Week Fourteen 4/19-4/25: Strategies for Increasing Consumer Participation in the Policy Process

It is important to encourage consumers to participate in health policy, because consumers are stakeholders in the legislative process. However, Hibbard and Peters (2003) explain that consumers may not have the cognitive capacity or the motivation to educate themselves on every aspect of health policy. If health care providers want consumers to increase their participation in health policy, then it is important to engage participants through experiential processing and decrease analytical processing. Consumers may not understand how they are directly affected by health policy. Health care providers can help patients have a better idea of how health policy affects them by connecting through personal stories and experiences, similar to explaining to legislators how health policy impacts patients and practice. It is important to involve consumers in health policy, because health policy is aimed at improving patient outcomes, quality, and decreasing health care costs. However, the amount of information on health policy can be overwhelming. One approach is to decrease the cognitive load by highlighting important factors to consider that is meaningful to the patient, such as the impact of health policy on health, finance, and access to care. Other strategies include empowerment, education, and increased awareness of important health policies. It is also important to take into consideration the age, literacy, cultural differences, and education of the patient to gauge comprehension and use of health policy information and to tailor health policy information that specifically affects that patient. Referring patients to use the web for further health policy information opens up the most opportunities for engagement and information. When consumers join an advocacy group on the web, it brings together consumers with similar interests, information-sharing, and support (Hibbard and Peters, 2003).

If consumers want to learn more about health policy, they could also learn about health policy by starting a blog and going through the same process we have done in our DNP Health Policy class. In sum, we learned the basic policy making process, statutory and regulatory mechanisms, and identify the roles and positions of institutions, actors, legislators, and advocacy groups. We also learned to consider all sides of an issue including financial costs and benefits, local, state, national, and federal involvement, different position statements of advocacy groups, the impact of the health care policy on health, and ethical decision making. Other strategies included becoming involved in a larger advocacy group to share ideas, learn, and grow in becoming a health policy change agent. Reading the news and staying updated on health policies of interest were important ways to stay involved. Subscription to related social media, such as news feeds, Twitter, and Facebook also helped to stay knowledgeable about health policy topics. Lastly, initiating dialogue among experts in health policy topics was also a great way to gain insight and understanding into the experience of those working in the trenches and working in the front-lines.

Reference
Hibbard, J.H., & Peters, E. (2003). Supporting informed consumer health care decisions: Data presentation approaches that facilitate the use of information in choice. Annual Review of Public Health, 24, 413-433. doi: 10.1146/annurev.publhealth.24.100901.141005

Week Thirteen 4/12-4/18: Sustaining Innovative Environments: Considerations of Time and Scope

Health policy change can create sustainable positive or negative consequences for stakeholders. If nurse practitioners in Arizona were legally allowed to “recommend” and “certify” medical marijuana for patients with qualifying medical conditions, they still would not be able to manage the patient’s use of marijuana or dose, because this would be “prescribing.” Marijuana is still a Schedule I drug and is defined as having no medical value. Rescheduling of marijuana at the federal level should be changed in order to provide follow-up, guidance, and assistance with dosing beyond explaining the health risks and benefits of medical marijuana.

However, it is difficult to dose marijuana, also known as cannabis. According to Carter, Weydt, Kyashna-Tocha, and Abrams (2004), there are many variables such as differences in phenotypes, composition (varying amounts of THC, cannabidiol, or cannabinol), and differences in potency during harvesting times. In addition, the effects are different on everyone, such as patients who are marijuana naïve compared to someone who has built tolerance. Furthermore, the effects are different depending on the method of administration. For example, the effects of marijuana fade rapidly over 30 minutes if smoked compared to effects lasting 1-6 hours if ingested with a delayed onset. The metabolites of marijuana also compete with the cytochrome P450 system if ingested. Fortunately, the safety profile of cannabis is similar to gabapentin. The toxicity is low and dosing limits can be high. A person would have to smoke 628 kg of marijuana in 15 minutes to achieve a lethal dose (Carter, Weydt, Kyashna-Tocha, & Abrams, 2004).

