HPM Midterm Flashcards
Private Policy
- Hospital employee flu shot = private “policy”
- Private accrediting bodies (Joint Commission, NCQA)
Public Policy
- Public policies are authoritative decisions made in the legislative, executive or judicial branches of government
- Public policies that pertain to health are health policies
Role of the legislative branch
- FORMULATES POLICY
- enacts laws
- creates and funds health programs
- balances health policy with other domains
Role of executive branch
- IMPLEMENTS POLICY
- proposes legislation
- approves or vetos legislation
- promulgates rules and regulations
Role of judicial branch
- INTERPRETS POLICY
- interprets constitutional and statutory law
- develops body of case law
- preserves rights
- resolves disputes
Operations Decisions
- Once laws and regulations establish programs (like Medicare, Medicaid), health agencies (CDC, FDA, state Health Departments) have discretion to manage the programs
- Agency operational decisions by government officials are “health policy”
- example of decisions in Medicare: eligibility and coverage determinations, payment, fraud and abuse
Categories of health policies
Allocative & Regulatory
Allocative health policy
- Policies that distribute or re-distribute finite resources
- Often provide net benefits to one group at the expense of others to meet policy objective
Regulatory health policy
- Directives that influence the actions, behaviors or decisions of others
- Examples: licensing of practitioners, certificate of need, FDA safety/efficacy regs, antitrust, workplace safety
Why the government is involved in health policy
- In a market economy, the private market should determine the production and consumption of health services
- Government intervenes when the private market fails to achieve desired public objectives
How & Why the US health sector has failed
Failed to: guarantee access & control healthcare costs
Because: buyers and sellers do not have sufficient information to make informed decisions & small number of sellers control market, barriers to entry
National healthcare spending trends
- private has decreased, public has increased, now about equal
- government share now accounts for more than half of U.S. health care expenditures
- growing entitlement spending
Why should be care about health policy
- Cost – largest component of the economy – and growing
- Quality – substantial evidence that the quality is not as good as it could be
- Access – literally millions of people have inadequate access to health care services
- Variability – all of these characteristics vary by location, ethnicity, income, etc.
Trends of healthcare cost over time
- dramatic increase in US health expenditures, now approaching 3 trillion, nearly 18% of the GNP
- US spends the most compared to all countries
Why does US healthcare cost so much?
- higher prices than other countries for same services
- higher administrative overhead costs
- high-cost, high-tech equipment and procedures
- American tort laws can lead to “defensive medicine”
Four main drivers of cost
- technology and prescription drugs
- chronic disease (more people who are “sick” in population: diabetes, hypertension, HIV)
- aging of the population
- administrative costs
- (higher inflation rate in healthcare)
Combination effect
combination of increasing life expectancy and the increase in chronic disease with age produces a progressively on “on average” older, sicker population
Measurements of healthcare quality
- life expectancy at birth
- childhood mortality
- US sucks and is worse quality than many countries, even though it also costs more
- medical error rates
- loooots of geographic variability - cost, quality, etc
Conditions necessary for free markets
- infinite buyers and sellers
- zero entry and exit barriers
- perfect factor mobility
- perfect information
- zero transaction costs
- profit maximization
- homogeneous products
- non-increasing returns to scale
Forms of health policy
- laws, regulations, operational decisions, judicial decisions
Interest groups
- Interests of those employed in health sector more concentrated than individual consumers
- Both proactive and reactive (block legislation)
- Seek to influence policymaking to some advantage of the group’s members
How interest groups influence policy making
- lobbying
- electioneering
- litigation
- shaping public opinion
Problems that get on the policy agenda
- important and urgent
- issues/trends that reach an unacceptable level
- widespread applicability or impact small but powerful group
- closely linked to other problems (like cost)
Agenda setting
agenda setting as a consequence of the health-related problems, possible policy solutions that address those problems and the current political circumstances
Political circumstances that either open or close the window of opportunity
- political “will” necessary
- competing issues on the agenda
- which party controls the chamber and the executive branch
- fillibuster
Committees with health jurisdiction
- Senate: Aging & Youth, Consumer Protection & Professional Licensure, Law & Justice, Public Health & Welfare, Veterans Affairs & Emergency Preparedness
