Abstract
Policy studies are a recent addition to the American Physical Therapy Association's Research Agenda and are critical to our understanding of various federal, state, local, and organizational policies on the provision of physical therapist services across the continuum of care. Policy analyses that help to advance the profession's various policy agendas will require relevant theoretical frameworks to be credible. The purpose of this perspective article is to: (1) demonstrate the use of a policy-making theory as an analytical framework in a policy analysis and (2) discuss how sound policy analysis can assist physical therapists in becoming more effective change agents, policy advocates, and partners with other relevant stakeholder groups. An exploratory study of state agency policy responses to address work-related musculoskeletal disorders is provided as a contemporary example to illustrate key points and to demonstrate the importance of selecting a relevant analytical framework based on the context of the policy issue under investigation.
Policy analyses1–3 are a welcome addition to the physical therapy literature. Such analyses are critical to advance our understanding of the impact of various federal, state, local, and organizational policies on the provision of physical therapist services across the continuum of care and to advance the profession's various policy agendas. However, the field of policy analysis has only recently been added to the American Physical Therapy Association's (APTA) Research Agenda.4 Physical therapists are likely to have received minimal training in policy analysis and may be largely unfamiliar with its implications for practice and professional advocacy. For the purpose of this article, policy is broadly defined as the federal or state government's action to a given societal problem. Legislative bodies create policy in the form of acts, laws, and statutes (eg, the state practice acts in physical therapy). The legislature may direct various governmental administrative agencies to create policy in the form of regulations, rules, or administrative codes that hold the force of law. These agencies also may generate rules based on their interpretation of statutes (eg, rules created by some state boards of physical therapy without specific direction by the legislature).
The translation and application of the rich and extensive literature on theories of policy making and methods for policy analysis to physical therapy is still in its infancy. At the same time, the evaluation of policy implementation, the development of systems models to explain the multiple factors that influence policy making, and the advancement of knowledge within specific policy arenas are redefining the field of policy analysis.5 Although consensus regarding best practice remains elusive, there appears to be little disagreement that policy analysis is complex. Moreover, there is growing recognition that analytical approaches are situational and require an understanding of the context within which the analysis is conducted.5
A key element of a credible policy analysis involves the use of an analytical framework grounded in one or more theories and models of policy making. These frameworks help to identify and interpret the relationship between key variables relevant to the policy issue of interest. The purpose of this perspective is to introduce the physical therapy community to the value and relevance of policy analysis to the profession by: (1) demonstrating the use of a policy-making theory as an analytical framework for a policy analysis, and (2) discussing how sound policy analysis can assist physical therapists in becoming more effective change agents, policy advocates, and partners with other relevant stakeholder groups in the evolving health services delivery environment. More detail about the policy analysis example used in this article is provided in eTables 1–9 and the eAppendix.
Overview of Public Policy Making and Definition of Terms
A review of the theories of public policy making is beyond the scope of this article. The reader is referred to some introductory, yet comprehensive, resources on this topic.6–8 Policy-making theories are similar to how we view various theories and schools of thought that form the foundation of physical therapist practice (eg, various theories of motor control). The theories are not necessarily contradictory; rather, each is incomplete in explaining the experiences of policy stakeholders. Just as the theoretical basis for clinical practice is based on a combination of elements from multiple theories, so, too, is our contemporary understanding of policy making.
Regulatory policy making is particularly relevant to the provision of physical therapist services across the continuum of care. Policy scholars make a distinction between economic regulation (competitive regulatory policy) to ensure proper functioning of markets and social regulation (protective regulatory policy) that addresses information transparency and the negative consequences of production or service delivery.7 Physician self-referral laws, commonly known as the “Stark Laws,”9 and the annual Medicare reimbursement cap on the provision of rehabilitation services10 exemplify the concept of competitive regulatory policy. The language in various state practice acts and related rules regarding access to physical therapist services11 demonstrate the concept of protective regulatory policy. Another contemporary example of protective regulatory policy is regulation affecting the use of dry needling by physical therapists.12
There are 3 general types of state and federal agency policy responses: regulation, incentives, and outreach or consultation to promote voluntary self-regulation. Examples of regulatory policy responses were provided above. In this article, the use of incentives and outreach or consultation will be referred to as nonregulatory policy responses. Medicare's Physician Quality Reporting System is a contemporary example of the use of incentives and educational outreach to promote voluntary self-regulation.13 This is also an illustrative example of a combined incentive or “carrot” approach (a positive payment adjustment for participation) and a “stick” approach (payment penalty for nonparticipation).