According to Carter, Weydt, Kyashna-Tocha, and Abrams (2004), the current guidelines for dosing marijuana used Dronabinol (Marinol) prescribing guidelines to guide dosing recommendations. Dronabinol is pure synthetic THC and it is also a Schedule III drug. A conservative dose of Dronabinol is 2.5 to 60 mg of THC a day. The average medical marijuana patient uses 10-20 grams a week or 1.42 to 2.86 grams of cannabis a day (one joint is usually 0.5 to 1.0 grams), and one gram of cannabis is estimated to contain about 10%-15% of THC. This translates to about 34-68 mg of THC a day, which is similar to the amount of THC in a conservative dose of dronabinol. It is recommended that patients’ self-titrate as needed to determine therapeutic effects or relief of symptoms (Carter, Weydt, Kyashna-Tocha, & Abrams, 2004).

According to CostHelper (n.d.), the average cost of a gram is $5-$20, an eighth (3.5 grams) is $20-$60, and an ounce usually costs about $200-$400. Edible products are $2-$5 a dose, tinctures are usually $15-$50 per 1-oz bottle, and concentrates such as hash, oils, and waxes cost $20-$60 per gram. In addition, rolling papers cost about $2, glass pipes cost $20, a water pipe (bong) is about $50-$300, and vaporizers cost $100-$700 (CostHelper, n.d.).

References

Carter, G. T., Weydt, P., Kyashna-Tocha, M., & Abrams, D. (2004). Medicinal cannabis: Rational guidelines for dosing. Retrieved from http://cannabisplus.net/cannabis-research-pdf/Dosage/Abrams%20%20Medicinal%20Cannabis%20Rational%20Guidelines%20for%20Dosing%20.pdf

Cost Helper. (n.d.). Medical marijuana cost. Retrieved from http://health.costhelper.com/medical-cannabis.html

Week Twelve 4/6-4/12: Healthcare Financing

According to Longest (2010), the President’s Office of Management and Budget develops a 5-10 year budget request for Congress. The annual budget request includes the President’s recommendations on how much funding should be appropriated to each “discretionary” program, a general overview of the U.S. budget, tax revenue, estimated deficit or surplus, and any suggested changes in funding mandatory programs or taxes (Longest, 2010). The discretionary budget for fiscal year 2016, which begins October 1, 2015 to September 30, 2016, was $1.168 trillion (Amadeo, n.d.). President Obama has recommended that Congress appropriate $79.9 billion to Health and Human Services (Amadeo, n.d.). Longest (2010) states that Congress takes the President’s suggestions into consideration and then direct the House and Senate to develop a budget resolution. The budget resolution then goes to the floor to be amended and hopefully passed by both House and Senate by April 15. The budget resolution also includes a “302(a) allocation” which determines the total amount of funding, or budget authority, for each of the 19 budget functions or federal spending categories. The House and Senate Appropriations Committees divide up the total amount of funding in 302(a) allocations to 302(b) allocations and then 12 subcommittees appropriate the money into specific programs (Longest, 2010). The 12 subcommittees must produce 12 Appropriation Bills by June 10 (Amadeo, n.d.). All 12 bills must be approved by the House and Senate by June 30 and submitted to the President for approval or veto before the fiscal year starts on October 1 (Amadeo, n.d.). If all Appropriation Bills are not passed by October 1, a continuing resolution may be passed by Congress or else there is a “government shutdown,” or closure of some federal programs (The Committee for a Responsible Federal Budget, 2014).

