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Week 8

PUB-7019 v1: Public Policy Administration (5264028831)

Creating a Public Policy Administration System

Public policy management requires dedicated efforts. Policymakers have an important

responsibility to ensure the public is protected from abuse from organizations, protected

from fraud, and protected from abuse by financial institutions. Federal policymakers are

also tasked with ensuring quality services are delivered to members of the public, whose

abilities to make an honest living are impacted by circumstances beyond their control such

as being laid off from work due to company closures, having a physical or mental

disability, being financially disadvantaged due either to aging, lack of parental support

with a reliance on state government programs, or being affected by homelessness. The

reasons vary for people’s continuous reliance on governmental services. Nevertheless,

policymakers are responsible for ensuring social programs are efficiently designed with

eligibility criteria that do not discriminate against members of the public, provide equal

opportunities for services, and for those who are able, help individuals graduate from

dependence on social programs.

The needs of the general population are important. Being able to meet the needs of the

public should be important to national governments without advocating for total

dependence on governmental services. Social programs should encourage individual

growth and independence, offer opportunities for training and education for those who

are able to take advantage of these opportunities and should promote self-reliance to the

extent that individuals are physically and mentally capable of being self-reliant.

Policymakers are usually good at examining the needs of the public and usually meet the

public’s demands either from the initial release of the policies or through policy

modifications.

A policy administration system is used to manage important policy measures for a

particular organization. This system is carefully designed to allow administrators to

evaluate policies for efficiency, assess policies for expiration, and manage policies by

answering questions from internal and external stakeholders, offering recommendations

for ways to potentially improve policies within the system based on feedback from the

public or particular industry leaders, and examining policies to ensure they are meeting

their intended purpose. This is an important role because this is where policy

management comes into play and there should be a team of policy experts that not only

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Books and Resources for this Week

Additional actions could further

improve policy management. (2017).

GAO Reports, i-42. Link

Chen, S. C., & Pearson, S. D. (2016).

Policy framework for covering

preventive services without cost

sharing: Saving lives and saving money?

JAMA… Link

Langbein, L. I. (2015). Public program

evaluation: A statistical guide (Vol.

Second edition). London: Routledge. Link

Scott, T. A., & Thomas, C. W. (2017).

Unpacking the collaborative toolbox:

Why and when do public managers

choose collaborative governance… Link

administer policy changes, but also should have demonstrated capabilities serving as

policy expert to determine whether policies lack substance and need replacement.

References:

Be sure to review this week's resources carefully. You are expected to apply the

information from these resources when you prepare your assignments.

80 % 4 of 5 topics complete

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Week 8 – Signature Assignment: Design a System to

Manage Administrative Policies Assignment

Due May 1 at 11:59 PM

Policy administration is an important element of public policy. Policies need to be housed

somewhere with the proper oversight and responsible agents to efficiently manage and

enforce each policy. To do this, agents must be experts in their field and must understand

each policy they are responsible for managing. Policy offices within the federal

government usually have a team of experts ready to assist with interpreting policies,

checking for outdated policies, conducting policy research, and helping create new agency

policies.

The Signature Assignment requires you to create and implement a public policy

administration system that will manage all agency policies for a public agency. Choose a

public agency and assess the types of policies that the agency manages and operates

from, and then determine how you would create a system managing all policies for the

organization. This system will monitor policies across your agency and evaluate them for

efficiency and make a determination as to whether policies will be changed, remain in

place, or be eliminated. As the policy director, you must ensure you understand the

historical context of each policy under your charge and be responsible to make decisions

regarding the policies’ existence. Be sure to include the following in your paper:

1. Create a policy management system for a public agency of your choice.

2. Explain why you chose that agency.

3. Explain the importance of policy administration.

4. Describe the policy cycle and how it impacts policy decision-making.

5. Identify three main policy areas for the agency you chose and explain their

functions and effectiveness.

6. Determine particular policies for your agency that would change and give

appropriate reasons for your decision.

7. Determine existing policies for your agency that you would keep in place and

explain your reasoning.

Length: 10-12 pages, not including title and reference pages.

References: Include a minimum of 5 scholarly resources.

Your paper should demonstrate thoughtful consideration of the ideas and concepts

presented in the course and provide new thoughts and insights relating directly to this

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topic. Your response should reflect scholarly writing and current APA standards. Be sure

to adhere to Northcentral University's Academic Integrity Policy.

Upload your document and click the Submit to Dropbox button.

Copyright 2016 American Medical Association. All rights reserved.

