Health Policy Engagement Strategy for the Health Information Technology Policy Project of the Transdisciplinary Collaborative Center for Health Disparities Research

Abstract

Rulemaking is one of the most important ways the federal government makes public policy. It frequently has significant impact on individuals, communities, and organizations. Yet, few of those directly affected are familiar with the rulemaking process, and even fewer understand how it works. This article describes a case study of the Transdisciplinary Collaborative Center for Health Disparities Research Health Information Technology (TCC HIT) Policy Project’s approach to health-policy engagement using: 1) social media; and 2) a webinar to educate stakeholders on the rulemaking process and increase their level of meaningful engagement with the Medicare Access and CHIP Reauthorization Act of 2015 (MACRA) proposed rule public comment submission. The webinar “Paying for Quality: What Is the Impact on Health Equity” was promoted through Twitter and held in June 2016. In total, we posted 19 tweets using two distinct hashtags (#MACRA4Equity, #MACRA2Equity) to raise awareness of the upcoming MACRA proposed rule and its possible effects on health equity. Overall, 252 individuals registered for the webinar, and more than half participated (n=133). Most (67%) registrants reported that health policy was not the primary focus of their current position. Based on information provided in the webinar, 95% agreed that their understanding of the topic improved. By the end of the webinar, 44% of participants indicated that they planned to submit public comments for MACRA, a 12% increase compared with those who planned to submit at the time of registration. The TCC health-policy engagement strategy demonstrates the feasibility of engaging a diverse audience around health policy issues, particularly those who are not typically engaged in policy work.

Introduction

Governmental policies are critical in the effort to eliminate health disparities and achieve health equity. Laws and policies have the potential to impact large segments of the population, to prioritize health equity and to allocate needed resources. Research evidence, including quantitative studies evaluating policy impact and qualitative studies of those affected by policies, should inform policymaking efforts. However, the gap between research and policy has been well-documented.1

The policymaking process at the state and federal levels provides several important opportunities for researchers, stakeholders and communities to inform policy. One such opportunity is the ability to provide public comments during the administrative rulemaking process to inform the development of regulations. Accurate information and stakeholder engagement is essential to a productive notice and comment process, which is tied to effective policy-making.2,3 High levels of stakeholder engagement have been found to increase the likelihood that agencies modify their proposals, specifically for highly complex rules.4 The public comment process has effectively contributed to modifications of proposed regulations, which guide policy implementation.5

Engagement in this process is especially critical for health-related policies, which require expertise that public administrators and legislators may not have. Health professionals, as stakeholders, are in a unique position to contribute effectively to rulemaking as experts who can help translate effective health policy to improved health outcomes.2,6 The impact of the policy-making process is magnified when health professionals, who will be directly affected by policies, or lack thereof, can clearly articulate the effect a policy will have on their community or practice.7 In order for the policy-making process to be most effective for improving population health, health professionals must be equipped with contemporaneous knowledge of relevant evidence-based information and policy proposals under consideration, understand the nuances and implications of the proposed policies if adopted, and have the capacity to organize an informed response that reaches policy makers. Informed policy makers are then better able to make decisions that benefit the health of the community. Despite this need, numerous obstacles limit the flow of evidence, health equity analysis and engagement in the process.

This article describes a case study of the Morehouse School of Medicine’s Transdisciplinary Collaborative Center (TCC) for Health Disparities Research, Health Information Technology (HIT) Policy Project. The TCC HIT Policy Project developed a practical approach to raise awareness and engage affected stakeholders in the public comment process by equipping a community of health professional and research stakeholders with an informed interpretation of the Medicare Access and CHIP Reauthorization Act of 2015 (MACRA) and its impact on health equity. The purpose of this effort was threefold: 1) to communicate the research evidence and a health equity-focused analysis of the proposed rule; 2) to raise awareness of the public comment process among researchers and health professionals; and 3) to gain feedback from a community of affected stakeholders to inform the TCC’s public comment.

