When people find out I write about health care policy, I usually get one of two responses: either a polite “Oh, great!” or an eye-glazed stare. Even people who like me would rather not hear any more about it. This is because policy and politics, like statistics and laundry, are boring. As doctors and nurses, we want to go save lives and publish great research, not plod through a book of state nursing regulations or sift through ICD-9 coding requirements. The incredible importance of having people who care about policy is that the work they do profoundly impacts the work we do.

For example, have you ever heard of the notice-and-comment rulemaking of administrative law? (Oh, now don’t whine. Keep reading. It’s good for you.) I hadn’t either. But Dr. Margaret Moss of the Yale University School of Nursing has. She is not only a nurse and policy expert, but a lawyer as well. She says that everyone can have a say in how we practice.

“I think you need to know policy because policy touches everything you do. Its guiding who you can see, when you can see them, how often you can see them, how much you are going to get paid for seeing them, where you can see them, everything. Everything you can do was first a regulation in your state register, only nobody noticed. If you don’t know anything else about law or policy, you’d better know the notice comment rule part of administrative law. Everything you’ve done, everything you will do comes out in the register. There’s an open period there—30 to 90 days. If every nurse—which is impossible—said something, commented, it would be law. Because it sits there, they have to accept every comment that comes in. In most states, it can be online now. And then they have to publish those comments and they have to—if they are not going with the wave—have to have a big explanation or they go with where the wave is going.”

Here’s how it works. Every bill, including the Affordable Care Act, that passes a legislature is really an authorization to do “something.” That something comes from taking each section of the bill and turning it into a proposed rule. When finalized, the rule then becomes the law, as a regulation. But before any regulation can become law, it has to spend a period of time in an open comment period: the notice-and-comment rule. During that time, anybody can say anything they want about the regulation, and it has to be published, and it has to be taken into consideration. After that, it becomes a final rule. Final rules have the force of law.


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These proposed regulations are published regularly in state and federal registers. Here is one from the secretary of the state of Massachusetts: http://www.sec.state.ma.us/spr/sprpub/pubhear.htm. If you go to this website, you can see that for October 10, the state has issued a number of proposed regulations. Each entry tells you what the proposed regulation wants to do, what groups would be most affected, what the impact on small business would be, and the deadline for comments.

One of these entries is a proposal to require all providers to enter immunization information in the Massachusetts Immunization Information System (MIIS). In this case, the notification states that the proposed regulation “…applies to all heath care providers licensed in the Commonwealth who administer immunizations to any person, regardless of whether or not that person is a resident of the Commonwealth, and any entity that accesses the MIIS.” That is a lot of providers. The proposal declines to estimate the number of doctor-owned small businesses that would be affected, but notes that pharmacies that give immunizations are also included in the groups that would have to comply. The register also tells you what new requirements the proposed rule would impose. In the case of the MIIS, the proposal acknowledges that a small administrative burden will be imposed, but that small business in Massachusetts would not be adversely impacted.

If you are a primary care physician or NP in Massachusetts, the proposed immunization regulation has potentially significant implications. It is another layer of documentation and it requires ready availability of computers that can access the MIIS. Additionally, the presence of a computerized record of all immunization activity at your office can now be easily analyzed and potentially tied to reimbursements. You might think it is a great idea, because it provides valuable population data for improvements in immunization rates. Either way, you might really care about this. 

What usually happens is that we practitioners cruise along doing our thing until suddenly the rules change. We grumble and moan about “government regulation” and then proceed to comply with the new rule. This happens over and over again, in all areas of health care. If enough people read a proposed regulation and submit their opinion, the politicians have to pay attention. In other words, we are not completely powerless. Drop by the registers once in a while. Have a say in how you practice.