Lawmaking and Health Policy



Lawmaking and Health Policy





Health care is regulated for the public good, to ensure quality to a public that is powerless to assert quality control as individuals. That is the theory at least. In the real world, health care is regulated for quality reasons, and because professional groups lobby for regulations that support their profession and businesses lobby for regulations that help their businesses. Regulation is imposed through statutes, regulations, and policies, and when a statute or regulation is challenged in court, through the judicial system.


The Legal Process


Statutes

A statute is a law enacted by a state legislature or Congress. Laws are found in state and federal codes. For example, Maryland statutes are found in the Maryland Code Annotated, and federal statutes are found in the US Code Annotated (U.S.C.A.).

Citizens have input into the enactment of statutes by electing representatives who they think will vote as they would wish and by lobbying those representatives for passage of bills about specific issues.

For example, in many states, NPs’ prescriptive authority is found in a statute. In those states, the legislatures have considered the issue of NP prescribing and have approved.


Regulations

A regulation is law written by a state or federal agency in accordance with a statute. Agencies are a part of the executive branch of government. A regulation cannot directly contradict a statute but may expand upon a statute, supplying details not
included in the statute. The divided responsibility—between the legislature to enact statutes and the executive branch agencies to write regulations—is part of the balance of power constructed by the US Constitution.

Citizens have input into regulations in that regulations, prior to being adopted, usually are published for public review, with an opportunity for public comment. Agencies may or may not accept the comments. Further, citizens who are unhappy with a current regulation could enlist their legislators to enact laws that would require agencies to change the regulations. For example, if state regulations addressing nursing homes do not address NP practice in nursing homes, a state NP organization will want to: (1) ask the director of the appropriate state agency for a change of regulation to include NPs as providers in nursing homes; (2) ask legislators to request a regulation change, and, if necessary; (3) ask legislators for a statute that would require the agency head to change regulations to allow NPs to practice in nursing homes.


Policies

Policies are rules, made by companies or government agencies, that do not have the force of law but that dictate day-to-day decisions. Citizens have input on policies only insofar as they can convince whoever has authority for the policy to change it. Citizens may also lobby legislators for a law that requires companies or government agencies to change policy. For example, a hospital may have a policy to give admitting privileges to physicians only. Local NPs who want admitting privileges will want to persuade the appropriate hospital decision maker, through facts, figures, and a presentation of projected benefits to the hospital, of the need to change policy and allow NPs to admit patients.


The Judicial System

A state court may hold that a state law is unconstitutional, and a federal court may hold that a federal law is unconstitutional. Courts may interpret laws and determine whether laws have been applied as the legislature, or Congress, meant the law to be applied. A citizen who believes that a law has been misapplied and who has suffered damage as a result may bring suit for a court decision in an effort to force correct application of a law. For example, in 1983, the Medical Board in Missouri brought legal action against two NPs practicing in a women’s services clinic on the basis that the NPs were practicing medicine without medical licenses. The lower court found that the NPs were practicing medicine without a license, but the NPs took the case to the highest court in Missouri, and after reviewing historical documents, the state’s highest court held that the intent of the legislature in expanding the nurse practice act had been to expand the scope of practice to include the activities performed by the NPs.



Health Policy

Policy is defined by the Merriam-Webster Collegiate Dictionary as “a definite course or method of action selected … to guide and determine present and future decisions.”1 Presidents and governors have policies on health care. Executive branch policies may influence the activities of federal and state agencies. However, unless policy becomes law, policy is like nursing theory: it may or may not have any effect on the way people do things.

An example of the influence of policy on the healthcare industry is President Clinton’s 1994 effort at healthcare reform. The president had a definite course of action, a move toward a one-payer system: that is, government-run health care. The president’s plan was not enacted; in fact, it was criticized so soundly that it never was introduced as a bill in Congress. However, the threat implied by the Clinton healthcare reform policies—that if the healthcare industry did not change itself, the government would impose changes—encouraged the private sector to reform itself. Health care today is quite different from health care in 1993. Managed care is now a household word.


Laws and Rules That Affect NPs

NPs are affected by laws, regulations, policies, and court decisions that address:



  • Scope of NP practice


  • Reimbursement for health services


  • Qualifications for NP licensure and renewal


  • Delegation of authority by physicians


  • Quality of care


  • Requirements for collaboration


  • Confidentiality and patient privacy


  • Electronic medical records and e-prescribing


  • Medical home

NPs have found laws, regulations, and policies to be barriers to the practice for which they were educated. How can NPs change these legal barriers?


Changing Laws

NPs who seek to change laws generally do so because they find that a statute, regulation, or a policy keeps them from doing something necessary for practice. For example, NPs who were enrolled as Medicaid providers found that once Medicaid patients began enrolling in managed care health plans, the NPs could no longer be the primary providers for the patients because the policies or the managed care organizations (MCOs) precluded NPs from being admitted to primary care provider (PCP) panels.


In some states, the quest to change MCO policy has turned into an effort to enact new statutes. That is because MCOs, when asked to admit NPs to provider panels, said that the state law was unclear. So NPs have sought to clarify state laws such that NPs are specifically designated by statute as PCPs.


▪ Understanding the Big Picture

Managed care is one aspect of the big picture that has and will affect NP practice.


What Is Going on in Managed Care?

