Available online 18 April 2024, 151901

Author links open overlay panel, ABSTRACT

Health policy and quality improvement initiatives exist symbiotically. Quality projects can be spurred by policy decisions, such as the creation of financial incentives for high-value care. Then, advocacy can streamline high-value care, offering opportunities for quality improvement scholars to create projects consistent with evidenced-based care. Thirdly, as pediatrics and neonatology reconcile with value-based payment structures, successful quality initiatives may serve as demonstration projects, illustrating to policy-makers how best to allocate and incentivize resources that optimize newborn health. And finally, quality improvement (QI) can provide an essential link between broad reaching advocacy principles and boots-on-the-ground local or regional efforts to implement good ideas in ways that work practically in particular environments. In this paper, we provide examples of how national legislation elevated the importance of QI, by penalizing hospitals for low quality care. Using Medicaid coverage of pasteurized human donor milk as an example, we discuss how advocacy improved cost-effectiveness of treatments used as tools for quality projects related to reduction of necrotizing enterocolitis and improved growth. We discuss how the future of QI work will assist in informing the agenda as neonatology transitions to value-based care. Finally, we consider how important local and regional QI work is in bringing good ideas to the bedside and the community.

Section snippetsINTRODUCTION

Advocacy and healthcare policy is often aimed at increasing value by improving delivery of care. This goal makes quality improvement scholarship a natural partner with policy reforms. This affiliation is magnified in the neonatal intensive care unit (NICU), where costs are disproportionately large compared to other aspects of pediatric care. Here we review three different means by which quality improvement and policy reform interact, providing examples of how regulations create incentives and

INCENTIVIZING QUALITY VIA REGULATION

Recent history on the intersection between QI and policy begins with the 2010 passage of the Patient Protection and Affordable Care Act (ACA). At the time of passage, 50 million Americans lacked health insurance (1). Over 90% of the uninsured earned less than 400% of the federal poverty level (1). The framework of the ACA's provision to increase insurance coverage via Medicaid Expansion, creation of the healthcare exchanges and cost subsidies are credited with insuring over 40 million more

HOW ADVOCACY FACILITATES QUALITY: MEDICAID AND DONOR MILK

The previous example of CLABSI and the ACA demonstrate how legislation and regulation can push QI efforts by creating national-based reform. However, advocacy efforts at the state level can also assist quality efforts by easing implementation, essentially taking ongoing projects and providing financial or other support to ensure efforts do not significantly increase upfront costs. At the state level, reducing these initial cost barriers can facilitate dissemination in less-resourced neonatal

THE FUTURE ROLE OF QUALITY IN ADVOCACY: VALUED-BASED PAYMENT

Despite initial hesitation to introduce quality in NICU payment, QI metrics are poised in the future to be an integral part of calculated reimbursement. As pediatrics transitions to alternative payment models, QI projects will assist in defining “quality care” and model how improvement can be achieved across units. Over the past decade, multiple state Medicaid programs have adopted degrees of value-based payment systems (45). A departure from a traditional fee-for-service based paradigm is

THE KEY ROLE OF QI IN BRINGING ADVOCACY PRINCIPLES TO THE PATIENT

Many of the efforts described so far reside in federal advocacy. Local efforts to leverage priorities and values must take into consideration the state and local environment. Practice varies across the country based on resource availability, Medicaid leadership, hospital association priorities and community values. Although reducing CLABSI and improving equitable access to donor milk have universal appeal, issues like vaccination mandates, masking in school, firearm safety or health care for

CONCLUSION

The partnership between advocacy and quality improvement science takes many forms (Table 1) and is not always direct. Regulation can clearly impose penalties for poor value-based performance, motivating improvements in pursuit of greater reimbursement or avoidance of penalties – as outlined in the ACA. Other times, advocacy simply makes quality improvement easier to accomplish by lowering barriers for hospitals to engage in this work. Finally, this work will define what metrics truly describe

FIGURE LEGENDS

Table 1: Summary of the relationships between advocacy and quality improvement with examples.

Disclosures

The authors report no proprietary or commercial interest in any product mentioned or concept discussed in the article.

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