“Federalism” is a term used to describe shared power in policy making and policy implementation involving various levels of government.6,8 The Medicaid program is a common example of federalism involving the states and federal government, and the current debates about Medicaid expansion across the United States highlight the tensions that often arise in such a shared governance model.
Policy Analysis Example: State Agency Policy Responses to Prevent Work-Related Musculoskeletal Disorders
Work-related musculoskeletal disorders (WMSDs) represent one of the largest and most costly groups of work-related illnesses in the United States,14 and the implementation of government regulations to prevent these injuries has been highly contentious. In 2000, the Clinton administration promulgated a comprehensive federal ergonomics standard that included specific requirements for public and private companies to address identified risk factors in the workplace. However, the Bush administration repealed this standard in 2001 and replaced it with a plan promoting voluntary action by employers.
States also play a visible and important role in occupational safety and health. The Occupational Safety and Health Act (OSH Act) of 1970 provided states with a mechanism to administer their own occupational and health consultation programs and to enact standards (including those that target the prevention of WMSDs) that are stricter than those in effect at the federal level.15 In these types of arrangements, state agencies are often dependent on federal appropriations to carry out program delivery.16
Selection of a Relevant Analytical Framework
Lowry's Dimensions of Federalism model17 provided a relevant analytical lens to explore the influences on state policy responses to prevent WMSDs.18 Although this model was originally applied to the environmental pollution control policy arena, there are several relevant parallels to the occupational safety and health policy arena:
The framework includes a focus on federalism. At the time the example study was conducted, 27 states had federally approved occupational safety and health programs.
The framework includes an important focus on the potential influence of interstate competition for economic development on state policy responses. At the time of the study, some states were seen as reluctant to enact regulations to prevent WMSDs for fear it would create a competitive disadvantage in attracting business compared with states with no or less stringent regulations.
The framework incorporates variables that have been identified in other studies as influencing state policy making, including interest group pressures, political culture, state resources, and federal aid. The potential to develop WMSDs exists in virtually all workplace settings, and attempts to prevent these problems through regulation drew widespread opposition from business interest groups. Political party control and the ideological differences between Democrats and Republicans also were seen as potential influences on policy responses to prevent WMSDs. More affluent states, as determined by per capita income, and policy arenas involving high levels of federal aid to states were hypothesized to lead to more robust policy responses to prevent WMSDs.
The model starts with the premise that there is a direct relationship between problem severity and state policy response (Fig. 1). Lowry17 was particularly interested in leadership (state-level experimentation, innovation, and policy development) that was more stringent than or exceeded that of the federal government (ie, state regulatory response). Lowry found that the strength of this relationship was influenced by several variables, the most notable of which were the level of federal involvement (ie, level of regulatory policy making) and level of interstate competition for business. In cases where federal involvement was low and interstate competition was high, Lowry found little correlation between problem severity and policy response. I have characterized this variable as having an inhibitory influence on the relationship. Conversely, when federal involvement was high and interstate competition low, there was a strong correlation between problem severity and policy response. I have characterized this variable as having a facilitating influence on the relationship. Finally, in cases where federal involvement and interstate competition were either both high or low, other variables, such as interest group pressure, state resources, level of federal aid, and political culture, became more influential in predicting state policy response. Lowry also found that high federal involvement enhanced communication and coordination of policy adoption and implementation across states, with the federal government using state exemplars to effect change in other states. Conversely, Lowry observed that when federal involvement was low, there was little spread of policy adoption across states.
My representation of the Lowry framework.18 An assumption is made that there is some relationship between problem severity and state regulatory policy response and that it is significantly affected by the tension between federal involvement and interstate competition. In cases where the influences of federal involvement and interstate competition cancel out each other, other variables take on greater importance in determining the strength of the relationship between policy need and policy responses. F=facilitating influence, I=inhibitory influence.