The Administrative Rulemaking Process

Regulations are developed at the federal level through the administrative rulemaking process. This process consists of publication of a proposed rule, a public comment period where members of the public have the opportunity to provide feedback to the federal agency on the proposed rule, and publication of a final rule. When Congress passes a law, it tasks an executive agency with administering the law. The agency publishes a proposed rule in the Federal Register based on Congress’ legislative directives. The proposed rule is generally available for public comment for 30-60 days. Upon closing of the public comment period, the administering agency is required to consider all public comments in developing the final rule (also known as a regulation). In this case, Congress passed MACRA as a piece of bipartisan legislation to shift reimbursement for Medicare services from a volume-based payment system built on fee-for-service reimbursement to a value-based system built on paying for improving quality and outcomes. The MACRA legislation is 95 pages in length and the proposed rule is 426 pages in length. The public was given approximately 60 days to comment on the proposed rule. Reviewing and interpreting that volume of legal writing is challenging to seasoned policy professionals and even more so to the average health professional or research stakeholder, whose input via public comment, was being solicited. Figure 1 illustrates the timeline of the MACRA administrative rulemaking process.

Figure 1. Timeline for the adoption of and administrative rulemaking process for the Medicare Access and CHIP Reauthorization Act of 2015 (MACRA).

The Quality Payment Program (QPP), which resulted from the MACRA legislation, was designed to slow the increase in health care costs, particularly those generated by Medicare beneficiaries, and to improve overall quality of health care services.8-10 Congress tasked the Centers for Medicare and Medicaid Services (CMS) with administering the law. The CMS published the proposed rule: the Merit-based Incentive Program (MIPS) and Alternative Payment Models (APM) Incentive under the Physician Fee Schedule on May 9, 2016.11

MACRA, Health Care Quality and Health Equity

Informing policy related to health equity is the primary focus of the TCC HIT Policy Project. “Health equity is achieved when all people have the opportunity to attain their full health potential” and in turn, “health care equity refers to ensuring that everyone has equal access to, utilization of, and quality of healthcare services”.12,13 Value-based payment programs, including the QPP have the potential to reduce health disparities and to advance health equity.14 However, these value-based payment programs also have the potential to exacerbate existing disparities if they are implemented in inequitable ways.15

Many quality improvement programs tend to focus on population-level efforts intended to improve health care quality for all patients. However, these programs are often not tailored to address unique needs of certain high disparity sub-populations and reductions in health disparities do not necessarily occur.14 Instead, these high-disparity communities may experience exacerbations in the deleterious impact of poverty, food deserts, homelessness and poor housing conditions. Left unaddressed these social determinants of health result in higher burdens of chronic diseases and more complex medical conditions.16,17 Laws and policies that incentivize quality improvement and spur health care innovation must account for this in their design or else risk exacerbating existing disparities.18

Health care providers and hospitals most likely to serve high-disparity patient populations are uniquely challenged in providing low-cost care for the complex and costly chronic conditions that typically characterize high-disparity populations. Due to having higher Medicaid payer mixes and more uninsured patients, health care providers who serve these communities often lack the resources necessary to support the significant clinical and administrative changes necessary to implement significant policy changes such as MACRA. The delicate balance of achieving high-quality health outcomes while continuing to suppress and reduce health care costs make pay-for-performance models, eg, Accountable Care Organizations, and value-based payment systems less attractive to providers serving these populations, as they are more likely to be penalized under value-based payment systems.19 For these reasons, research evidence and stakeholder feedback are particularly important and critical to the development and implementation of such a significant regulatory scheme.

The Role of E-Technology

Technologies, such as social media, can be used to build online partnerships that engage communities in support of causes and to respond to important issues. Additionally, webinars that demystify the rulemaking process can be used to engage community stakeholders.20 Such technologies open the regulatory process to a broader base of community stakeholders who might have been unaware of the opportunity to offer their views before a proposed policy is finalized.21 Former President Barack Obama’s administration used social media and other online technologies to make government more transparent, participatory, and collaborative.22 Despite these efforts however, the principal barriers to public participation in rulemaking still exist. These barriers include lack of awareness of the rulemaking process, lack of direct experience, career obligations among health professionals, and the voluminous and complex rulemaking materials.23,24 Contemporary technologies that enable stakeholders to form groups, develop coalitions, argue for change or influence, and then disband are powerful tools.