- House: Aging & Older Adult Services, Children & Youth, Health, Human Services, Professional Licensure
- jurisdictions overlap & multiple committees oversee health
Legislative hearings
Hearings provide a forum where facts and opinions can be presented from witnesses with varied backgrounds (experts & other interested parties)
Types of legislative hearings
- legislative
- oversight
- investigative
- confirmation
Policy Formation - Exemplary Policies
- Healthcare Associated Infections (HAIs)
- Prescription drug monitoring
- SEE WEEK 3 POWERPOINT FOR FULL EXAMPLES
Policy implementation
- Health policies must be implemented effectively if they are to carry out the intent of the authoritative decision
- Health policies must be implemented effectively if they are to affect the determinants of health
- Implementation is a management exercise by the executive branch (with legislative oversight)
Types of implementation activities
- rulemaking - establishment of formal rules necessary to effect the intent of laws
- operation - activities of implementing organizations to carry out the law
Implementation responsibilities of the three branches of government
- executive agencies - primary role is implementation of laws formulated by legislative branch
- legislative oversight - appropriation committees (funding) & standing committees (direct oversight)
- judicial role - Administrative Procedures Act (ALJs)
Key features of the rule making process
- Congress (or state legislature) grants rulemaking authority to an agency
- Agency develops draft proposed rule and publish in Fed. - - Register
- Public comment
- Agency responds to comments and makes revisions
- Governmental Review (OIRA/OMB or IRRC at state level)
- Publication of Final Rule, Rule takes effect
Key features of operation
- resources (budget)
- management: leadership and personnel
- competencies: policy, conceptual, technical, interpersonal
Policy Implementation - Exemplary Policies
ACA Health Benefit Exchanges
Clean Indoor Air Act
SEE WEEK 4 POWERPOINT FOR FULL EXAMPLES
What gives authority to states to regulate Public Health?
- Tenth amendment of the constitution (powers not delegated to the feds are reserved for the states)
- police power
- McCarran-Ferguson Act of 1945 (gives states authority to regulate the “business of insurance” without interference from federal regulation)
State and Local Roles in Health Policy
- Protector of the Public Health and Welfare (environmental regulations, restaurant inspection)
- Purchaser of Healthcare Services (Medicaid)
- Regulator (health professions, hospitals, nursing homes, health insurers)
- Safety Net Provider (health clinics, state mental institutions, manage federal programs like WIC)
- Health Education (subsidize GME, loan repayment, carry out public health education)
- Policy Laboratory (medical home, health information exchange, HAI reduction)
Air Toxic Guidelines
ATGs are not a regulation; they are used as guidance during Installation Permit (IP) reviews to evaluate the impact of air toxic emissions on Public Health
Features of the Proposed ATG’s
- Derived by true consensus of ATG committee members
- Science-based, sensible risk levels
- Cumulative risk (rather than chemical by chemical)
- Toxicity information from authoritative published sources
- Easy-to-follow steps to guide modeling requirements
- Environmental Justice through protection of high risk “hot spots”
- Creative and flexible off-setting process (including mobile sources)
- Written in simple “non-legalistic” style
Policy modification
- Consequences of existing policies constantly feed back into policy formulation & implementation (dynamic and cyclical)
- Majority of health policymaking is modification of existing policy
- Modification can result from both negative and positive consequences of policies
- Continual modification of U.S. health policymaking process is best described as incrementalism
Policy modification process
- same process as initial/original policy
- agenda setting
- development of legislation
- rule making
- operations (internal & external)
Policy Modification - Exemplary Policies
- Medicare Part D
- SEE WEEK 6 POWERPOINT FOR FULL EXAMPLE
Medicare benefit structure
- Part A: inpatient, skilled nursing, home health, hospice
- Part B: physician visits, outpatient, preventive services, home health
- Part C: medicare advantage
- Part D: drug benefit
Four key features of Medicare Part D
- Market-based insurance
- government can’t negotiate drug prices
- donut hole
- formulary rules
Leadership
complex and ambiguous concept, emphasizing the qualities and behaviors seen as necessary for, and characteristic of effective leadership, especially at the top nature of relationship between leaders and followers - Political/socio-cultural skills - Promoting change - Long term horizon - Strategic focus - Making waves and innovating - Proactive, risk-taking - Radical change
Management
the process (or art) of getting things done through and with people
- Technical/functional skills
- Maintaining stability
- Short-term horizon
- Operational focus
- Conforming to standards
- Reactive response
- Incremental change