Policy Framework for Covering Preventive Services Without Cost Sharing Saving Lives and Saving Money? Stephanie C. Chen, BA; Steven D. Pearson, MD, MSc, FRCP

P rior to The Patient Protection and Affordable Care Act (ACA),most preventive services covered by insurance required pa-tient cost sharing because many do not save money when delivered broadly to an entire population and because of the ad- ministrative complexity of exempting services from standard co- payment levels only for specific individuals.1 The preventive care pro- visions of the ACA, however, introduced major changes that were touted by President Obama as “saving lives and saving money.”2 The ACA mandates that all private, nongrandfathered, insurance plans cover without any patient cost sharing the preventive services en- dorsed by 4 expert committees: the US Preventive Services Task Force (USPSTF), the Advisory Committee on Immunization Prac- tices (ACIP), the Health Resources and Services Administration (HRSA) Bright Futures Project, and the Institute of Medicine (IOM) committee on women’s clinical preventive services.3 The tests and treatments recommended by these groups now represent a growing list of over 100 preventive services that are free for most Americans.

Notably, the ACA neither provides guidance nor mandates the development of a specific set of criteria by which preventive ser- vices should be selected, evaluated, and prioritized for free cover- age. Instead, each committee named under the ACA has devel- oped its own criteria for evaluating and recommending preventive services. This has led to important variations in their approach, but even their common elements have come under criticism. Some com- mentators have raised concerns that all the expert committees ex- clude entire categories of preventive services that have significant potential to improve health and reduce future health care costs.4 For example, diagnostic tests are not even eligible for consideration. Thus a 50-year-old woman can receive biennial screening mammo- grams for free, but only if she has no signs or symptoms of breast

cancer. A woman who has noticed a lump in her breast would not be able to receive a free screening mammogram but would have to pay a copayment for a diagnostic mammogram. As commentators have noted, in terms of saving both lives and money, diagnostic mam- mography is far more effective than screening mammography, yet it is only screening mammography that is free.5

Another category of excluded services are those that prevent adverse consequences associated with established disease.4

Treatment of hypertension prevents strokes, and insulin treat- ment of diabetes prevents coma and death, but these kinds of services are currently excluded even from consideration for free coverage. If the goals of the ACA preventive services provi- sions were to reduce barriers to a prioritized list of preventive services that would have the largest effect on improving health and reducing future costs, the current approach appears inconsis- tent, potentially incomplete, and open to being perceived as capricious.

Herein, we analyze the criteria used by each expert committee for developing its recommendations. Then, we propose a new, com- prehensive framework and associated criteria to help policy mak- ers in the future develop a more evidence-based, consistent, and ethically sound approach.

Current Methods Used to Develop the List of Free Preventive Services The current set of free preventive services totals 114, including 54 from the USPSTF, 27 from the ACIP, 25 from Bright Futures, and 8 from the IOM committee on women’s health. Forty-nine of these ser- vices are screening tests, and 28 are immunizations. The rest in- clude a wide range of services, from iron supplements for children to skin cancer behavioral counseling. Five recommendations are for

The US Affordable Care Act mandates that private insurers cover a list of preventive services without cost sharing. The list is determined by 4 expert committees that evaluate the overall health effect of preventive services. We analyzed the process by which the expert committees develop their recommendations. Each committee uses different criteria to evaluate preventive services and none of the committees consider cost systematically. We propose that the existing committees adopt consistent evidence review methodologies and expand the scope of preventive services reviewed and that a separate advisory committee be established to integrate economic considerations into the final selection of free preventive services. The comprehensive framework and associated criteria are intended to help policy makers in the future develop a more evidence-based, consistent, and ethically sound approach.

JAMA Intern Med. 2016;176(8):1185-1189. doi:10.1001/jamainternmed.2016.3052 Published online June 27, 2016.

Author Affiliations: Department of Bioethics, Clinical Center, National Institutes of Health, Bethesda, Maryland (Chen, Pearson); Institute for Clinical and Economic Review, Boston, Massachusetts (Pearson).

Corresponding Author: Steven D. Pearson, MD, MSc, FRCP, Department of Bioethics, 10 Center Drive, 1C118, Bethesda, MD 20892-1156 ([email protected]).

Clinical Review & Education

JAMA Internal Medicine | Special Communication | HEALTH CARE REFORM

jamainternalmedicine.com (Reprinted) JAMA Internal Medicine August 2016 Volume 176, Number 8 1185

Copyright 2016 American Medical Association. All rights reserved.

Copyright 2016 American Medical Association. All rights reserved.

services addressing men’s health, while 28 are related to women’s health. The composition and methods of the 4 committees are de- scribed in further detail below.