Methods

The TCC HIT Policy team analyzed the proposed rule for its potential to impact health equity. This analysis consisted of key word searches, content analysis and a literature review. The team strategized on the best ways to share this information with the community of interest and have dialogue about the possible effects on their communities. In order to have the broadest geographic reach and provide information in a practical way to health professionals and researchers, the webinar “Paying for Quality: What Is the Impact on Health Equity?” was created. To raise awareness across a wide cross-section of stakeholders, a social media platform was utilized to highlight MACRA and promote the upcoming webinar.

Awareness Strategy

The TCC promoted awareness of the MACRA proposed rule and upcoming webinar through the TCC Twitter page, using Twitter handle @TCC_HITPolicy. Twitter was used as the platform of choice because the TCC already had an established account with a following. At the time of the webinar, the @TCC_HITPolicy twitter handle had 118 followers, which was a gain of about 1 per day in the previous 90 days. Two unique hashtags were created to track impressions (potential reach) related to conversation around the MACRA proposed rule (#MACRA4Equity and #MACRA2Equity). We posted 11 tweets using the #MACRA4Equity hashtag and 8 tweets using the #MACRA2Equity hashtag between May 9, 2016 when the proposed rule was published and June 2, 2016 when the webinar was hosted. The TCC_HITPolicy Twitter page had a total of 13,872 impressions during the months of May and June 2016.

Engagement Strategy

A free, publicly accessible one-hour webinar, “Paying for Quality: What Is the Impact on Health Equity?” was hosted on June 2, 2016. The learning objectives of the webinar were: 1) distinguish between the concepts of improving overall quality and eliminating health disparities in underserved populations; 2) identify provisions of the MACRA proposed rule that will advance health equity; and 3) assess the practical implications of health equity provisions in the MACRA proposed rule. Participant feedback was sought during the registration process from everyone who registered and throughout the webinar using polling questions from everyone who participated in the webinar. A post-webinar evaluation was sent to all webinar participants immediately following the webinar via email. The registration, in-webinar polling and post-webinar questions were used to assess: 1) participants’ intent to submit comments during the open public comment period; 2) participants’ perception about the importance of health equity issues within the proposed rule; and 3) participants’ overall satisfaction with the quality and content of the webinar.

Population Characteristics

Two hundred fifty-two individuals from 38 states across the United States registered for the webinar. Most registrants held a graduate degree (52%); 23% reported having a bachelor’s degree and 16% a doctorate degree; 13% were registered nurses; and 6% held a PhD. Registrants worked in various public and private settings including: federal agencies (21%); state agencies (12%); physicians (7%); college/university (7%); CBO/NGO (7%); and other (46%) organizations including local health departments, non-profit organizations, consultants, and hospital/medical institutions. Interestingly, 67% of registrants stated that health policy was not the primary focus of their current job/position.

Results

Pre-Webinar Questions (n=252)

At the time of registration, 68% of registrants did not plan to submit comments for the MACRA proposed rule on the Merit-based Incentive Program (MIPS) and Alternative Payment Models (APM) Incentive under the Physician Fee Schedule. Most registrants (98%) felt that it was important to ensure that the MIPS and APM programs advance health equity for underserved populations. Similarly, the majority (97%) of registrants indicated that health equity was a priority issue for their organization.

Webinar Poll Questions (n=133)

More than half (53%) of those who registered participated in the webinar. Of the participants who responded to the poll questions, all (100%) felt that achieving health equity and integrated behavioral health care should be adopted as Clinical Practice Improvement Activities (CPIA) subcategories. When asked how health equity should be incorporated into the quality performance category, 76% of participants chose stratification of and stand-alone health equity clinical quality measures (CQMs); 13% chose stratification of CQMs by a disparity variable only; 9% chose stand-alone health equity CQM only; and 2% felt that it should not be incorporated. The majority (84%) of participants felt that the proposed advancing care information framework was an improvement over the meaningful use program. At the end of the webinar, 44% of participants indicated that they planned to submit public comments on the MIPS & APM proposed rule, a 12% increase from those who planned to submit at the time of registration.

