An Ecological Model for Health Policy Review: The Integration of New Institutional and Public Choice Theory for Public Policy Assessment

Designed as a qualitative multiple-case evaluation, this study assessed the nature of policy congruence in health care organizations by evaluating the relationship of policy implementation strategies in these organizations with policy objectives contained in legislative enactments. The Program of All-Inclusive Care for the Elderly (PACE) was the conduit for this study, and research emphasis focused on how PACE programs attempt to implement policy objectives engrossed in the Patient Protection and Affordable Care Act of 2010 (ACA), even when not specifically required to do so. The problem identified has been that questions of policy consistency with the ACA continue to permeate the discussions surrounding PACE, and its utility as an alternative elder care initiative as contrasted against those concepts promoted in the ACA. The purpose of this research project was to advance theory and the application of theory in policy analysis. No review of PACE had been conducted through a theoretical perspective, and the theories of public choice and new institutionalism served as the theoretical framework which guided this study. Phone interviews of twelve PACE managers were conducted to ascertain organizational response to policies promoted in the ACA. Observational research was conducted at three PACE locations where high levels of policy congruence with the ACA were detected. This was complemented with public record document review which served to triangulate the research project. The study's key finding is that uncertainty in markets where PACE is located has led most PACE programs to reflect characteristics of mimetic isomorphism. Furthermore, the ACA can be seen as subtly coercive in that regard, whereby PACE managers migrate PACE towards policies promoted in the ACA, and attempt to attain institutional legitimacy through mimetic behavior, which leads to more homogenous health care organizations. This study confirms the utility of public choice theory and new institutional theory in the investigation of public policy, and organizational strategies associated with public policy implementation. Evaluating PACE through public choice and new institutional theory expands the understanding of these theories, and their applicability and utility in evaluating the linkage between the policy theory, promulgation, and implementation processes, and thus, consequent effective governance strategies.