Community: Health Policy & Healthcare Delivery

Why is health policy important?

• The public health nurse (PHN) needs to understand how to influence public health policy through leadership and advocacy.​

• Need for increased nursing engagement in health policy!​

• Change in the healthcare system is only possible by change in healthcare policy. ​

What is Public Health Policy?

consists of the legislation and funding that we adopt to govern the provision, regulation, and research of healthcare

What is a Policy?

an action that the government takes (or does not take) to address a problem or concern​

What is Politics?

the process by which we determine who gets what, when they get it, and how they get it​

What is Substantive Policy?

a policy that involves an action or activity such as the funding of a health program (i.e. federal funding of the Indian Health Service)

What is Procedural Policy?

involves the procedure by which the outcome is sought (i.e. voting rights policy and legislature)​

What is Distributive Policy?

policies that allocate services or benefits to specific groups of people (i.e. Medicare for a certain age group)​

What is Regulatory Policy?

policies that limit the activities or behaviors of certain groups (i.e. restricting people under 21 from ordering alcohol)​

What is Public Policy?

impacts health and wellness at local, state, and national levels​

Which of the following is an example of a regulatory policy?​

1. policies about gun ownership​

2. a policy restricting anyone under the age of 21 to buy tobacco products​

3. policies surrounding Medicare eligibility and funding​

4. a policy regarding medical and safety procedures​

a policy restricting anyone under the age of 21 to buy tobacco products​

What are local policies subject to?

State and National regulations

• Example: In 2016, Chicago established a restriction to prevent the sale of tobacco to people under 21 due to local health data about new smokers being teenagers. ​

What do State Policies do?

regulates things such as health professional licensure and scope of practice, immunization requirements, some public health codes

What do National Policies include?

includes things such as funding for Medicare and health research

How does a bill become a law?

• An issue is identified, and solution is proposed.​

• A bill is introduced.​

• The bill goes to committee: representatives or senators meet to discuss and make changes to a bill, then either:​

  • To the house or senate floor for debate ​

  • To a subcommittee for further research​

• Congress votes- both house and senate go through this process.​

• Presidential action results in:​

  • Approve and pass: the bill is law​

  • Veto ​

  • No action​

  • Pocket Veto​

What does it mean when a bill is vetoed?

president rejects the bill, it returns to congress with reasoning, and congress can override the veto with a 2/3 majority vote

What happens if there is no action on a proposed bill?

If 10 days of no answer while congress is in session, the bill automatically becomes law

What is a pocket veto?

If congress adjourns within the 10 days of giving the president the bill, the president can choose to not sign it and it does not become law. ​

What is the Rule making and implementation phase of Health Policy that leads to Health Outcomes?

after the bill is passed, the relevant administrative agency takes on developing the guidelines around how to implement and operationalize the law

What are the three types of evaluations when it comes to health outcomes?

• Content evaluation: evaluating if a law/change is projected to make an impact​

• Policy implementation evaluation: evaluating if a “roll out” was successful and as planned​

• Policy impact evaluation: evaluating outcomes to determine if the change had the desired effect​

What is Content evaluation?

evaluating if a law/change is projected to make an impact​

What is Policy Implementation evaluation?

evaluating if a “roll out” was successful and as planned​

What is Policy Impact Evaluation?

evaluating outcomes to determine if the change had the desired effect​

A community health nurse is working in a pediatric office, and a parent asks about routine vaccinations. The nurse knows that she should visit which website to obtain information about specific vaccine regulations?​

1. The state immunization website​

2. A national website discussing immunization schedules​

3. The CDC​

4. The county immunization website​

The state immunization website​

What is Social Justice?

• the foundation of community health nursing, and referenced in the following nursing guidelines and codes:​

  • The American Association of Colleges of Nursing (AACN) emphasizes the importance of social justice as a foundation of nursing​

  • The American Nurses Association (ANA) Code of Ethics says that nurses should participate in changing “aspects of society that detract from health and well being” ​

What is Health Equity?

ensures that all people have an equal opportunity to achieve improved health and well being, considering social determinants of health

How would you apply Policy Analysis to Practice?

• Find a problem you are passionate about addressing.​

• Conduct a policy analysis using a framework of your choosing. ​

• Given this analysis, the nurse can determine the most appropriate next steps.​

What are the steps in Policy Analysis?

Step one: consider your community when choosing what to address. ​

Step two: what is the problem? Are there policy solutions in place? Who are the stakeholders?​

Step three: once analysis is complete, the level of involvement can be determined in the context of time, resource management, priority, etc.

What is the Rational Framework for Policy Analysis?

• A straightforward, logical way to comprehend policy creation and implementation.​

  • First step involves identifying the issue that requires policy intervention. ​

  • Step two is understanding all options for policy intervention, considering all perspectives. ​

  • Step three is choosing a policy intervention, implementing and evaluating impact.​

What is the Kingdon’s Framework for Policy Analysis?

• Policy is enacted when a window of opportunity opened.​

  • A converging of a policy problem, a viable solution, and political will. ​

    • Policy problem: defined by “focusing events”, which are incidents that reveal a need for change. ​

• Window of opportunity is not open permanently-changes with society. ​

What is a way that PHN can take action at the local level?

serving on community health boards, provide education and feedback about health policy and health promotion, serve on school boards, etc. ​

What is a way that PHN can take action at the state level?

ensure state organizations understand health priorities, advocate for relevant health policy changes​

What is a way that PHN can take action when it comes to Research?

focus on research questions within the context of community health needs and social determinants of health​

What is “Advocacy” when it comes to Public Health Advocacy and Lobbying?

is the first step: it mainly refers to education and awareness of a health issue.