Post Webinar Questions (n=43)

Participants rated the webinar positively, with the majority (57%) rating the quality as excellent, 41% as good, and 2% rated as fair. Most (95%) participants agreed that the webinar was a good use of their time. When asked if the session improved their understanding of the topic, 56% strongly agreed, 39% agreed, and 5% were neutral. Participants were asked to provide comments that could help improve future webinars; eighteen (18) comments were received. Eight of the comments related to positive feedback of the webinar; one participant stated “This was - by far - the best webinar I have listened to in a long time. The presenters were fantastic in terms of content knowledge and presentation skills. They kept my attention the entire time (versus usually multitasking). Thank you!!!” Allotting more time for the webinar and questions/answers was mentioned seven times. Including practical solutions that can be applied was suggested by two participants. Having presentation slides available for participants during the webinar was suggested twice.

Discussion

The TCC was able to effectively pilot an awareness and engagement strategy utilizing a webinar and social media promotion in their approach to health policy rulemaking. The use of e-technology platforms proved to be a sensible vehicle for presenting information and engaging stakeholders in a dialogue about policies that would affect them. Consequently, the TCC submitted their own public comments on the MACRA proposed rule, using the data from the webinar registration, polling and post-webinar questions to inform policy. This is an example of informing evidence-based health policy. Research evidence was utilized in combination with webinar data in order to produce an informed and sound public comment submission. The TCC’s public comments were acknowledged in the final rule and some of the health equity-focused recommendations were incorporated into the final rule, while others were not.

The project successfully engaged a diverse audience of health professionals and researchers who may have had limited prior engagement with the policy process related to health equity. The majority (67%) of our registrants stated that health policy was not the primary focus of their current job/position yet 97% of participants indicated that health equity was a priority issue for their organization. This reveals that there may be a disconnect between wanting to achieve health equity but not being equipped with the know-how to inform policy change. This presents an opportunity for health policy professionals to enact a similar strategy as the TCC to translate daunting legislative policy into an understandable and applicable synopsis to stakeholders and disseminate this information using today’s digital platforms. In recent years, the use of social media and digital platforms has been encouraged as research dissemination strategies by government agencies, clinicians, and researchers as an optimal route to reach the communities and stakeholders that they serve.25-27

In addition to engaging stakeholders and exchanging perspectives, TCC also observed a shift in behavioral intention among participants to submit public comments. By the end of the webinar, 44% of participants indicated that they planned to submit comments, a 12% increase from those who planned to submit at the time of registration. While we acknowledge that behavioral intention does not necessarily result into action, we are confident that the webinar educated stakeholders about the rulemaking process and how they could contribute an informed response to policy makers. Future research may apply behavioral theories such as the Theory of Planned Behavior to better understand how and whether awareness campaigns such as this result in changes in behavior.

Future Directions

Feedback from participants is encouraging for continuing this series of webinars for future iterations and requests for comments to proposed rules. The QPP is an ongoing federal program, and proposed changes to the rule arise each year to improve the program giving stakeholders the opportunity to submit public comments. In response to the feedback received from the webinar, more time will be allotted to cover presentation materials and respond to questions/comments from participants. For future iterations the use of multiple social media platforms will be considered to maximize engagement across a larger audience. The Pew Research Center reports that the majority of US adults use Facebook (68%) and YouTube (73%), with Twitter used only by 24%.28 Although this was an assessment of best-to-use social media channels, the level of engagement that can be generated, and potential for engaging new voices in the conversation has yet to be adequately evaluated. This project provides a roadmap and proof of concept for engagement of community stakeholders and influencers in the health policy process.

For programs that seek to replicate our process, there must first be an examination of evidence-based material, the willingness to partner with subject matter experts/organizations, and the technical infrastructure to deliver professionally produced information to a clearly segmented audience. Additionally, a social media platform will need to be used in order to engage a cross-section of professionals. This requires a steady stream of messages designed to generate dialogue on the subject and maintain interest.

Conclusion

Policy-making engagement by health professionals and other affected stakeholders can be stimulated by communication strategies including social media and webinars that inform health equity policy. Use of social media platforms is useful for increasing awareness and promoting policy-related education and trainings through webinars, which effectively engage participants and solicits valuable feedback.

The Affordable Care Act, Meaningful Use and MACRA are federal policies that have reshaped the US health care system. Each of these policies sought the opinions and comments of health professionals before the proposed policies were put into law. In doing so, the legislative process was significantly enriched by the clinical and community-level experiences of frontline health professionals. Moving forward, it is imperative that community stakeholders increase their active participation in the rulemaking process so that the voices of underserved communities are heard.