背景:无数的联邦,state,和组织政策旨在改善基于证据的医疗保健,但是这些政策的影响可能会有所不同,重新解释,以及在整个实施过程中对政策要求的遵守不力。加强执行和遵守政策意图的战略可以改善人口健康。严格评估实施卫生政策及其相关卫生服务的多层次环境对于设计有效的政策层面实施战略至关重要。加州通过了2019年的健康保险福利授权,要求为因医疗而有不孕风险的个人提供生育力保护服务。以改善对否则成本过高的服务的获取。我们的目标是记录和理解多层次的环境,关系,以及使用国家福利授权来促进患者获得生育保护服务的活动。
方法:我们进行了混合方法研究,并使用了政策优化的探索,准备,实施,和维持(EPIS)框架,以分析加利福尼亚州在州保险监管机构及其之间的生育力保护福利任务(SB600)的实施情况,保险公司,和临床水平。
结果:审查了17份可公开获得的生育力保护受益授权相关文件。采访了四家保险公司;25家财务公司,行政,来自16个肿瘤和生育诊所的提供者参与者;三名生育药物代表;和两名患者倡导者。授权和保险监管机构的指导意见代表了两个“大P”(系统级别)政策,这些政策导致了监管机构之间的一系列“小P”(组织)政策,保险公司,诊所,和病人。许多很少的p政策是支持各级实施和生育保护服务获取的桥梁因素。表征任务的功能(即,政策目标)和形式(即,制定政策的方式)导致确定(1)有意和无意的实施,服务,和患者的结果,(2)按层次和EPIS阶段的实施过程,(3)参与者划定的关键过程和它们之间的异质性,和(4)驱动适应的内部和外部上下文决定因素。
结论:在中下游实施州健康保险福利授权之后,生成的数据将有助于制定政策层面的实施战略,评估有效实施的决定因素和重要成果,以及未来任务的设计,以提高贴合性和保真度。
BACKGROUND: A myriad of federal, state, and organizational policies are designed to improve access to evidence-based healthcare, but the impact of these policies likely varies due to contextual determinants of, reinterpretations of, and poor compliance with policy requirements throughout implementation. Strategies enhancing implementation and compliance with policy intent can improve population health. Critically assessing the multi-level environments where health policies and their related health services are implemented is essential to designing effective policy-level implementation strategies. California passed a 2019 health insurance benefit mandate requiring coverage of fertility preservation services for individuals at risk of infertility due to medical treatments, in order to improve access to services that are otherwise cost prohibitive. Our objective was to document and understand the multi-level environment, relationships, and activities involved in using state benefit mandates to facilitate patient access to fertility preservation services.
METHODS: We conducted a mixed-methods study and used the policy-optimized exploration, preparation, implementation, and sustainment (EPIS) framework to analyze the implementation of California\'s fertility preservation benefit mandate (SB 600) at and between the state insurance regulator, insurer, and clinic levels.
RESULTS: Seventeen publicly available fertility preservation benefit mandate-relevant documents were reviewed. Interviews were conducted with four insurers; 25 financial, administrative, and provider participants from 16 oncology and fertility clinics; three fertility pharmaceutical representatives; and two patient advocates. The mandate and insurance regulator guidance represented two \"Big P\" (system level) policies that gave rise to a host of \"little p\" (organizational) policies by and between the regulator, insurers, clinics, and patients. Many little p policies were bridging factors to support implementation across levels and fertility preservation service access. Characterizing the mandate\'s functions (i.e., policy goals) and forms (i.e., ways that policies were enacted) led to identification of (1) intended and unintended implementation, service, and patient outcomes, (2) implementation processes by level and EPIS phase, (3) actor-delineated key processes and heterogeneity among them, and (4) inner and outer context determinants that drove adaptations.
CONCLUSIONS: Following the midstream and downstream implementation of a state health insurance benefit mandate, data generated will enable development of policy-level implementation strategies, evaluation of determinants and important outcomes of effective implementation, and design of future mandates to improve fit and fidelity.