Arizona received $12.8 billion from federal funds in fiscal year 2014 and $16 billion from state funds (Ballotpedia, n.d.). Arizona’s Budget Process (n.d.) for General Appropriations to state agencies starts on July 1, 2015 to June 30, 2016 for fiscal year 2016. State agencies must have submitted their budget requests to the Governor’s Office of Strategic Planning (OSPB) by September 1, 2014. General Appropriations at the state level must also be passed by the House and Senate and signed by the Governor or pass with two-thirds vote in both the Senate and the House (Arizona’s Budget Process, n.d.). While other state programs suffer from budget cuts, the Arizona Medical Marijuana Program is self-funded and generates a surplus for the state. An estimated $112 million was generated in marijuana sales in 2013-2014 (Arizona Department of Health Services, 2014). Revenue is also generated from the dispensary application fee, renewal fee, patient ID registration fee, caregiver fee, dispensary agent fee, and sales tax (State Medical Marijuana Programs’ Financial Information, 2013). Expenses include salaries, wages, and benefits for employees, operating expenses, and capital equipment (State Medical Marijuana Programs’ Financial Information, 2013).

References

Amadeo, K. (n.d). Federal budget process. Retrieved from http://useconomy.about.com/od/fiscalpolicy/p/Who_budget.htm

Amadeo, K. (n.d.). Current US discretionary federal budget and spending. Retrieved from http://useconomy.about.com/od/usfederalbudget/p/Discretionary.htm

Arizona’s Budget Process. (n.d.). Retrieved from http://www.azleg.gov/jlbc/budgetprocess.pdf

Arizona Department of Health Services. (2014). Arizona medical marijuana act end of the year report. Retrieved from http://azdhs.gov/documents/preparedness/medical-marijuana/reports/2014/arizona-medical-marijuana-end-of-year-report-2014.pdf

Ballotpedia. (n.d.). Arizona State Budget and Finances. Retrieved from http://ballotpedia.org/Arizona_state_budget_and_finances

State Medical Marijuana Programs’ Financial Information (2013). Retrieved from http://www.mpp.org/assets/pdfs/library/State-Medical-Marijuana-Programs-Financial-Information.pdf

The Committee for a Responsible Federal Budget. (2014). Appropriations 101. Retrieved from http://crfb.org/document/appropriations-101

Week Eleven 3/30-4/5 Characteristics of Innovation and Change Agents

I am currently in Washington D.C. for the AANP Health Policy Conference and I am learning a lot about the characteristics of being a change agent that I would like to share with everyone. We spent the day preparing for our future appointment to talk to our state representatives. The topic of discussion was to ask our state representatives to support full scope of practice for nurse practitioners in all states without physician supervision.

Former Congressman Alan Wheat D-MO and Kenny Hulshof R-MO were able to meet with us to help us to prepare to talk to our congressmen. It is important to understand that congressmen come from all different backgrounds. They may have no knowledge of what nurse practitioners do. They may not be aware that nurse practitioners have prescription authority or know all of the education and experience needed to earn our degree. Congressmen do not want to look at facts, evidence or statistics when you talk to them. They are moved by personal stories that are clearly relevant to why they need to vote on a bill or why they need to have a law amended. Alan Wheat stated, “Have 3-4 talking points prepared and repeat it three times.” It is important to know your congressman, find a common ground with them or their family, and talk to them in lay man terms and a personal voice about how the law is affecting patient care. Also, writing a one page e-mail to your congressman is more effective than writing 26 pages. You can use examples of other states that have passed similar laws that resulted in good outcomes to prove your point. Realize that you may not be able to sell your idea to everyone. Congressmen may hear arguments from other organizations that are equally persuasive. It would be a good idea to research the health care stance of other organizations that have already met with the congressmen to know what you are up against. Furthermore, Alan Wheat also advised us to, “Pretend that you are Jan Towers” when we talk to a congressman. Jan Towers has lobbied many years for the unrestricted scope of practice for nurse practitioners.

Jan Towers
Jan Towers and I at the 2015 AANP Health Policy Conference in Washington, D.C.

We also learned that 100% of congressmen have Twitter and Facebook so it is important to follow them, comment, like, and share the post or comment so that it can increase awareness of the profession and create a viral effect. Congressmen look at the number of comments on these social media sites to gauge how much people care about an issue.