What is “Lobbying” when it comes to Public Health Advocacy and Lobbying?

the act of communicating with legislators to promote change. ​

What are some Current US Health Policies brought about by Healthy People 2030?

• addressing social determinants of health and health inequity​

• addressing healthcare needs of the nation​

• design better payment models​

• foster nurse’s role as leader and advocate​

What are some Current US Health Policies brought about by the ACA and Community Nursing?

• Established in 2010 during the Obama administration, the Affordable Care Act sought to require health insurance for every US citizen.​

• Community health nurses play a crucial role in advocating for improved access to health care services and insurance coverage.​

Blue Cross (health insurance) was developed to be used where/by who?

Pay for hospital visits

Blue Shield (health insurance) was created to be used where/by who?

Pay the physician

What did the 2010 Patient Protection and Affordable Care Act (ACA) do?

• Expanded Medicaid in many states​

• Extended coverage to low-income individuals/families​

• Required coverage of preventative care​

• Eliminated preexisting conditions exclusions​

• Allowed to stay on parent’s plan till 26​

When it comes to Reimbursement, Who pays for Health Care?

• Critical, complex topic​

• Reimbursement pays the patient’s bills for services provided​

• Hospitals close if they cannot cover costs (this is a huge problem for rural hospitals)​

  • Effect on access to care​

• Crisis in safety net hospitals (hospitals that serve populations who have limited or no resources to pay for services)​

• Payment-related stress on patients (bankruptcy #1)​

• Healthcare exchanges via the ACA for financial support​

What is the Third-Party Payer System?

• Fee-for-service​

• Deductibles and copayment: out of pocket​

• Underinsured adults and children

How does the Fee-for-service payment method and economic incentives contribute to increased costs?

• The more tests or procedures performed, the greater the physician’s earnings because earnings tied to procedures​

• Economic incentives to provide as much care as possible​

• Patients insulated from costs because insurance was paying the bill​

What is Medicare?

• (65 years and older/ESKD/Disability/ALS)​

• Largest health insurance program in the U.S.​

• Entitlement program based on age or disability criteria rather than on need​

• Part A covers inpatient hospital services, skilled nursing facilities (SNFs), and home health benefits​

• Part B covers physician services​

• Part C administered by private insurance contracted by Medicare (PPO/HMO)​

• Part D provides a prescription medication benefit​

What is Medicaid?

• Joint federal-state program to provide health insurance coverage for impoverished families​

• Intended to improve access to health care for the poor​

• Currently covers 48.6 million people (continues to grow)​

• Covers primarily disabled persons, low-income households with children, and those in nursing homes who qualify on the basis of low income ​

• Primary payer of long-term care nationwide​

• For most states, Medicaid represents the fastest growing component in the state budget​

• Recipients are not as likely to obtain needed health services​

What is the Patient Protection and Affordable Care Act (PPACA)?

• Expands health insurance coverage access to uninsured Americans while controlling costs and improving the quality of health care​

• Addresses many issues including employer requirements, health insurance exchanges, and prevention and cost-reduction approaches​

What are some Trends and Issues Influencing Health Care Economics?

• High cost of health care in the United States​

• Cost-control measures​

• Access to health services​

  • Uninsured​

  • Underinsured​

  • Underserved​

• Medical bankruptcies​

• Health care rationing​

• Managed care

What is the Social Justice view of Health Care Rationing?

• Health care as a right (Is it a right or a privilege?)​

• Equitable distribution according to clinical need​

• Not based on income or where one lives​

• Focuses on needs of population more than individual

What is the Free Market Economy view of Health Care Rationing?

• Health care as a product (It is a business after all)​

• Rationing as government control, limiting choices​

• Concern over decline in quality, increased waiting​

What is a Retrospective payment concept?

• Fee-for-service​

• Reimburse after service rendered​

• Abused through the requesting and ordering of unnecessary tests​

• Encouraged sickness rather than wellness​

What is a Prospective payment concept?

• External authority sets rates​

• Rates derived from predictions set in advance​

• Fixed rates rather than cost coverage​

• Imposes constraints on spending​

• Providers at risk for losses or surpluses​

What are some demographic trends when it comes to the Aging Baby Boomer generation?

• 77 million babies born between 1946 and 1963​

• Expected to live on average to 83 years of age, with many surviving into their 90s​

• Cost of Medicare expected to rise astronomically​

• Fewer workers paying taxes into the Medicare system

What is the Demographic Trend when it comes to the Rise in Foreign-born population?

• Mexico largest source, followed by Asia​

• United States more diverse than ever

What are some Social and Economic Trends?

• Changing lifestyles​

• Growing appreciation of quality of life​

  • Health seen as an irreplaceable commodity​

• Changing composition of families​

• Changing household incomes​

  • Growing gap between richest and poorest​

• Revised definition of quality health care​

  • Rise in complementary and alternative therapies​

What are the benefits of Telehealth and Electronic Health Records (EHR)?

• 24-hour availability ​

• Increased coordination and quality of care​

• Improved quality measurement and monitoring​

• Reduced medical errors

What are the Drawbacks of Telehealth and the Electronic Health Record (EHR)?

• Privacy and security concerns​

• Inconsistent quality of online resources​

• Expensive equipment that requires higher training​

What are the Implications for Community Health Nursing when it comes to Healthcare Delivery?

• Need to adapt to constantly changing system​

• Development of innovative modes of service delivery​

• Variety of practice settings (what is cheaper)​

  • Hospital 2,500-3,500/day; Home average cost of in-home care in the United States is $4,957 a month.​

• Development of skills in teamwork, leadership, and political activism​

• Recognition of importance of outcomes for both client and agency