To more clearly fit the WMSD context, 4 modifications to Lowry's model were made based on a review of literature from the occupational safety and health policy arena (Fig. 2)19–26:
The conceptualization of problem severity was changed to perceived policy need. Perceived policy need is certainly influenced by problem severity; however, the understanding of problem severity is often incomplete. Moreover, perceived policy need can be influenced by other factors, including agency and legislative agenda setting, complaints from the private or public sector, and so on.
The conceptualization of policy response was expanded to include nonregulatory policy responses. As noted above, government agencies often engage in educational outreach or develop incentive programs to encourage voluntary self-regulation to address occupational safety and health problems.
Workers' compensation (WC) was added as a variable in the model. Workers' compensation is a universally adopted state-run program that is unique to the occupational safety and health policy arena.
Additional changes to the modified analytical framework evolved through the data analysis phase of this study (see discussion below). Three additional variables were identified through the within-case analyses: agency resources, key personnel and organizational structure. See eTable 1 for study variable definitions.
Modified analytical framework. F=facilitating influence, I=inhibitory influence, Dem=Democrat, Rep=Republican.
Methods
A multiple case study methodology was used to explore state agency policy responses to prevent WMSDs in its real-life context.27,28 Understanding the phenomenon under investigation, in this case the influences on the relationship between policy need and state policy responses to prevent WMSDs, is a critical element of this methodology and often requires triangulation of different sources of data, as well as an understanding of the perspectives of various stakeholders associated with the phenomenon. The methodology provided a structure to: (1) study each case (state) separately; (2) analyze, interpret, and identify patterns within each case; and (3) analyze, interpret, and identify similar patterns, as well as differences, among the cases.27 Causation is conjectural in comparative case study research, as the methodology tends to work backward from the outcome (ie, state policy responses to address WMSDs) and explores antecedent conditions (ie, factors influencing those responses). However, conditions or influences shared by cases often help to identify the necessary combination of conditions needed to produce the outcome under investigation.
Four states were selected to participate in the study. These states met the criteria for case selection,27 including:
The relevance of the case to the phenomenon under investigation. The 4 states all developed policy responses to address WMSDs.
The diversity between the cases. Two of the states had federally approved state programs; 2 states did not. Each state adopted or attempted to adopt different types of legislation or rules to prevent WMSDs, and the policies were developed at different times in the context of federal policy responses to address WMSDs.
The opportunities to learn about complexity and contexts. These states provided a rich opportunity to explore and compare the influences on their respective policy responses.
These states were also all exceptional in the context of their unique policy responses to prevent WMSDs or in their historical significance29 (Table).
Diversity in Federally Approved State Plans and Legislation or Rules Addressing Work-Related Musculoskeletal Disorders (WMSDs) in Sample States
A temporal dimension (1985–2009) was integrated into the analytical framework to capture the time period before and after the federal ergonomics regulation debate. The period was divided into 3 blocks:
1985–1989: Time period preceding the public debate and promulgation of the federal ergonomics rule.
1990–2000: Time period capturing high federal regulatory attention on ergonomics.
2001–2009: Time period following repeal of federal ergonomics rule.
The variation in federal involvement over this time period helped to operationalize high versus low federal involvement in the model.
The primary data for this study were derived from semistructured interviews with state agency personnel (or retirees) with oversight responsibilities for occupational safety and health programs and representatives from each state's chamber of commerce. A primary goal was to identify and recruit personnel (eTab. 2) with institutional memory over the time period under investigation, with a focus on gathering in-depth data from a small number of relevant sources.30
Additional data sources included (1) submitted or adopted bills regarding WMSDs; (2) historical records of political party dominance in the respective state legislature and governor's office and presidential election results; (3) state agency website information and documents, such as annual reports, that included information about WMSDs; (4) annual state per capita income; (5) annual incidence rate data for WMSDs; (6) compensable WC claims data related to WMSDs; and (7) the annual State by State Guide to Workplace Safety Regulation and Occupational Safety and Health Administration (OSHA) State Plan Association's Grassroots Worker Protection Reports.
