treating conditions early in their development can be the difference between a needed trip to the ER and far less expense, and more effective therapy provided by a skilled provider. That is the role that can be played by a cancer rehabilitation therapist who addresses symptoms of fatigue and lymphedema as soon as they develop in the trajectory of cancer treatment.
What you might find equally interesting is that this solution, like so many of the solutions that you describe, depends on the EMR. Cancer rehabilitation therapists know cancers, they know treatments, and they know when impairments are likely to occur. If the EMR were used to trigger periodic assessments at crucial milestones in the treatment trajectory, cancer rehabilitation specialists could catch and address problems as they are developing, before they accumulate and worsen over the course of treatment.
I learned about this role of cancer rehabilitation specialists, which can be framed as a significant cost saving to healthcare providers from a webinar by Dr. Michael Stubblefield, the leading expert in the field. If you have interest in pursuing this line of thought, here is a link to his March 26 webinar, sponsored by the National Coalition of Cancer Survivors:
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