Angela Goldman, former president of the AANP also emphasized the importance for us to introduce ourselves with Dr. in our title when we graduate to appreciate all the work that previous NPs have done to advance our profession. She states that it is not fair that one profession gets to claim the word doctor. Doctor is a degree that is earned. Physicians should be referred to as a physician, not a doctor. It will garner respect and also get you upgrades on your hotel room.

If I were going to talk to my congressmen about marijuana issues at the federal level, I would ask our congressmen to vote on a the new bill known as the Compassionate Access, Research Expansion, and Respect States (CARERS) Act to reclassify marijuana as a schedule II drug instead of a schedule I drug (Miller, 2015). This would help to alleviate the fear of recommending a federally illegal substance, allow marijuana to be sold in pharmacies, allow providers in the Department of Veterans Affairs to recommend medical marijuana to patients, and decrease barriers to research on marijuana.

References

Miller, J. (2015). Bill to legalize medical marijuana introduced in the house. Retrieved from http://www.cbsnews.com/news/bill-to-legalize-medical-marijuana-introduced-in-the-house/

Week Ten 03/23/15-03/29/15: Change Theory

According to Dr. Carter, a psychologist (2012), change is often a long, difficult, and chaotic process with many barriers, challenges, lessons, relapses, regressions, and advancements. However each small win is an accomplishment and every mistake is a learning experience. Persistence, strategy, organization, and motivation increases the likelihood of achievement and success, and success can be defined in many different ways (Carter, 2012). Kotter describes 8 Steps in Change Management to facilitate changes in healthcare: developing urgency, building a guiding team, creating a vision, communicating for buy-in, enabling action, creating short term wins, don’t let up, and making it stick (Cambell, 2008). Prochaska and DiClemente developed the Transtheoretical Model or the Five Stages of Change to describe individuals in each stage and discusses strategies to facilitate progression to the next stage and strategies to maintain successful behavior change (Carter, 2012).

The 8 Steps in Change Management Model would be an appropriate conceptual framework to create buy-in from nurse practitioners to assist the Arizona Medical Marijuana Program to screen and appropriately certify patients for medical marijuana. This is important, because even if nurse practitioners were granted certifying privileges to certify patients for medical marijuana in Arizona, health care facilities or individual nurse practitioners may make it a policy or choose not to utilize their scope of practice to the fullest extent. If many nurse practitioners do not adapt and change to be competent in their role to certify and manage patients who need medical marijuana, then a change in law may not make a difference in access to care or increased safety and regulation of patients with medical marijuana cards.

The Five Stages of Change would be an appropriate conceptual framework to help an individual addicted to marijuana to abstain from marijuana or other substance abuse. Substance abuse for tobacco, alcohol, and illicit drugs costs the U.S. more than $700 billion in health care related costs, economic costs, and crime-related expenses (National Institute on Drugs, n.d.). According to the National Institute on Drug Abuse (2014), 9% of people who use marijuana will become addicted and this increases to approximately 17% if people start using marijuana in adolescence. Marijuana addiction increases to 25-50% if used daily (National Institute on Drugs, 2014).

According to Carter (2012), individuals with addiction in the pre-contemplation stage do not see a need for change or don’t want to change. Strategies for change in the stage include increasing awareness of the problem and recognizing that a change is needed to achieve future goals or aspirations. Awareness may develop over time, through encouragement, media, education, or court-ordered interventions. Contemplation is when an individual sees that they should change and they want to change, but they have not decided to do anything to start changing. They are weighing in the pros and cons of change. A strategy for this stage would be to encourage individuals to make a pro and con list and then brainstorm ideas on how to overcome barriers. Preparation is when the individual is motivated to make a change, starts to do research on how they can change, and takes steps towards change, such as developing a plan, and avoiding triggers (i.e. avoid hanging out with friends that encourage and engage in substance abuse). Action is plan implementation and management of challenges using planned strategies to prevent relapse. The maintenance phase is usually 6 months post intervention where the individual enjoys the new behavior and prevents return of the old behavior (Carter, 2012).

References

Campbell, R.J. (2008). Change management in health care. The Health Care Manager, 27(1), 23-39.