Interviews were audiotaped and transcribed at a later date. Data were analyzed using standard qualitative approaches30,31 to identify similarities and differences among states. Data reduction involved the use of verbal memos, field notes, and summary forms to organize the data (eAppendix). Within-case tables identified the relevant sources of data associated with each variable by time period (eTab. 3). Interview transcripts and documents were coded using the list of defined variables. For example, interviewee comments about the federal ergonomics rulemaking initiative were highlighted and coded as Federal Involvement (FI). Another researcher with experience in qualitative methods completed independent coding of interview transcripts from one state agency to validate the coding scheme. Content validation of the coding scheme also was supported by numerous reviews of the interview quotes by 3 other social science researchers. Following the validation of the coding scheme, I then coded the remaining interview transcripts.
This initial coding work led to the discovery of relevant comments that were not assigned to the prespecified variables of interest and the creation of 3 additional variables, as mentioned above. Agency resources appeared to be an important influence on state policy responses. As one source of agency resources, federal aid was eliminated as a stand-alone variable and encompassed under this new variable. The following quote illustrates how interviewer responses led to the creation of the agency resources variable:
When the rule came about, there was a big shift [emphasis added]—a big push of resources into ergonomics that we'd never really seen in this agency before. We hired more ergonomists because there was going to be a lot more work…. Most of the new people we hired went into the training and outreach group to develop the education materials, so that was a lot of what the focus was.
The second new variable was key personnel. The following quote exemplifies the importance of this variable to the model:
The department was blessed with some very talented people that could do this sort of thing. I am not sure there are many state agencies of occupational safety and health that could do something like this. We were just fortunate to have a group of people who were very bright and understood the issues and were also very pragmatic.
The third new variable was organizational structure. Certain organizational structures appeared to either facilitate or inhibit policy responses. The following quote highlights the importance of this variable in the model:
The fact that you have at the table ensuring the implementation—the hospital association, a number of representatives from a whole bunch of different hospitals, SHARP [Safety & Health Assessment & Research for Prevention], the 3 unions that are involved in health care—all working together to make sure that this thing actually works. It's really quite remarkable. It's turned out to be a model for other ventures.
These variables, in turn, were added to the modified analytical framework. The electronic and paper documents were then coded using the revised list of variables in the model.
A second level of coding was performed to assign federal involvement and interstate competition as high or low over the time period of this study. A third level of coding was then conducted to classify whether each of the variables had a facilitating, inhibitory, or neutral (neither facilitating nor inhibitory) influence on the relationship between perceived policy need and policy responses during each of these time blocks for each state. One interviewee observed:
I think that the federal effort [1990s], frankly, kind of hurt the state…so that anti-forces gelled at the federal level to fight that…we never could get it [the state rule] detached [from the federal rulemaking initiative]…you saw some of the familiar faces from the DC anti-ergo coalition and from some of the significant anti-OSHA litigation.
This and similar statements helped to support coding federal involvement during this time period as having an inhibitory influence on the state's regulatory policy response.
For each state, a time line was created to represent the temporal relationship between the federal and state regulatory and nonregulatory policy responses from 1985 through 2009 (eTab. 4). The influences of the other variables were then analyzed in the context of this time line. Various within-case displays were created to organize and visually represent the data and enable conclusion drawing and verification. These displays included the contact and document summary forms, field notes, and data source tables described above (eTab. 3, eAppendix), as well as various matrices (eTab. 5) and tables (eTabs. 6 and 7) to assess the influence of the variables (facilitating, inhibitory, or neutral) on the respective state policy responses.
The purpose of the cross-case analysis was 2-fold. First, comparisons were made between the findings of the within-case analyses.27 The focus of these comparisons was to identify similarities (themes and patterns) and differences across the cases, an analytic strategy known as pattern clarification.30 The second purpose of the cross-case analysis was to assess the application of the modified analytical framework in this study. This assessment involved comparing and contrasting the modified Lowry framework17 with the framework that was supported by the empirical data.
Conclusion drawing and verification were iterative processes, as is typical for this type of study. The identification of new variables, patterns, or themes in the data led to the final propositions about the influences on state policy responses to prevent WMSDs, a process known as logical analysis.32 Because this example was an exploratory study of 4 states, the focus of conclusion drawing was to provide plausible explanations for the observed state policy responses and a rationale for the proposed modifications to the Lowry framework17 as an analytical tool for future studies of policy making in a federalism model (Fig. 3).
