Please respond with substantial detail that provokes further discussion. Readily offers new interpretations of discussion material. Ideas are expressed clearly, concisely
Discussion question:
1. How does the political climate affect the chance of policy tools and the assumptions made by policymakers?
2. If policy predictions are wrong, what can be a consequence?
3. The original premises of the IOM report was the Triple Aim. Why do you suppose another aim was added, so that now we discuss the quadruple aim. How does this last aim support or undermine the first three aims?
4. In thinking about the checks and balances of state and federal governments, what are some health and nursing practice policies in New York State that differ from other states and why explains these differences. How do these differences impact upon the quality and cost of health care in NYS.
Discussion1: Samantha
1. The political climate and current social issues are going to draw the most attention to the public and policymakers. “The scope of the federal government’s involvement in social issues in the United States expanded rapidly in the 20th and 21st centuries,” (Milstead, 2022). In recent years, the challenges that nurses deal with have become increasingly public knowledge. This has created an opportunity to bring different public health issues to light. For example, Milstead highlights Title VIII of the Public Health Service Act. The act supplies funding to: nursing development programs that support recruitment, retention, and advanced education programs for nursing professionals, education nursing grants for clinical nurse specialists and leaders, define nurse-managed clinics, add clinical nurse specialists to National Advisory Council on Nurse Education and practice, and support in loan repayments, scholarships, and grants for education, (Milstead, 2022). Unfortunately, it can take a crisis or in recent times, a global pandemic for policy makers to be aware of social issues that require change. These changes that are needed become complicated and there is not an easy solution for policy makers to create and then implement.
2. “Policies are usually designed to influence behavior and motivate individuals to do what they ordinarily might not do,” (Milstead, 2022). If the predictions or aims are wrong the consequences could include policy failure and public backlash. If predictions are wrong and are implemented, it can cause public mistrust with policymakers. “The decisions that relate to, or have an impact on, perceived social problems often are made hastily because of lack of information, constituency impatience, and lack of expertise,” (Milstead, 2022).
3. The original premises of the IOM report was the Triple Aim that included enhancing patient experience, improving population health, and reducing cost. An additional aim was added: healthcare team well-being. In prior years, the improvements in healthcare were all based around patients and outcomes. Only recently have policymakers implemented changes to improve healthcare providers’ well-being. Healthcare provider “burnout” has been associated with a decrease in patient satisfaction and in return impact patient outcomes. Adding an aim to include improving the wellbeing of healthcare providers should create an environment that supports the first 3 aims. According to Arnetz et al., 2020, reducing stress by acknowledging burnout does not take away the demands of increased productivity and providing high-quality care. Although the goal is to improve health care providers’ work life, it does not address the root cause of the issue. The Quadruple Aim will have to create change slowly over time to eventually improve the work life of health care providers, but this is a complicated process with many factors that can take years to truly implement and create change.
4. When thinking about health and nursing practice policies in New York state that differ from other states, the first policy that comes to mind is the Nurse Practitioner Modernization Act. This act allows NPs to practice independently of physicians, (NYSNA, 2022). In neighboring states such as Pennsylvania, an NP cannot practice independently of a physician’s supervision and limits the medications that can be prescribed by an NP, (Mitchell & Bhai, 2022). The Modernization Act helps improve access to care for the NY population overall. The act also helps bridge the gaps in care that have been created with a decrease in physicians and shortage of primary care physicians, (Mitchell & Bhai, 2022). When there are shortages in physicians, this can create a longer wait time to see physicians, then can cause patients conditions to worsen. A then “sicker” population is forced to seek emergency medical treatment which create crowded ER’s and a decrease in quality care, outcomes, patient satisfaction, and a difficult work-life balance for healthcare providers. All the above creates an environment for increased health costs. Passing the NP Modernization Act in NY helps decrease healthcare costs and helps with patient satisfaction and job satisfaction for healthcare providers.
Discussion 2: Andrew
1. Political climate affects the chances of policy tools and the assumptions made by policy makers, in a behavioral dimension, based on the dominant political tendency at the time. The five broad categories of policy tools used by governments are “authority, incentive, capacity-building, symbolic and hortatory, and learning” (Schneider & Ingram, 1990). Authority tools guide behavior with hierarchy in chain-of-command, incentive tools assume an individual’s resources are fulfilled and only act with encouragement or threat-of-force; Capacity-building tools provide education and training to enable others to make their decisions and carry out activities; Symbolic tools assume internal motivations and belief-based decision making; and learning tools assess the target population for its means for problem-solving action (Schneider & Ingram, 1990).
