Policy and How to Change It

The development of mobile integrated healthcare practice offers great promise for emergency medical services. Not least of this is the opportunity for EMS to mature into an integral part of the broader healthcare system. Indeed, the proposed MIHP framework envisions that EMS systems will provide the underlying structure for the coordinated delivery of nonemergent (unscheduled), interdisciplinary, patient-centered and cost-effective healthcare—in other words, the right care in the right place at the right time and at the right cost.

For EMS to fully participate in this new model of healthcare delivery, however, several policy obstacles need to be overcome. Specifically, state and local regulations governing scope of practice will likely require changes to permit EMS providers to deliver nonemergent care. State and federal reimbursement rules will also need to be changed if EMS systems intend to seek reimbursement for clinical care rather than simply ambulance transport. The implementation of MIHP programs will also have other policy implications, such as the potential application of anti-kickback statutes to nonemergent medical referrals.

Consequently, advocates for EMS in the context of MIHP should have a basic understanding of policies, policy process and policy change. The same is true for EMS providers generally. This article discusses the role of policies in EMS, the opportunities for EMS advocates to influence the policy process, and the importance of identifying and taking advantage of opportunities for policy change.

Policies in EMS

Countless policies impact the provision of emergency medical services in the United States at all levels. At the agency level, rules and procedures outline certain responsibilities and expectations for EMS providers, such as timeliness, appearance and prohibited conduct; many agencies also have their own medical protocols. At the state and local levels, laws and regulations often define a provider’s scope of practice, impose regulatory requirements on EMS agencies and establish limitations on the provision of healthcare services. Finally, at the federal level, administrative laws and regulations also influence the provision of EMS, including by establishing national standards for training providers and outlining rules for Medicare reimbursement.

Failure to ensure compliance with the policies that govern EMS can result in severe consequences, including termination of employment, loss of licensure for both providers and agencies, and denial of reimbursement claims. Sometimes, however, existing rules and regulations can become an obstacle to the effective provision or development of emergency medical services. For example, treatment protocols may be rendered obsolete by new research evidence. Similarly, the development of innovative approaches to EMS healthcare delivery may run up against existing scope-of-practice regulations. Federal training standards and reimbursement schemes may also fail to keep pace with new developments in the field.

For these reasons, advocates for EMS (whether street-level providers, midlevel administrators or top-level leaders) need to do more than simply ensure compliance with existing rules and regulations. We must also be able to effectively advocate for changes to those rules when they stand in the way of providing high-quality patient care and meeting the healthcare needs of our communities. This requires an understanding of the policy process.

The Policy Process

The policy process is how ideas are translated into actual policies and then implemented. Policy ideas are solutions proposed to address a particular problem or condition; they can range from large-scale proposals (such as changing the federal reimbursement model) to small-scale suggestions (such as updating local protocols to incorporate new evidence-based guidelines). Regardless of their scope, however, all policy ideas must successfully navigate the policy process to become policies.

Several elements comprise the policy process:

• Problems;
• Agenda-setting;
• Policy formulation;
• Decision-making;
• Implementation;
• Evaluation;
• Learning.

Though not always the case, these elements often combine to form a sequential policy process cycle. If a problem gains sufficient attention to be discussed by decision-makers (agenda-setting), it may become the subject of policy ideas developed by interested groups and individuals (policy formulation). Decision-makers may then decide to apply one or more of these policy ideas to the problem (decision-making), resulting in a policy that is subsequently put into effect (implementation). Following implementation of this policy, its effects may be studied to determine if the policy is successful at addressing the problem (evaluation). The success or failure of the policy may then provide the basis for future policy ideas (learning) and even restart the policy process cycle from the beginning.

Understanding the policy process cycle is crucial to understanding how EMS advocates can influence policy-making. We are already accustomed to identifying problems in our systems (for example, outdated agency protocols or overly rigid state regulations). Identifying problems, however, is just the first stage in the policy process. EMS advocates must also find ways to bring attention to those problems. Depending on the scope of a particular problem, this might require nothing more than notifying the responsible person within an agency—or nothing less than a full-fledged public advocacy campaign.

At the same time, EMS advocates must also offer policy ideas to address the problems we identify, either by researching existing proposals or developing our own. Participating in strategic planning and performance management efforts at the agency level often provides a good opportunity to not only identify problems but also develop potential solutions. Once we have these policy ideas in hand, we must seek to persuade decision-makers to translate appropriate policy ideas into actual policies. The most effective way to accomplish this is to ensure that we have a seat at the decision-making table.

Accordingly, EMS advocates should actively participate in policy-making within our agencies, perhaps by joining a quality improvement or training committee. We must also engage with governing bodies at the local, state and federal levels (for example, by participating in legislative advocacy efforts through professional associations such as the NAEMT). Finally, after new policies are implemented, EMS advocates should continue to identify additional opportunities for improvement.

Policy Change

Unfortunately, understanding the policy process is not sufficient, by itself, to produce policy change. This is because few problems gain sufficient attention to make it onto the agendas of decision-makers. Even then, only certain policy ideas are seriously considered when addressing those problems. Consequently, if EMS advocates are to be successful in generating policy change, we must also understand the factors that drive policy change—and how to take advantage of them.