The final model. FI=federal involvement, IC=interstate competition, IG=employer interest groups, PC=political culture, AR=agency resources, WC=workers' compensation, KP=key personnel, OS=organizational structure, F=facilitating influence, N=neutral (neither facilitating nor inhibitory influence), I=inhibitory influence, U=unclear influence. WMSD=work-related musculoskeletal disorder.
Findings
The results of the cross-case analysis revealed that the strength of the relationship between perceived policy need and regulatory and nonregulatory policy responses to prevent WMSDs was moderated by a complex interaction of several variables, and the nature of these influences was found to be highly contextual (eTabs. 8 and 9).
The results of the cross-case analysis supported the inclusion of perceived policy need in the modified framework. Several factors were found to inform perceived need across the states, including complaint data reported by employees through field consultation or inspection staff, national injury and illness data, agency leadership preferences, and the legislature (Fig. 3). Given these realities, the distinction between perception of policy need and policy need based on actual problem severity is a subtle but important one. This finding is consistent with many policy arenas, where accurate measures of problem severity do not exist, and perception of need is based on several inputs. An illustrative parallel in physical therapy is the difficulty in aggregating valid data about truncated services within a state or across the country related to the Medicare financial cap. Legislative agenda setting and directives also were seen in 2 states, where perceived need drove agencies to seek objective data on problem severity. This is reflected as a bidirectional arrow in the final model (Fig. 3).
Another important finding was that several variables had different influences from those proposed in the modified Lowry framework.17 Perhaps the most important of these variables was the influence of federal involvement. The results of this study suggest that high federal involvement can actually have an inhibitory influence on state policy responses as exemplified in the quote above about the federal effort in the 1990s. Moreover, low federal involvement did not necessarily lead to weaker state policy responses.
The distinction between regulatory and nonregulatory policy responses also revealed that some variables can inhibit one type of policy response while facilitating another. An example of this phenomenon was the influence of some employer interest groups, who generally exerted an inhibitory effect on regulatory responses but created demand for consultation and educational outreach services at the same time. This distinction is also important because the results of this study suggest that one form of policy response may actually influence another, as exemplified by the following comment:
The department and the state OSHA program…really had in place by the middle of the 90s virtually all of the things that could be done other than having a specific ergonomics rule in place…so there were ergonomists on staff, there were technical people who could provide technical assistance and advice to employers, there were publications, there were workshops…all of the tools available to the department to encourage employers to voluntarily use ergonomics to reduce musculoskeletal injuries were in place. We felt we had done everything conceivable [emphasis added] other than a rule, and while that was all necessary, it was not sufficient.
The bidirectional influence between the forms of policy response also is reflected in the final model.
No clear pattern of influence was found with some variables (ie, state resources and political culture) as defined in this study. Although political culture exerted no clear influence on state policy responses in this study, other policy debates (eg, those surrounding the Affordable Care Act) clearly suggest political party differences affect policy response. Therefore, political culture was left as a moderating variable in the final model. Financial support was an important influence in the model that was made more apparent by creating the state agency resources variable and incorporating federal aid as one source of agency funding support.
In summary, the results of this study supported the additional changes to the modified Lowry framework17 (Fig. 3). This study added new insights into: (1) the factors that inform perceived policy need, (2) the important distinction between regulatory and nonregulatory responses, and (3) opportunities to improve the strength of state policy responses. This study also set the stage for testing the model through more empirical methods in the future.
Implications
The effectiveness of our federal system of government remains a topic of popular and scholarly inquiry.33–35 The argument that states will create the least burdensome policies possible to avoid negative competitive economic consequences (“race to the bottom” argument) is based on the premise that states are too susceptible to various sub-national influences. Without strict federal control and oversight, policy responses will be weaker and misaligned with federal intent. Conversely, some scholars suggest universal policy responses at the federal level typically fail because they do not take into account local context, but instead support the states as “laboratories of democracy” for policy development and implementation.6
This study was situated in a policy arena that involved varying degrees of federal-state interaction. The role that states play in the occupational safety and health policy arena is no less important today than when the OSH Act was enacted in 1970. This role may become more important as increasing financial pressures on all levels of government potentially threaten coordinated regulatory and nonregulatory policy responses. Moreover, the results support several modifications to the Lowry model17 that enhance our understanding of state policy responsiveness.