Carter, S.B. (2012). Change is heard, here’s why you should keep trying: Understanding the 5 stages of change can help you make long-lasting changes. Retrieved from https://www.psychologytoday.com/blog/high-octane-women/201210/change-is-hard-heres-why-you-should-keep-trying

National Institute on Drug Abuse. (n.d.). Trends & Statistics. Retrieved from http://www.drugabuse.gov/related-topics/trends-statistics

National Institute on Drug Abuse. (2014). Marijuana: Is marijuana addictive? Retrieved from http://www.drugabuse.gov/publications/research-reports/marijuana/marijuana-addictive

Week Nine 3/16-3/22: Policy Governing Access to Data in an Electronic and Genomic Age

Arizona Statues 36-509 on Confidential Records; Immunity (n.d.) states that a health care entity must keep patient records confidential. Records should only be disclosed to providers or entities that provide health services involved in patient care, third party payers, lawyers of a health care entity if needed for legal advice, auditors or accreditation committees if they remove personal identifying information (i.e. name, address, birth date, social security number, any identification number, etc.), persons authorized by court order, persons involved in research activities following federal or state laws and institutional review boards, persons permitted by federal regulations on alcohol or drug abuse treatment, persons who maintain public health statistics, state prison officers if the patient is a prisoner, law officers in relation to a patient that may be a danger to the public, is involved in a crime, or one who left unauthorized. Patient records may also be released to the State Board if they are investigating complaints of negligence. A provider should only disclose patient information to family members after talking to the patient or their decision maker first and making sure that they do not object to disclosure. If there is an emergency situation where the patient or their decision maker do not have the chance to object, then the provider may release patient information to the best of their judgment. Health care entities cannot be sued for damages from breach or disclosure of protected health information, because they are presumed to have acted in good faith, unless there is evidence that this was not the case (Confidential records; immunity, n.d.).

In Arizona, medical marijuana dispensaries need to keep track of how much marijuana has been dispensed to a cardholder and make sure it is not over the legal limit for possession. Dispensary agents register with the Arizona Department of Health Services to access the ID Card Verification System online. The ID Card Verification System is only for the use of law enforcement and dispensary employees and employers to verify a registry identification card (Verification system, n.d.). Verification must be done over an encrypted connection and if the user fails to type in their correct log-in information or an incorrect identification number five times, then they will have to contact the Arizona Department of Health Services to verify their identity and reactivate their account (Verification system, n.d.). Cardholder identification and records are protected under law and cannot be disclosed except to carry out business related to the Arizona Medical Marijuana Program, such as applications, renewals, etc. or when needed to report fraudulent information and criminal violations (Confidentiality, n.d.). Providers may also be reported to their licensing boards if they do not comply medical marijuana certification rules. There is an annual report generated by the Department of Health Services, but identifying information about cardholders, dispensaries, and physicians are not revealed, they are only identified as numbers (Annual Report, n.d.).

There are some states that made it illegal for their state department to track identifying information, because cardholders, dispensary agents, and other stakeholders fear discrimination. Under Arizona Legislature, Discrimination is Prohibited (n.d.), schools and landlords cannot refuse to enroll, lease, or penalize a person because of their cardholder status unless it violates the rules and regulations of a federal program that they are participating in. Employers also may not discriminate a person based on their cardholder status or if they test positive for marijuana on a drug test. However, the person can be subjected to termination if they bring or use marijuana into their workplace. The cardholder may also use their marijuana if they are authorized to do so by a physician in a medical facility (unless the facility is involved in a federal program). In addition, cardholders cannot be denied custody or visitation with a minor unless there is evidence of child endangerment (Discrimination prohibited, n.d.).

