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                             Discussion: Financing of Health Care

With coinciding concerns about health care costs and the imperative to improve quality of care, health care providers and others face difficult decisions in the effort to achieve an appropriate balance. Such decisions often are addressed in the policy arena. How do policymakers evaluate which health care services should be financed through government programs? How do ethics-related questions and other considerations play into this evaluation process? Is it possible to contain costs and provide accessible, high-quality care to all, or is the tension between cost and care inherent in the U.S. health care delivery system? These questions are central to health care financing decisions in the United States.

For this Discussion, you will focus on the policy decision-making process that determines what types of care are covered by public and private insurers and the ethical aspects of such financial decisions.

                                                     To prepare:

Read the case study “Economic Impact of States Declining Medicaid Expansion”  page 190 of the Milstead text( BOOK :HEALTH POLICY AND POLITIC ATTACHED BELLOW) .

Review the information in the Washington Post article “Review of Prostate Cancer Drugs Provenge Renews Medical Cost-Benefit Debate” in the Learning Resources. ( DOCUMENT ATTACHED BELLOW)

Consider how policy decisions currently are made about what will and will not be paid for and what changes, if any, could improve the process.

Reflect on how the Washington Post example illustrates the tension between cost and care.

Post your analysis and assessment of the ethical and economic challenges related to policy decisions such as those presented in the Washington Post article. 

How does this type of situation contribute to the tension between cost and care? Substantiate your response with at least two outside resources. 

CHECK THE MEDIA PRESENTATION ATTACHED BELLOW

washingtonpost.com  >  Health

Correction to This Article Previous versions of this article misspelled the name of Tito Fojo, of the National Cancer Institute. This version has been corrected.

Review of prostate cancer drug Provenge renews medical cost-benefit debate

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By Rob Stein

Washington Post Staff Writer Monday, November 8, 2010; 7:52 AM

Federal officials are conducting an unusual review to determine whether the government should pay for an expensive new vaccine for treating prostate cancer, rekindling debate over whether some therapies are too costly.

The Centers for Medicare & Medicaid Services , which dictate what treatments the massive federal health-insurance program for the elderly will cover, is running a "national coverage analysis" of Provenge , the first vaccine approved for treating any cancer. The treatment costs $93,000 a patient and has been shown to extend patients' lives by about four months.

Although Medicare is not supposed to take cost into consideration when making such rulings, the decision to launch a formal examination has raised concerns among cancer experts, drug companies, lawmakers, prostate cancer patients and advocacy groups.

Provenge, which was approved for advanced prostate cancer in April, is the latest in a series of new high-priced cancer treatments that appear to eke out only a few more months of life, prompting alarm about their cost.

"This absolutely is the opening salvo in the drive to save money in the health-care system," said Skip Lockwood, who heads Zero – the Project to End Prostate Cancer , a Washington-based lobbying group. "If the cost wasn't a consideration, this wouldn't even be under discussion."

Those concerns have been heightened because the review comes after the bitter health-care reform debate, which was marked by accusations about rationing and "death panels." The appointment of Donald M. Berwick to head Medicare only intensified anxieties. President Obama sidestepped a Senate battle by naming Berwick , who has advocated for scrutinizing costs, when Congress was in recess in July.

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Because men tend to be elderly when they get diagnoses of advanced prostate cancer, Medicare's decision will have a major effect on Provenge's availability. Regional Medicare providers paying for Provenge would have to stop. Private insurers also tend to follow Medicare's lead.

Medicare officials, who are convening a panel of outside advisers to vet the issue at a public hearing Nov. 17, say Provenge's price tag isn't an issue. But Berwick and other officials declined to discuss the rationale for the review.

"Certainly no one in the Medicare program would publicly state that the price tag would have anything to do with Medicare looking at it. But they are human beings, too. They notice things like that," said Sean Tunis , director of the Center for Medical Technology Policy and a former chief medical officer at Medicare. Tunis said, though, that other factors, such as the special nature of the therapy and lingering questions about its effectiveness, were probably playing a more crucial role.

The review comes as the Food and Drug Administration considers withdrawing an approval for another expensive cancer treatment- Avastin for metastatic breast cancer – which triggered a similar debate even though the FDA too is not supposed to factor costs into its analyses.