The study enhances physical therapists' understanding of: (1) the importance of the states in policy arenas involving federal-state partnerships, (2) the variety of potential state regulatory and nonregulatory policy responses, and (3) the various facilitating and inhibitory influences on the development of various state policy responses. It provides critical contextual information that can assist physical therapists in becoming more effective advocates, change agents, and partners with state agencies in the occupational safety and health policy arena. There are opportunities for enhanced collaboration between physical therapists and state agencies in the development, implementation, and evaluation of regulatory and nonregulatory policy responses designed to prevent or decrease the risk of incurring one of these serious workplace disorders. This is arguably an underdeveloped area of physical therapist practice to date. The interviewees in this study consistently viewed both regulatory and nonregulatory policy approaches as necessary to address workplace safety and health problems. It was evident that the state agencies in all 4 states were devoting at least some resources toward nonregulatory policy (consultation and education) initiatives. Moreover, regulation was found to prompt a great deal of nonregulatory consultation activity to help employers with their compliance efforts. These responses are highly congruent with the physical therapist's expertise in ergonomics and injury prevention and may provide new opportunities for therapists in this area of practice.
The interviews in all 4 states revealed a very limited to nonexistent understanding of the physical therapist's role in the prevention of WMSDs. It is my experience that, in 2015, the physical therapy profession still struggles with a major public relations problem. Although physical therapists are somewhat visible to federal legislators due to APTA's federal advocacy efforts, I believe we are still relatively unknown at the state level, certainly within relevant agencies such as the respective state departments of occupational safety and health or public health. I would argue that, even with stakeholders who know something about physical therapy, there is a very narrow understanding of the scope of physical therapist practice in the arena of disease and injury prevention and health promotion.
The model discussed in this article has particular relevance to the policy debates around safe patient handling. This topic has gained a great deal of recent attention from the federal government and numerous state governments.36 Physical therapy researchers could test the applicability of the model in this policy arena. Physical therapists can use this model in the development of advocacy strategies to shape potential policy responses at both state and federal levels. Physical therapists are also potential providers of services resulting from any regulatory or nonregulatory policy responses developed to prevent injuries associated with patient handling and have tremendous potential to become partners with federal or state agencies in policy implementation.
The ongoing implementation of the Affordable Care Act also should provide physical therapists with more opportunities to become partners with others who seek to change our health care system from one that is “disease focused” to one that is “health focused.” The current focus on access to care for all citizens, as well as the focus on prevention and community-based care models, will only increase in importance. It also is likely that states will continue to be major players in ongoing policy implementation. Physical therapists have a unique opportunity to be part of this historic change in health care delivery. If we are to realize the profession's collective potential in this arena, the critical first step is to educate state and federal agency staff and legislators about the physical therapist's expertise in disease and injury prevention and health promotion.
Summary
Policy analyses are emerging as an important area of scholarly inquiry in the physical therapy literature. The need for both researchers to conduct sound policy analyses and for other stakeholders to interpret these studies is critical to advance both this research agenda and various professional advocacy initiatives. The example in this perspective article demonstrated the use of a policy-making theory as an analytical framework in a policy analysis. The study adds to the limited scholarship on state policy making in areas where federal and state governments share responsibility for policy responses. The study also provides physical therapists seeking to influence policy development or participate in policy implementation with a different lens and understanding of this complex landscape.
The broader implications of this study are related to the importance of identifying and applying a relevant analytical framework. Although the example was from an exploratory qualitative case study, the selection of an appropriate analytical framework is equally important in larger quantitative studies designed for the purpose of generating generalizable knowledge. It is my hope that this article will serve as a foundational resource for future health policy researchers, educators in their training of future physical therapists, and clinicians in their advocacy efforts.
Footnotes
I thank the Section on Health Policy and Administration of the American Physical Therapy Association (APTA) for the grant that supported the data collection phase of the example study and the APTA Section on Education for the Adopt-A-Doc Scholarship that supported the data analysis phase of this study.
- Received January 16, 2015.
- Accepted October 4, 2015.
- © 2016 American Physical Therapy Association
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