Waiving or Changing Burdensome Regulatory Requirements

Regulations are rarely revised or deleted. However, they are frequently augmented. Whether it is the state legislature or Federal government making requirements of state bureaucrats or whether it is in response to a problem at a specific agency, we tend to change by adding regulations rather than modifying or eliminating old rules. Providers respond by adding to, not eliminating or changing paperwork. The outcome is a morass of burdensome paperwork that makes health care expensive, less responsive to individual client needs, and less able to adapt to improvements in care models or standards.

Many regulations provide the regulator with the ability to waive rules within certain parameters. Using waiver authority can allow a state or other regulator to pilot test potential changes to regulations prior to going through the full regulatory change process. A system-level Change Project to address regulatory burden might look like this:

• PLAN. After several treatment agency-level Change Projects, spend a learning collaborative session using the nominal group process to identify state-level changes that would reduce the regulatory burden. Some things that have been identified in other states include eliminating forms that don’t make sense anymore (paperwork), annual site visits for licensure or accreditation, laws that govern group size or lengths of stay, data reporting requirements or collection methodologies, and contracting processes and contract reporting requirements.

• DO. Identify a small group of providers from an existing learning collaborative for whom you feel comfortable waiving the requirement for a short period of time. Pilot test this change.

• STUDY. Measure the impact on provider goals (e.g., shortened waiting times or increased retention) and the impact at the state level. Does this change decrease the workload for state staff, for example? Measure any impact on the goal for which the regulation was created. For example, annual licensing reviews were probably created to ensure safety and likely arose out of a crisis. Are there criteria under which it is possible to have reviews every two or three years instead of annually? Are there other ways to document safe practices?

• ACT. If the elimination or change in a regulation improves the access or retention measure and does not create additional risk, then you can go through the regulatory process with confidence that you are making the right decision to change or eliminate a regulation.

Different rules have different levels of requirements for changing them. Some may require legislative action; others may be in the power of the Executive Sponsor to change. Whichever is the case, you will want to work closely with providers to identify truly burdensome regulations, ensure that they can be eliminated or changed safely, and work through the regulatory process when you are ready to permanently adopt the change.

Examples

Licensing and Accreditation

The state of Iowa, as part of its STAR-SI project, confronted and debunked myths about provider licensure standards.

• Myth: Licensure standards won’t allow paperless Release of Information forms.
  Reality: Yes, it is legal to scan release of information documentation into the data system; you don’t need the paper copy
• Myth: State will dock us if clients wait times to access treatment is too long.
  Reality: That is not correct: the state wants accurate data.
• Myth: Magellan (state managed care provider) will penalize providers for allowing client waits times greater than 20 days.
  Reality: Magellan’s response to this myth was: “It is important to serve the potential client as soon as possible, but there are no penalties.”

The Iowa Department of Public Health's Bureau of Administration, Licensure and Regulation was not meeting its goals of providing timely recertification of its provider agencies. As part of the STAR-SI initiative, Iowa developed a new process to more efficiently provide licensing to the provider organizations in the state. Read the full story for more information.

The state of Illinois identified the minimum components of initial screening, assessment, and client engagement and also allowed three rule exceptions to reduce the time between initial contact and the first treatment sessions.

• Section 2060.417 – Exception to the requirement for face-to-face assessment services. As a result, any portion of the assessment may be conducted by telephone or web-based camera.
• Section 2060.417© – Exception to the requirement for physician confirmation of the diagnosis and initial placement. This exception shall apply to patients without bio-medical problems identified in ASAM Dimension 1 or 2 intervention or patients identified in ASAM Dimension 3 requiring physician consultation regarding medication management or monitoring.
• Section 2060.421(b) – Exception to the requirement for physician confirmation of the initial treatment plan. This exception shall apply to patients without bio-medical problems identified in ASAM Dimension 1 or 2 that require medical or psychiatric intervention or patients identified in ASAM Dimension 3 requiring physician consultation regarding medication management or monitoring.

Read the full story for more information.

As part of the STAR-SI project, the state of Wisconsin provided variances for the participating STAR-SI providers. Providers were allowed to sign up for any one or more of the variances, including increasing counseling group size to 10, documenting the formal treatment plan by the end of the fifth visit, and using STAR-SI change projects as a substitute for program evaluation. Ninety-two percent (92 percent) of providers signed up for the group counseling size variance; 72 percent signed up for the treatment plan variance; and 88 percent signed up for the service evaluation variance. Read the full story for more information.

Contracting and Purchasing

The state of Maine moved to a performance-based contracting system with providers on July 1, 2007. Provider performance is now consistently measured in relation to access and retention standards. Providers are eligible for incentives as well as reduced levels of payment based on performance. The move to performance-based contracting is effectively spreading provider knowledge of and attention to access and retention issues statewide. Data indicate that agencies using process improvement perform better and are more likely to get incentives. OSA is working to extend access and retention performance contracting to all purchased services and all levels of care beginning July 1, 2009.

Additional Training

During a STAR-SI Learning Collaborative Session, Oklahoma providers identified the need for more American Society of Addiction Medicine (ASAM) Patient Placement Criteria and Addiction Severity Index (ASI). Substance abuse treatment contracts require treatment professionals to be trained in certain clinical instruments to conduct assessments. Staff cannot assess clients until they complete the appropriate trainings. By evaluating their methods and increasing the number of trainings in metropolitan areas, Oklahoma was able to have provider staff complete training 25 days sooner. Read the full story for more information.