The US Preventive Services Task Force Established by Congress in 1984, the USPSTF has contributed the largest number of services to the free coverage list. The Task Force makes recommendations exclusively for “persons without recog- nized symptoms or signs of the target conditions” and it has “de- cided not to make recommendations concerning services to pre- vent complications in patients with established disease (eg, coronary artery disease and diabetes).”6 When deciding whether to recom- mend a service, the USPSTF balances health benefits against po- tential harms and recommends the service based on the strength of evidence and magnitude of net benefit. It explicitly excludes con- sideration of the cost or cost-effectiveness of a service in its deci- sions about whether to recommend a service.7

The Advisory Committee on Immunization Practices Established by federal legislation in 1964, the ACIP develops na- tional policies on the use of vaccines. The ACIP lists many factors, including the cost of interventions, that are taken into consider- ation in prioritizing candidate vaccines for review and is the only com- mittee whose methods explicitly acknowledge a role for cost con- siderations. However, the ACIP states that “there is no consensus on the weight that should be given to economic data. In practice, vaccine recommendations are made primarily on the basis of the bur- den of disease, vaccine effectiveness, and safety.”8

Bright Futures A partnership between multiple federal health agencies that began over 25 years ago, and now a partnership between the American Academy of Pediatrics (AAP) and the federal Health Resources and Services Administration (HRSA), Bright Futures makes recommen- dations regarding services provided in pediatric primary care. Throughout its methodology statement there is little information on how the committee defines the scope of pediatric prevention, pri- oritizes potential services for review, or evaluates individual ser- vices. The Bright Future Guidelines state that “evidence for effec- tiveness is a core criterion”9 and cites professional guidelines and clinical studies as the primary source of evidence. Whether cost is considered at any point of the recommendation development pro- cess is not addressed.

Institute of Medicine Committee on Women’s Preventive Services The ACA mandated that insurers cover “with respect to women, such additional preventive care and screenings…as provided for in com- prehensive guidelines supported by the Health Resources and Ser- vices Administration (HRSA) for purposes of this paragraph.”3 Sub- sequently, the HHS convened an IOM committee to draft such “comprehensive guidelines,” a committee that saw itself as focus- ing on “conditions unique to women or that affected women in some specific or disproportionate way.”10 Like the USPSTF, the IOM Com- mittee excludes cost and cost-effectiveness analyses from consid- eration, and also excludes services that address existing illnesses be- cause they believed services involving treatment decisions are viewed as “outside of its scope.”10

A Framework for Recommending Preventive Services for Free Coverage The 4 expert committees have similar goals, but they lack a com- mon overarching conceptual framework to guide the work that ul- timately produces a national list of free preventive services. The com- mittees have different processes and criteria for identifying services, evaluating them, and prioritizing them for recommendation. Meth- ods for evaluating the relative clinical benefits of different preven- tive services vary across committees. The ACIP is the sole commit- tee that considers costs but does so in an ad hoc fashion. It is not therefore surprising that the relative cost-effectiveness of the pre- ventive services currently recommended varies widely.11,12 In an in- dependent review of 25 recommendations by the USPSTF and ACIP, only 5 services were judged to be cost saving; all other services were estimated to add costs to the health care system, even over the long-term.13

We propose that all of the current committees should adopt a clear and uniform framework for recommending free preventive ser- vices. They should use a consistent methodology to measure the health effect of preventive services for individuals and the entire population. This methodology must be transparent and, given the linkage between committee recommendations and mandated cov- erage, it must be rigorous and resistant to external lobbying. With this foundation in place, we believe the committees should broaden the scope of their reviews to include diagnostic services and ser- vices that can prevent serious adverse outcomes for patients with established conditions. Finally, we propose a new committee be cre- ated and charged with the important task of adopting an explicit methodology for considering the cost effect of recommended pre- ventive services. This new committee would also be responsible for integrating the clinical recommendations of all four existing com- mittees with cost considerations as part of a uniform final pathway for determining which preventive services will be provided free.

Rating the Magnitude of Health Impact and Level of Confidence in the Evidence Only the USPSTF and the ACIP have clearly defined methodologies for evidence rating, and each committee uses a different approach. The home-grown USPSTF system assigns a letter grade, such as “A,” “B” or “C” that reflects a joint judgment of two factors: (1) the net health benefit, determined by assessing the balance of benefits and potential harms; and (2) the level of certainty in the net health ben- efit that the existing evidence can provide.14 The ACIP had fol- lowed USPSTF methodology until 2011 when it switched to an- other evidence rating system developed by an international consortium known as GRADE.15 GRADE also assigns letter grades re- flecting the strength of evidence, but the methodology uses differ- ent terminology and is structured differently than that of the USPSTF, so that the meaning of the letter grades and the criteria by which the evidence is judged do not match between the 2 committees.

We believe that either the USPSTF or the ACIP (GRADE) meth- odology should be used as a common approach for all 4 commit- tees. A common framework, terminology, and grading system would bring greater transparency and consistency to the recommenda- tions across the committees. Both the USPSTF and ACIP favor di- rect evidence from high-quality randomized clinical trials (RCTs) on key outcomes such as disease-specific or overall mortality. Only rarely, however, have such data been available: cervical cancer screening

Clinical Review & Education Special Communication Policy Framework for Covering Preventive Services

1186 JAMA Internal Medicine August 2016 Volume 176, Number 8 (Reprinted) jamainternalmedicine.com

Copyright 2016 American Medical Association. All rights reserved.