References

Annual report. (n.d.). Retrieved from http://www.azleg.gov/FormatDocument.asp?inDoc=/ars/36/02809.htm&Title=36&DocType=ARS

Confidentiality. (n.d.). Retrieved from http://www.azleg.gov/FormatDocument.asp?inDoc=/ars/36/02810.htm&Title=36&DocType=ARS

Confidential records; immunity. (n.d.). Retrieved from http://www.azleg.state.az.us/FormatDocument.asp?inDoc=/ars/36/00509.htm&Title=36&DocType=ARS

Discrimination prohibited. (n.d.). Retrieved from http://www.azleg.gov/FormatDocument.asp?inDoc=/ars/36/02813.htm&Title=36&DocType=ARS

Verification system. (n.d.). Retrieved from http://www.azleg.gov/FormatDocument.asp?inDoc=/ars/36/02807.htm&Title=36&DocType=ARS

WEEK EIGHT 03/02 – 03/08: Private Sector Innovation and Policy Advancement

The private sector includes interest groups that are not run by the state. They are run by individuals that believe in a common cause and they work to advance health policy through raising awareness, advertisements, developing campaigns, and petitioning for the creation of new laws. For example, the Marijuana Policy Project (MPP) is the largest national organization that drafts bills and provides funding to support marijuana-related bills for legalization, regulation, and decriminalization at the federal and state level. They raise awareness to gather support and donations for their cause through national and local media outlets, the news, radio, videos, the internet, blogs, on Facebook and Twitter, etc. They also support state representatives that will sponsor their bills and they gather signatures for voter initiatives. In addition, they encourage college students to start chapters at their schools to increase awareness and to lobby for sensible drug policies (Students for Sensible Drug Policy, n.d.). Another national interest group promoting legalization of marijuana is NORML. Both NORML and MMP want to reform marijuana laws, however, MPP is more active in getting laws to change, while NORML supports legalization and regulation, but also has a lot of articles and blogs about the benefits of marijuana. However, you have to be skeptical while reading information presented in any interest group website, because they are very biased. NORML tries so hard to convince the public that marijuana is harmless that they have all sorts of claims on their website from marijuana may be safe to use in pregnancy to smoking pot may make you a better parent (NORML, n.d.). There are also community groups that are against legalization of marijuana such as, Yavapai County’s MATFORCE. MATFORCE launched a marijuana prevention awareness program known as Marijuana Harmless? Think Again, where they disseminate information about the risks of marijuana through social media and receive pledges/resolutions to keep communities drug-free. National anti-marijuana organizations, include Project SAM (Smart Approaches to Marijuana), But What About the Children? Campaign, and Parents Opposed to Pot. The But What About the Children? Campaign is interesting, because they want provisions in place to protect kids if marijuana is legalized instead of being opposed to marijuana legalization. Project SAM also takes a neutral approach and states that they do not “demonize” marijuana, but want to prevent marijuana from being abused like alcohol and tobacco (Smart Approaches to Marijuana, n.d.). I am not aware of an advocacy group in Arizona that raises the awareness of the need for nurse practitioners to certify patients for medical marijuana. However, there are advocacy groups in other states that support the need for nurse practitioners to certify patients for medical marijuana, especially in rural areas, such as the Medical Marijuana Caregivers of Maine (caregivers meaning marijuana growers, not actual caregivers). In addition, there are advocacy groups to maintain the rights of nurse practitioners (NPs) and physician assistants (PAs) to recommend medical marijuana. For example, the Rhode Island Medical Society, Rhode Island Advocacy Coalition, and Rhode Island Academy of Physician Assistants sued the Rhode Island Department of Health in 2012 for attempting to prohibit NPs and Pas from recommending patients for medical marijuana without going through the formal policy change process (Gallegos, 2012).

References

Gallegos, A. (2012). Doctors join legal battle against change in medical marijuana policy. Retrieved from http://www.amednews.com/article/20121105/government/311059962/7/

Marijuana Policy Project. (n.d.). Campaigns. Retrieved from http://www.mpp.org/our-work/campaigns/

NORML. (n.d.). Women’s issues. Retrieved from http://norml.org/women

Smart Approaches to Marijuana. (n.d.). Our wish list. Retrieved from http://learnaboutsam.org/our-wish-list/

Students for Sensible Drug Policy. (n.d.). Start a chapter. Retrieved from http://ssdp.org/chapters/start/