Simply put, managed care is a system where the insurer is not only the payer, but also the provider of health care. Prior to managed care, insurance companies paid bills submitted by providers. The insurer had no control over the quality or quantity of care being given. The insurer had no responsibility to the patient other than to pay the bills. Under managed care, the insurer is responsible for the care given. The insurer keeps close tabs on the services provided. The insurer monitors how the healthcare services are utilized and sometimes denies, in advance or retrospectively, payment for services. Under fully developed managed care, insurers agree with purchasers to give care—whatever care is needed—for a fixed monthly or yearly fee, and clinicians agree with insurers to give whatever care is needed for a fixed monthly fee. The clinician shares with the insurer the financial risk that a patient will need more care than a payment covers.

Insurers are not only concerned with cost, but also they now monitor the quality of care given by providers and practices.

The healthcare industry has recently come under scrutiny regarding quality of care from the people who purchase the most services—employers who buy health care for employees—and from consumer-oriented groups such as the National Committee for Quality Assurance (NCQA), which accredits health plans and monitors and reports on quality of care. Employers are beginning to base decisions about which health plan services to offer employees based upon quality data gathered as reported by the NCQA. Employers monitor the NCQA data, NCQA monitors health plans, health plans monitor practices, and practices monitor individual providers.

State and national legislators, wanting to ensure that citizens’ best interests are not overshadowed by the goals of employers and insurers to make money, are introducing bills to improve quality and to make sure that citizens get the care they want or need. For example, some state legislatures have passed bills requiring that health plans allow postpartum mothers to stay overnight in the hospital for 24 hours after delivery. Health plans had been requiring mothers to go home after delivery. Citizen groups felt that good care required that postpartum mothers have at least a one-night hospital stay. Thus, legislatures have been delving into healthcare decisions formerly made only by clinicians, and lately made by insurers and clinicians.



Stages of Managed Care

NPs’ place in the managed care landscape will depend upon the stage of managed care in the region. In the early stages of managed care, most patients are covered by traditional insurers, and MCOs try to encourage employers who purchase health plans to enroll employees by offering premiums that cost less than those of traditional insurers. In the middle stages of development of managed care, more patients are enrolled, and MCOs try to control costs by decreasing hospital visits, length of stay in hospitals, emergency department visits, and by bargaining with medical practices for reduced rates on visits. In the advanced states of managed care, most patients are enrolled in managed care, and medical practices have agreed to share the risks. In other words, medical practices agree to take care of patients for a fixed amount of money per year. If care costs more than the set fee, providers will lose money. If care costs less than the set fees, providers will make a profit. In the later stages of development, much attention is paid to providing care that will prevent hospitalization and other high costs in the future, and to providing the nuts and bolts of care most cost effectively. It is at these later stages that NPs are most likely to fulfill the needs of MCOs.


Where Do NPs Appear in the Managed Care Landscape?

The position of NPs is well described by a favorite quote of the late Congressman Sonny Bono, “We have good soap to sell, but we have to go out and sell it.” NPs are likely candidates for the position of PCPs, responsible for their own panels of patients. Consider the endorsement of NP practices given by Dr. Stephanie Seremetis, director of the Women’s Health Program at Mount Sinai Medical Center, “Probably in the future the best use will be nurse practitioners in independent practice, using a physician as a backup for complex conditions and for system analysis.”2 Or consider the endorsement by Joseph A. Califano, Jr.:


We should develop a three-tiered medical system: nonphysician practitioners, primary care physicians, and physician specialists. The first tier—the front line of delivery—should be the nonphysician practitioners: physician assistants, nurse practitioners, and certified nurse midwives. These professionals are capable, reliable and cost efficient…. They should be licensed to diagnose ailments, treat common diseases, prescribe drugs, admit patients to hospitals, and release them…. The second tier should be composed of primary care physicians: the family doctors, pediatricians, and general internists, including geriatric practitioners. These physicians should handle the more complex cases that do not require specialist care and be available to consult, guide, and, where appropriate, supervise the nonphysician practitioners…. The third tier should be specialists.3


The views expressed by Dr. Seremetis and Mr. Califano concern the general welfare. What about the welfare of the NP? Consider the view of Joseph Tommasino, a physician assistant writing about both physician assistants and NPs:


Our professional growth … is essentially stunted by the simple fact that we have nowhere to go. We all grapple with, but seldom talk about, our lack of vertical mobility…. Want to change jobs? Submit your curriculum vitae and join the throng of PAs or NPs that apply for the job. True, your experience should ultimately speak for itself, but even if it does, will you get the salary you deserve? I doubt it, especially given the propensity of administrators to fill slots with the least expensive PAs or NPs…. One thing is certain, NPs and PAs must be proactive in designing their own career tracks.4

Salary aside, NPs, who are practice owners, have the opportunity to design a flow of care that makes sense from the point of view of the NP owner. It is not cast in stone that care must be given through the office visit. The office visit mode of healthcare delivery came about because of a physician-driven effort to tie reimbursement to physician services. Under capitated managed care, any model of care delivery that keeps patients satisfied and meets quality standards is a good model. That could mean increased use of community health nurses, home visits, and school-based health care. Groups of NPs with open and creative minds could design effective models that get out of the box established by fee-for-service medicine. Currently, however, in most states, NPs are giving primary care but are doing so under the auspices of a physician. The present situation is a function of: (1) past history; (2) the present law; and (3) public perceptions of physicians as givers of medical care.

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Sep 9, 2016 | Posted by in NURSING | Comments Off on Lawmaking and Health Policy

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