Global Health : Final Project Two Submission: Policy Analysis and Testimony Transcript

Appendix

Testimony to the Texas House of Representatives

Good morning ladies and gentlemen. My name is xxxx, and I represent the Greater Houston Area Chapter of the Association of Women's Health, Obstetric, and Neonatal Nurses (AWHONN). We are a national organization whose members seek to empower and support nurses caring for women, newborns, and their families through research, education, and advocacy.

Today I am here to support the 2011 Texas House Bill 1983 from the 82nd Legislature, Regular Session, which mandates the timing for elective deliveries. The bill intends to protect the well-being of newborns delivered before the 39th week of pregnancy for non-medical reasons. Since the implementation of the policy, the number of early-term deliveries declined from 31% to 28%, and full-term deliveries increased from 44% to 48%, reflecting a positive effect of the policy ("Early Elective," n.d.). The change in the distribution of the gestational age saved the state an estimated $5.4 million ("Early Elective," n.d.).

Babies that are born prematurely have a myriad of potential complications. These complications lead to an increased number of costly neonatal intensive care admissions and longer lengths of stay. The desired effect of House Bill 1983 is to reduce the number of neonatal intensive care admissions. Policymakers anticipated a significant decrease in the number of admissions as a result of the bill. This effect has not yet come to full fruition. During the three months before the initiation of the policy, neonatal intensive care stays averaged around 13.5 days as compared to afterward when the stays averaged 13.4 days ("Early Elective," n.d.).

I believe that I have some insight as to why the statistics related to neonatal intensive care stays have not changed. According to the bill, the physicians determine the control of what constitutes a valid medical indication. Originally the determination of a list of medically necessary indications of labor was the responsibility of the legislature. In response to physician feedback, policymakers redrafted the policy to change this responsibility to the individual hospitals. To stay in compliance with regulations but still induce their patients when it is more convenient for them, physicians have found ways to circumvent the policy. This results in patients admitted for inductions of labor without a medical indication. For example, a low amniotic fluid volume is a medical reason for inducing labor. Amniotic fluid volume is determined by a bedside ultrasound that is performed and read by the physician. No hard copy documentation of the ultrasound becomes a part of the medical record. Physicians will diagnose a low amniotic fluid volume without any tangible proof that this fact is correct in order to induce the patient. Requiring that a radiologist verify a diagnosis of low amniotic fluid would ensure that women who have a low amniotic fluid index receive a valid diagnosis.

I have experience in both the private and academic healthcare environments. Academic settings generally have a reliable chain of command in case of concern for patient safety and quality of care. In many private institutions, physicians work without immediate supervision of their practices. Nurses who have concerns regarding questionable practices make reports that go unanswered. Hospitals are reluctant to discipline physicians for fear of losing the patients and funds the physician brings to the facility. Physicians without fear of repercussions for questionable behaviors have no incentive to change their behavior. They will continue to schedule inductions for their convenience instead of making this decision based on what is best for the mother and baby. An increased level of supervision of the physicians may be a motivator to change their behavior. Behavior change theorists recognize that the awareness that a threat exists prompts one to self-change behavior. A state mandate for hospitals to have a method of supervising physician practices with enforceable ramifications for those who are non-compliant has the potential to be a beneficial intervention to help change physician behaviors that are detrimental to patient outcomes.

Hospitals who receive reimbursement from Medicaid are required to participate in the process of proving their ability to provide a certain level of care set by the State of Texas. One element of the level of care designation process addresses the chain of command and accountability for physicians. The designation process is still in its infancy at this point but could prove to be a key component to improving patient outcomes. We can use the designation process to aid in enforcing the policy against early elective deliveries. Surveyors evaluate facilities during a hospital’s designation process. Participating in the survey provides the opportunity for an impartial outside party to review the care provided to patients critically. These reviews include physician practices, levels of supervision, and the power of a facility to discipline if needed. Finding the loopholes that physicians use to find ways to perform early elective inductions will require a thorough examination of a hospital's practices. More in-depth reviews will require increased training, time, and qualified individuals to perform them. Please support the designation process with the appropriate resources and funding to perform a useful review. We cannot afford to be lackadaisical about the evaluation process for the program to be effective.

Providing incentives and higher payments for quality care and outcomes rather than punitive measures may also be an effective method of improving compliance and patient outcomes. Value-based programs are essential because they focus on paying providers based on the quality rather than the quantity of the care that they give patients. Changing the reimbursement system to one that focuses on patient outcomes instead of services rendered gives healthcare providers increased motivation to adopt better practices.

A review of the effectiveness of the policy suggests that the method of data collection may not be giving accurate results. Using a hybrid methodology to analyze the policy from different angles by merging claims with birth certificate data is an alternative method to be considered for increasing accuracy in statistical data ("Early Elective," n.d.). An accurate method for assessing the data that more closely monitors the care provided to the patient is necessary to validate any effect on patient outcomes and create an element of accountability. Supervision by a party that controls reimbursement motivates one to comply with the policy.

Today what I ask of you is to continue to keep House Bill 1983 in place and provide the necessary resources, funding, and workforce to support the goals of the policy. Mandate hospitals to create actionable processes of supervising physicians. Use the levels of care designation process that is already in place to help enforce the policy against early elective deliveries. Change the reimbursement system to a value-based program. Invest in improving data collection processes. Through these efforts, we can continue to improve the quality of patient care and outcomes for Texas mothers and babies.