Medicare usually covers new cancer drugs once they have been approved by the FDA. The decision in June to scrutinize Provenge prompted several members of Congress to question the action. Supporters have inundated the agency with hundreds of thousands of comments .

"I don't want to blame Obamacare, but it just kind of figures that people are taking a look at what the cost-benefit ratios are and all that sort of stuff," said David Dykes, 69, of Lorton, a retired federal employee who was hoping to try Provenge. "That may sound pretty good to the people who want to cut costs, but it doesn't sound too good to me. This is something that could extend my life. I'd like to give that a shot."

Some fear the move will discourage pharmaceutical companies from developing new cancer drugs.

"It is extremely chilling if, after spending a huge sum of money, time and effort to get a drug through FDA approval, you'll then have to go through it all again to see if CMS will pay for it," said Allen S. Lichter, head of the American Society of Clinical Oncology . "Firing a shot across the bow like this is not the way to have an intelligent and meaningful discussion about how we start to address the complex issue of drug costs."

Provenge has long been the center of controversy. The FDA delayed Provenge's approval in 2007. The rejection triggered outrage among patients, advocates and investors in Dendreon , the Seattle company that developed Provenge. The campaign to win Provenge's approval included anonymous death threats, accusations of conflicts of interest, protests, congressional lobbying and vitriolic Internet postings.

Prostate cancer strikes 192,000 men in the United States each year and kills about 27,000. The only therapies are surgery, radiation, hormones and the chemotherapy drug Taxotere.

Unlike standard vaccines, which are given before someone gets sick to stimulate their immune system to fight off infections, Provenge is a "therapeutic vaccine," designed to attack cancer cells in the body.

To produce Provenge, doctors remove immune system cells from patients, expose the cells in the laboratory to a protein found on most prostate cancer cells and an immune system stimulator, and infuse the cells back into the patient in a month-long series of three treatments. In a study involving 512 patients with advanced prostate cancer, Provenge increased median survival from 21.7 months to 25.8 months.

"To charge $90,000 for four months, which comes out to $270,00 for a year of life, I think that's too expensive," said Tito Fojo of the National Cancer Institute . "A lot of people will say, 'It's my $100,000, and it's my four months.' Absolutely: A day is worth $1 million to some people. Unfortunately, we can't afford it as a society."

Others agreed, especially given the modest benefit.

"I'd like to think cost doesn't need to come up when it's a slam dunk," said H. Gilbert Welch of the Dartmouth Institute for Health Policy and Clinical Practice. "But when it's a close call like this, it certainly has to be a factor. That's $100,000 Medicare can't spend elsewhere."

But such commentary has caused widespread alarm among patients and advocates.

"The men most impacted by prostate cancer are African American men. If CMS doesn't approve this, then this treatment becomes an exclusive kind of treatment for men who can afford it out of pocket," said Thomas Farrington, president of the Prostate Health Education Network .

Others stressed that many men live far longer on the treatment and that even four months is extremely valuable to some.

"Whenever you are faced with a disease where you can lose your life, you really would like to extend it as much as you can," said Leibel B. Harelik, 61, a prostate cancer patient who is executive director of the Prostate Cancer Resource Center in Austin.

Company officials say the cost is not out of line with that of other cancer drugs. Each treatment with Provenge, which the company estimates cost nearly $1 billion to develop, is tailored to each patient.

"Because of that, we have higher costs associated with this product," said Mitchell H. Gold, Dendreon's chief executive. "Provenge is a unique new medicine that prolongs the lives of patients with late-stage prostate cancer. These patients need access to innovative new medicines."

Whatever the outcome on Provenge, many on both sides agreed that more debate over other new high-tech therapies was likely to come.

"At some point, if we keep paying these very high prices for treatments that provide very limited benefit, we're going to reach the point where we can no longer afford health care," said Alan Garber , a professor of medicine and economist at Stanford University. "Some say we're living through that right now."

