NURS 8100 Week 1 policy cycle post example

Week 1 Discussion: Initial Post

The Emptiest Chair in the Loop: Following Medicare's Temporary Telehealth Rules Through Longest's Policy Cycle

Nursing reaches legislators during policy formulation, but it is thin in the rulemaking and operation that implementation requires, and that is where the details that shape practice are decided. I want to test that claim on the temporary Medicare telehealth flexibilities that began during the public health emergency.

Longest (2016) describes public policymaking as a cycle with three interconnected phases: formulation, in which problems reach the agenda and legislation is developed; implementation, in which agencies write rules and programs operate; and modification, when what agencies and the public learned under a policy prompts it to be revised. The phases do not end in sequence. Each one continually reshapes the others, which is why the model is drawn as a loop rather than a line.

The telehealth case travels the whole loop. In formulation, Congress passed statutes that allowed the federal government to waive Medicare's long-standing limits on where patients could receive telehealth and which services qualified. In implementation, federal agencies translated those waivers into billing rules, lists of covered services and guidance on audio-only visits, and states and private payers made parallel decisions. In modification, the loop turned again: Congress extended the flexibilities more than once as their scheduled expiration approached, each time after agencies, clinicians and patients reported what had happened under the temporary rules. Commentators noted early that the post-pandemic shape of telehealth would depend heavily on regulatory decisions about licensure, payment and privacy, not only on legislation (Shachar et al., 2020).

My argument is that nursing's chair sits emptiest in the implementation phase. Nursing organizations testified for telehealth access and nurse practitioners were visible in formulation, but the technical comment periods on which services count, how supervision works and what documentation is required draw far fewer nurse voices, even though those rules decide what a nurse practitioner can bill for tomorrow. Mason et al. (2021) describe regulation as one of the most consequential and least visible arenas of health policy for nurses.

The practical implication for a DNP-prepared nurse is modest but concrete: read the proposed rules that follow a statute you supported, and comment on the ones that touch nursing practice, because that is where the statute becomes a billing code. Question for the group: has anyone here submitted a public comment on a proposed federal or state rule, and what did it take?

Reply to Rosa

Rosa, you argued that nursing's weakest phase is modification, because nurses rarely track whether a policy worked after it passes. That is a strong point, and the telehealth case supports it in one way: the evidence that shaped each extension came mostly from payers and physician groups. But I would link your point to mine. Modification depends on what was learned during implementation, and if nurses were absent from the rules, they have little standing to report on how the rules performed. Within the loop Longest (2016) draws, the two gaps feed each other. Perhaps the practical answer is the same for both: a nursing organization that comments on a rule should also commit to reporting on its effects a year later.

References

Longest, B. B., Jr. (2016). Health policymaking in the United States (6th ed.). Health Administration Press.

Mason, D. J., Perez, A., McLemore, M. R., & Dickson, E. (Eds.). (2021). Policy and politics in nursing and health care (8th ed.). Elsevier.

Shachar, C., Engel, J., & Elwyn, G. (2020). Implications for telehealth in a postpandemic future: Regulatory and privacy issues. JAMA, 323(23), 2375-2376. https://doi.org/10.1001/jama.2020.7943