Copyright 2016 American Medical Association. All rights reserved.

and lung cancer screening are the only 2 USPSTF recommenda- tions based, in part, on RCT evidence of improvement in overall sur- vival. Many other recommendations are based on RCT evidence for improvement in other patient-centered outcomes, including disease- specific mortality (colorectal cancer screening), HIV transmission (HIV screening for pregnant women), or prevention of neural tube defects (folic acid supplementation).

However, because long-term RCTs on the outcomes of screen- ing interventions and vaccination programs in general populations have generally not been done, the USPSTF and ACIP also consider studies of intermediate or surrogate outcome measures, or what is sometimes termed indirect evidence, that can nonetheless pro- vide moderate certainty that patient-centered outcomes are improved.14,15 The USPSTF definition of moderate certainty is when the available evidence is sufficient to determine the effects of the preventive service on health outcomes, but confidence in the esti- mate of the magnitude of improvement is constrained by such fac- tors as: (1) the number, size, or quality of individual studies; (2) in- consistency of findings across individual studies; (3) limited generalizability of findings to routine primary care practice; and (4) lack of coherence in the chain of evidence.14

Recommendations that have been based on moderate cer- tainty arising from indirect evidence tend to be more controversial and include those by the ACIP for immunization against human pap- illoma virus (HPV)16 and by the USPSTF for age-based screening for hepatitis C virus.17 Our point is not to question the evidentiary judg- ments for these specific recommendations but to note that the lack of a consistent evidence grading approach raises important con- cerns regarding the consistency of the evidentiary rigor applied both within and across all 4 existing committees. Using a single uniform approach to rating evidence should reinforce across all commit- tees that services supported by strong evidence of a substantial net health benefit should be prioritized above services with either in- direct or otherwise more limited evidence and/or a lower esti- mated net health benefit.

Including Additional Types of Preventive Services It is understandable that the USPSTF decided to focus its energies by limiting the types of preventive services it would consider. One reason to do so was to avoid overlap with the topics covered in clinical guidelines developed by professional specialty societies. In addition, unlike population-based screening and immunization programs, some diagnostic tests and treatments prevent sub- stantial clinical harms only for certain patients and may be over- prescribed. Nonetheless, we believe that careful consideration should now be given to including some of these secondary prevention services, such as treatments for diabetes and hyper- tension among high-risk populations, in the scope of the expert committees.

Including secondary prevention within the scope of consider- ation has become more feasible now that advances in billing and cod- ing mechanisms allow insurers to link patient diagnoses and other clinical characteristics with prescriptions to identify high-risk popu- lations and assign differential cost-sharing amounts as part of value- based insurance designs (VBID).18 In addition, the evidence base for secondary prevention can be very strong, arising from high-quality RCTs, and many of these effective services, such as those listed in the Box,19-25 have also been estimated to produce cost savings, al-

though the evidence on long-term cost-savings is almost always less certain than that on clinical benefits.

To manage the potential overlap and conflict with recommenda- tions on these topics from specialty societies, we propose that the USPSTF and other committees use the clinical guidelines from spe- cialty societies as a starting point. Clinical services recommended by specialty societies could be evaluated by the preventive services ex- pert committees, using the uniform and rigorous evidence rating ap- proach discussed above. Requiring that secondary preventive ser- vices pass through the same evidentiary gauntlet as other services would ensure consistency across the evaluation of primary and sec- ondary prevention services and help manage external pressures to have many treatments added to the free coverage list.

Integrating Consideration of Cost-effectiveness and Budget Impact Given limited resources available for health care, not all preventive services with a net positive health effect should be provided for free

Box. Examples of Effective and Cost-Saving Services Not Covered by the ACA

Preventive Services • Multicomponent interventions for diabetic risk factor control and

early detection of complications compared with conventional insulin therapy for persons with type 1 diabetes19a

• Multicomponent interventions for diabetic risk factor control and early detection of complications compared with standard glycemic control for persons with type 2 diabetes19b

• Preemptive virology screening in the pediatric hematopoietic stem cell transplant population20

Treatment • Cochlear implants in profoundly deaf children21

• Angiotensin converting enzyme inhibitors (ACEI) therapy for intensive hypertension control, as in the UK Prospective Diabetes Study, in persons with type 2 diabetes compared with standard hypertension control19

• ACEI or angiotensin receptor blocker (ARB) therapy to prevent end-stage renal disease (ESRD) for type 2 diabetes compared with no ACEI or ARB therapy19

• Early irbesartan therapy at the stage of microalbuminuria to prevent ESRD in peo