© 2010 The Washington Post Company

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S i x t h E d i t i o n

Jeri A. MilsteAd, Phd, rN, NeA-BC, FAAN NANCy M. short, drPh, MBA, BsN, rN, FAAN

heAlth PoliCy and PolitiCs A Nurse’s Guide

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Names: Milstead, Jeri A., editor. | Short, Nancy Munn, editor. Title: Health policy and politics : a nurse’s guide / [edited by] Jeri A.     Milstead, Nancy Munn Short. Other titles: Health policy and politics (Milstead) Description: Sixth edition. | Burlington, MA : Jones & Bartlett Learning,     [2019] | Includes bibliographical references and index. Identifiers: LCCN 2017029269 | ISBN 9781284126372 (casebound) Subjects: | MESH: Legislation, Nursing | Health Policy | Politics | Nurse’s     Role | United States Classification: LCC RT86.5 | NLM WY 33 AA1 | DDC 362.17/30973–dc23 LC record available at https://lccn.loc.gov/2017029269

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© Visions of America/Joe Sohm/Photodisc/Getty

Preface . . . . . . . . . . . . . . . . . . . . . . . . . . . . .vii

Acknowledgments . . . . . . . . . . . . . . . . . . . .x

Contributors . . . . . . . . . . . . . . . . . . . . . . . . xi

Chapter 1 Informing Public Policy: An Important Role for Registered Nurses . . . . . . . . . . . . . . 1

Jeri A. Milstead, Nancy M. Short

Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . .2

How Is Public Policy Related to Clinical Practice? . . . . . . . . . . . . . . . . . . . . .2

Healthcare Reform at the Center of the Public Policy Process . . . . . . . . . 11

Developing a More Sophisticated Political Role for Nurses . . . . . . . . . . . . . 11

Conclusion . . . . . . . . . . . . . . . . . . . . . . . . . . . 13

Discussion Points . . . . . . . . . . . . . . . . . . . . . 13

References . . . . . . . . . . . . . . . . . . . . . . . . . . . 15

Chapter 2 Agenda Setting: What Rises to a Policymaker’s Attention? . . . . . . . . . 17

Elizabeth Ann Furlong

Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . 17

Overview of Models and Dimensions . . . . . . . . . . . . . . . . . . . . . . . . 23

Summary Analysis of a National Policy Case Study . . . . . . . . . . . . . . . . . . 32

Theory Application to the Nebraska Nurse Practitioner Case Study . . . . . . . . . . . . . . . . . . . . . . . . . 32

Conclusion . . . . . . . . . . . . . . . . . . . . . . . . . . . 34

Discussion Points . . . . . . . . . . . . . . . . . . . . . 34

References . . . . . . . . . . . . . . . . . . . . . . . . . . . 35

Online Resources . . . . . . . . . . . . . . . . . . . . . 36

Chapter 3 Government Response: Legislation . . . . . . . . . 37

Janice Kay Lanier

Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . 38

Process, People, and Purse Strings . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 40

Playing the Game: Strategizing for Success . . . . . . . . . . . . . . . . . . . . . . . . . 50

Thinking Like a Policymaker . . . . . . . . . . . 52

Conclusion . . . . . . . . . . . . . . . . . . . . . . . . . . . 54

Discussion Points . . . . . . . . . . . . . . . . . . . . . 55

References . . . . . . . . . . . . . . . . . . . . . . . . . . . 56

Chapter 4 Government Response: Regulation . . . . . . . . . 57

Jacqueline M. Loversidge

Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . 58

Regulation Versus Legislation . . . . . . . . . 58

Health Professions Regulation and Licensing . . . . . . . . . . . . . . . . . . . . . . 60

The State Regulatory Process . . . . . . . . . 66

The Federal Regulatory Process . . . . . . . 72

Current Issues in Regulation and Licensure: Regulatory Responses . . . . . . . . . . . . . . . . . . . . . . . . . 78

Conclusion . . . . . . . . . . . . . . . . . . . . . . . . . . . 81

Discussion Points . . . . . . . . . . . . . . . . . . . . . 81

References . . . . . . . . . . . . . . . . . . . . . . . . . . . 84

Chapter 5 Public Policy Design . . . . . . . . . . . . . 87

Catherine Liao

Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . 87

The Policy Design Process . . . . . . . . . . . . 90

Contents

iii

Research Informing the Policy Process . . . . . . . . . . . . . . . . . . . . . . 91