In a US example, a political climate in which a liberal tendency using capacity-building tools to redirect funds to social programs is pitted against the conservative tendency for business interest, which can slow the application of a universal health program like Medicare-for-All. Both entities can use authority tools depending which group is in power at the time, which can further polarization of the two groups and decrease the likelihood of bipartisan cooperation (Schneider & Ingram, 1990). In the US example, the assumptions of capacity-building not assume that target population will make the desired decision, without acknowledging that symbolic and belief driven behaviors can create conditions against their own material interests. An example vignette would be political climate in which the largest health insurance lobby has the means to use symbolic tools of individualistic orientations “freedom of choice” to persuade lower income people against a universal plan to keep potentially inadequate health insurance plans.
2. Predictions of policy impact may be wrong, depending on the assumptions of the decision-making entity can mean unintended consequences or harmful outcomes. Poor policy design, uncertain articulation of policy goals, inappropriate evidence use, or evaluation techniques can contribute to wrong policy predictions (Oliver, et al. 2019). An example of an unintended consequence would be of a policy’s unplanned budget deficit, of which personal ideology and information sources can affect how negative the consequence can be perceived (Schneider & Ingram, 1990) but also, that the consequence may have been politically intended (Oliver, et al. 2019).
3. The Fourth aim was added to the IOM report, with the possible intention of a ‘check and balance’ to patient community needs. First, the IOM’s triple aim described the interdependency of population health, experience of care, and per capital cost, with the understanding that an improvement in one can positively or negatively affect the others (Bachynsky, 2020). This structure to delineate for healthcare improvement in these three facets was expanded to include the needs of the health care provider. This aim was added, as a check and balance, based on the provider burn-out which causes low patient satisfaction, poorer patient outcomes, and increase patient care costs (Bachynsky, 2020).
This fourth aim can be argued to undermine the first three aims in context of “tragedy of the commons,” describing the conflict of the common interests of an individual and the community (Bachynsky, 2020). Considering limited numbers and increased demand for health care providers, improving their needs in work-life balance can challenge traditional healthcare models of in-person or convenience access of providers. Here, it can per-capita costs with lower labor costs in number-of-care-days in telehealth, but negatively affect patient care experience and public health through intermittent but decreased provider supply.
4. The checks and balances of state and federal governments show that many previously federal responsibilities were shifted to state, in the belief states perspective best understands state needs. A nursing practice policy in New York State that differs from others in the United States is New York’s regulatory environment allows for reduced to full-practice for nurse practitioners, which allows NPs diagnostic, evaluative, and prescriptive roles (AANP, 2022). This regulatory environment in New York was initiated in 2015 to improve the supply of primary care providers in NY, however the NYS Nurse Practitioners Modernization Act, signed on April 2022, allows for NP full-scope of practice.This would be different from restricted-practice states like California or Texas, since these states require an agreement for supervision and delegation under another health care provider (AANP, 2022). The difference of NP scope-of-practice between such states shows an impact in quality and cost of healthcare in NY. While a study on expanded scope of practice was conducted prior to the signing of 2022 state budget, statistically significant evidence was found in quality and cost of care for Medicaid patients. Using data from 2013 to 2015 and comparing a restricted practice with the full practice environment showed Medicaid recipients would have more care-days provided. (Timmons, et al. 2021) Previous studies noted that state regulations restricting NP SOP do not improve quality of care (Perloff, et al. 2019), thus the expansion of NY NP SOP improves provider ability, supportive of improved care quality and no statistical difference in cost-of-care (Liu, et al. 2020).
The restricted-practice State may “have a better perspective” on its needs, but a State’s push-back against NP SOP, appears as an intent to increase the scarcity of health care providers. It is possible that controlling the availability of providers can be argued to be related to IOM 4th aim, of improved clinician experience in maintenance of physician prestige, or a per-capita-cost reduction measure, by drawing from increased full-practice NP salaries. But with evidence of improved care, and now that 25 states are allowing NP full-practice, a stronger case can be made for Federal healthcare workforce regulation to expand NP full-practice acts nationwide
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