Generally speaking, policy change depends upon three sets of factors. First, external factors can drive change in a system. More specifically, relatively sudden shifts in the public’s attention to a problem may punctuate the policy equilibrium in a system and create conditions that are favorable for policy change. For example, when the local newspaper runs a story about how long it took an ambulance to arrive on the scene of a pediatric emergency, the resulting public attention may cause decision-makers to consider changing staffing levels or deployment models.

EMS advocates can influence external factors in several ways. We can develop relationships with the media and help them learn more about issues that are important to EMS. EMS advocates can also engage in outreach efforts to inform the public about the importance of EMS issues to their communities. Finally, we can reach out to other outside groups (regulatory agencies, healthcare groups, etc.) and explain the impact of EMS issues on their interests. EMS advocates can then leverage these relationships to focus attention on policies when they need to be changed.

Sometimes public attention may shift very suddenly without warning. This is often the result of a “focusing event” that generates intense media and public attention due to its magnitude or significance (for example, the Newtown, Aurora and Washington Navy Yard shootings). Such focusing events can direct and magnify attention on new or existing problems and motivate decision-makers to seek solutions. EMS advocates must be cognizant of the impact of focusing events on the policy process and take advantage of opportunities to offer relevant ideas when they arise.

Second, internal factors can drive policy change. Changes in the identity of key players in a policy system (including managers, leaders and government officials) can result in opportunities for policy change; so can changes in the relative balance of power between groups of actors in the system. Even in the absence of such changes, “policy-oriented learning” can influence the policy beliefs of certain actors and make them more receptive to new policy ideas. For example, data regarding the proportion of nonemergent patients transported to emergency rooms, or research findings on the ability of EMS providers to accurately triage such patients, may persuade decision-makers to explore the possibility of transporting nonemergent patients to alternative destinations (or even treating them at home).

As EMS advocates, we may have limited control over the identities of (and balance of power between) other actors and groups in our policy systems. That said, when opportunities arise to influence these internal factors (such as during agency leadership vacancies and political elections), we should tie our support to greater attention to EMS issues and also serious consideration of our policy ideas. More important, EMS advocates should strive to constantly educate the other actors in our systems. To do this successfully, we must stay abreast of developments in our field (by reading trade magazines, attending conferences and participating in research) and then use this information to support our policy-change efforts.

Third and most important, the convergence of problems, policy ideas and politics can drive policy change. Within any policy system, a constant stream of problems (the “problem stream”) gains varying degrees of attention from the public and decision-makers over time. Similarly, a stream of policy ideas (the “policy stream”) is continually produced during that same period, with some ideas being selected for consideration and others being discarded. Finally, a “political stream” (composed of several elements including public opinion, interest group pressure and changes in leadership) continually alters the political environment in which policy-making takes place.

For the most part, each of these three streams operates independently. For example, problems often arise without proposed solutions. Similarly, many policy ideas are developed even in the absence of a problem. Importantly, political developments occur without respect to either problems or policy ideas. Only when all three streams converge (a problem gains broad attention at the same time that a policy solution has been made available and the political environment is amenable to change) does policy change actually take place.

The rapid development of MIHP over the past two years is a good example of how the convergence of problem, policy and politics is essential for policy change to occur. Indeed, the related problems of how best to care for nonemergent patients and frequent flyers have been around for some time. Policy solutions for these problems (treat-and-release protocols, transport to alternative destinations, cab vouchers, etc.) have also emerged over that time, with varying degrees of successful implementation.

The advent of the Affordable Care Act, however, with its emphasis on reducing healthcare costs (including by encouraging the development of accountable care organizations and penalizing hospitals for the readmission of certain patients within 30 days) has altered the political environment, making stakeholders across the healthcare system more receptive to policy change. As a result, EMS advocates are now working alongside hospital systems, insurance companies and public payers (both federal and state governments) to develop and implement new policies for how emergency medical services can contribute to the cost-effective provision of unscheduled healthcare services (both emergent and not) as part of the broader healthcare system.

Each of the problem, policy and political streams offers opportunities for EMS advocates to promote needed policy change. We have an important role to play in identifying problems in the EMS policy system—and also in developing proposed solutions. In addition, EMS advocates can do much to shape public opinion and influence agency and political leaders. Most important, we must be on the lookout for changes in our political environment that may cause the three streams to converge, and then make the most of the “policy windows” created when they do.

Conclusion

The provision of emergency medical services is greatly impacted by policies at all levels. In order to promote the continued development of EMS (including as a part of mobile integrated healthcare practice), advocates for EMS must understand the policy process and how to influence it. We must also understand the factors that drive policy change, so that we may take advantage of the opportunities that arise when they converge.

Mario J. Weber, JD, MPA, NREMT-P, is a paramedic with the Alexandria (VA) Fire Department. He has 15 years of EMS experience in career and volunteer systems in Virginia, Maryland and Florida. Mario currently serves on several committees at the Alexandria Fire Department, including the strategic planning, EMS training and quality management committees. He also serves on the ALS training advisory committee and the medical review committee for the Montgomery County (MD) Fire and Rescue Service. Prior to joining the Alexandria Fire Department, Mario worked as a litigation and regulatory attorney in Washington, DC. Reach him at mario.weber@alexandriava.gov.