The Design Issue . . . . . . . . . . . . . . . . . . . . . . 92

Policy Instruments (Government Tools) . . . . . . . . . . . . . . . . 93

Behavioral Dimensions . . . . . . . . . . . . . . . 95

Conclusion . . . . . . . . . . . . . . . . . . . . . . . . . . . 97

Discussion Points . . . . . . . . . . . . . . . . . . . . . 97

References . . . . . . . . . . . . . . . . . . . . . . . . . . . 97

Chapter 6 Policy Implementation . . . 101

Leslie Sharpe

Introduction . . . . . . . . . . . . . . . . . . . . . . . . . 101

Federal and State Policymaking and Implementation 101 . . . . . . . . . . 103

Implementation Research . . . . . . . . . . . 104

Conclusion . . . . . . . . . . . . . . . . . . . . . . . . . . 111

Discussion Points . . . . . . . . . . . . . . . . . . . . 112

References . . . . . . . . . . . . . . . . . . . . . . . . . . 113

Chapter 7 Health Policy and Social Program Evaluation . . . . . . . . 115

Anne Derouin

Introduction . . . . . . . . . . . . . . . . . . . . . . . . . 116

Nurses’ Role in Policy/Program Evaluation . . . . . . . . . . . . . . . . . . . . . . . . 117

Challenges to Effective Policy and Program Evaluation . . . . . . . . . . . 122

Conclusion . . . . . . . . . . . . . . . . . . . . . . . . . . 126

Discussion Points . . . . . . . . . . . . . . . . . . . . 128

References . . . . . . . . . . . . . . . . . . . . . . . . . . 129

Online Resources . . . . . . . . . . . . . . . . . . . . 130

Chapter 8 The Impact of EHRs, Big Data, and Evidence-Informed Practice . . . . . . . . . . . 133

Toni Hebda

Introduction . . . . . . . . . . . . . . . . . . . . . . . . . 134

Electronic Resources: Their Relationship to Health Care . . . . . . . 135

Big Data . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 137

Implications for RNs, APRNs, and Other Healthcare Professionals . . . . . . . . . . . . . . . . . . . . . . 145

References . . . . . . . . . . . . . . . . . . . . . . . . . . 148

Chapter 9 Interprofessional Practice . . . . . . . . . . . 151

J. D. Polk, Patrick H. DeLeon

Introduction . . . . . . . . . . . . . . . . . . . . . . . . . 151

References . . . . . . . . . . . . . . . . . . . . . . . . . . 152

The Evolving Interprofessional Universe . . . . . . . . . . . . . . . . . . . . . . . . . . 152

What Is Interprofessional Collaboration? . . . . . . . . . . . . . . . . . . . . 152

Core Attributes of Interprofessional Education . . . . . . . . . . . . . . . . . . . . . . . . . 153

The “Team 4” Concept . . . . . . . . . . . . . . . 155

The Future of IPE and Interprofessional Collaboration . . . . 159

References . . . . . . . . . . . . . . . . . . . . . . . . . . 159

Interprofessional Collaboration to Influence Policy . . . . . . . . . . . . . . . . 160

Bipartisan–Bicameral Action . . . . . . . . . 160

Personal Reflections . . . . . . . . . . . . . . . . . 163

Discussion Points . . . . . . . . . . . . . . . . . . . . 169

References . . . . . . . . . . . . . . . . . . . . . . . . . . 169

Suggested Readings . . . . . . . . . . . . . . . . . 169

Chapter 10 Overview: The Economics and Finance of Health Care . . . . . . 171

Nancy M. Short

Introduction . . . . . . . . . . . . . . . . . . . . . . . . . 173

Economics: Opportunity Costs . . . . . . . 174

Finance: Does More Spending Buy Us Better Health? . . . . . . . . . . . . . 174

Economics: Health Insurance Market . . . . . . . . . . . . . . . . . . . . . . . . . . . . 175

Finance: Health Insurance Exchanges . . . . . . . . . . . . . . . . . . . . . . . . 177

Finance: Healthcare Entitlement Programs . . . . . . . . . . . . . 180

iv Contents

Finance: Payment Models . . . . . . . . . . . . 183

Economics: Information Asymmetry . . . . . . . . . . . . . . . . . . . . . . . 184

Finance: Comparative Effectiveness Research and Quality-Adjusted Life-Years . . . . . . . . . . . . . . . . . . . . . . . . . . 186

Finance: Bending the Healthcare Cost Curve Downward . . . . . . . . . . . . 188

Discussion Points . . . . . . . . . . . . . . . . . . . . 188

References . . . . . . . . . . . . . . . . . . . . . . . . . . 190

Online Resources . . . . . . . . . . . . . . . . . . . . 191

Chapter 11 The Impact of Globalization: Nurses Influencing Global Health Policy . . . . . 193

Dorothy Lewis Powell, Jeri A. Milstead

Introduction . . . . . . . . . . . . . . . . . . . . . . . . . 194

Globalization and Its Impact on Nursing and Health Care . . . . . . . . . . 195

The Importance of Understanding the Cultural Context . . . . . . . . . . . . . . . 201

Nurse Involvement in Policy Decisions . . . . . . . . . . . . . . . . . . . . . . . . . 203

Conclusion . . . . . . . . . . . . . . . . . . . . . . . . . . 204

Discussion Points . . . . . . . . . . . . . . . . . . . . 205

References . . . . . . . . . . . . . . . . . . . . . . . . . . 211

Chapter 12 An Insider’s Guide to Engaging in Policy Activities . . . . . . . . 215

Nancy M. Short, Jeri A. Milstead

Strategies to Recognize Political Bias in Information Sources . . . . . . . . 215

Creating a Fact Sheet . . . . . . . . . . . . . . . . 217

Contacting Your Legislators . . . . . . . . . . 219

Example of a Fact Sheet . . . . . . . . . . . . . 220

What to Expect When You Visit Your Policymaker . . . . . . . . . . . . . . . . . . 223

Preparing to Testify . . . . . . . . . . . . . . . . . . 224

Participating in Public Comment Periods (Influencing Rule Making) . . . . . . . . . . . . . . . . . . . . . . 226

How to Write an Op-Ed . . . . . . . . . . . . . . 227

For Serious Thought . . . . . . . . . . . . . . . . . 230

Recommended Nonpartisan Twitter Feeds . . . . . . . . . . . . . . . . . . . . . . 230

Recommended E-Subscriptions . . . . . . . . . . . . . . . . . . . 230

Influential Organizations Affecting Health Policy . . . . . . . . . . . . 231

How to Become a Change Agent in Policy: Betty Sturgeon—One Exemplary Nurse’s Story . . . . . . . . . . . 232

Index . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 233

Contents v

© Visions of America/Joe Sohm/Photodisc/Getty

Preface

This is a contributed text for healthcare professionals who are interested in expanding the depth of their knowledge about public policy and in becoming more sophisticated in their involvement in the political and policy processes. The scope of the content covers the whole process of making public policy within the broad categories of agenda setting; government response; and program/policy design, implementation, and evaluation. The primary focus is at the federal and state levels, although the reader can adapt concepts to the global or local level.

▸ Why a Sixth Edition? The Sixth Edition began with succession planning, when Dr. Nancy Short became co-editor and took on the serious job of planning for this and future editions. Dr. Short’s expertise and credentials demonstrate her comprehensive viewpoint, and she is dedicated to the continuation of this broad-based text on the whole policy process. As founding editor/author, I could not have turned over this text to just anyone. Nancy is an astute editor, has asked relevant and incisive questions, and has been encouraging to me personally. It has been a real pleasure for me to work with her and get to know her deep intellect and caring personality.

The Sixth Edition also introduces new authors with fresh perspectives, all of whom have a significant experiential basis for their expertise. We welcome Dr. Leslie Sharpe, Dr. Toni Hebda, Ms. Catherine Liao, Dr. Anne Derouin, and Dr. Dorothy Powell. We also delight in those who have continued to contribute to this text over the years: Dr. Elizabeth Furlong, Ms. Jan Lanier, Dr. Jaqueline Loversidge, Dr. J. D. Polk, and Dr. Patrick DeLeon. They build on the work of Ardith Sudduth an

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