Sir_Excellence

Unit 5: Week 5 - Chapter 10 Outline

CHAPTER TEN: EXTERNAL CONTROL OF LONG-TERM CARE

LEARNING OBJECTIVES

After completing this chapter, the reader will be able to

1.   Understand why there is need for external control of long-term care and the problems inherent in such control.

2.   Discuss the ways in which quality and cost are controlled and by whom.

3.   Identify and discuss the respective roles of federal and state governments in regulating long-term care.

4.   Understand which individual long-term care practitioners are subject to specific controls and by whom.

5.   Identify and define nongovernment controls, such as accreditation and certification.

CHAPTER HIGHLIGHTS

Introduction - external controls can be divided into two categories: public and private.

·         Public controls result from passage of laws. They are non-voluntary and are imposed by government agencies.

·         Private controls are provided by nongovernment agencies and organizations, and compliance is voluntary.

Public (Government) Control Mechanisms - includes regulation of long-term care providers and licensure of individuals working in the field.

Regulation

·         Regulations vary from laws primarily in their specificity.

·         A legislative body enacts a law, and an agency enacts regulations to implement that law.

Who Regulates and Why

·         Regulations are imposed by a government unit, federal, state, or local (including county and municipal), because of the responsibility of that unit to protect the welfare of the public, particularly those that the government judges to be unable to protect themselves.

·         This protection covers two primary areas: quality and payment.

·         Long-term care has a great deal of regulation, more than many other fields of endeavor. There are several reasons for the relatively heavy regulation of long-term care

Regulation of Quality

·         Ensuring quality of care is the primary reason for regulation of long-term care.

Defining and Measuring Quality  

·         Quality of care is subjective, including both technical and personal components, and varying from individual to individual and situation to situation.

·         Most measures of quality fall into three categories: process, structure, and outcomes.

Who Should Measure Quality?

·         Historically, most quality measurement has been external, in the form of mandatory licensure surveys and reimbursement-driven regulations.

Types of Quality Regulations  

·         Most regulation of quality of care in long-term care organizations originates at the federal level.

·         Medicare and Medicaid account for a large proportion of federal regulations dealing with quality of care.

·         The primary role of state government in regulating long-term care quality is as the designated agency administering federal programs.

·         Municipal or county, agencies also have an interest in ensuring the quality of care received by consumers of long-term care and are usually represented by health departments.

Regulation of Payment

·         Nearly as much attention is given to avoiding excessive payments, saving money for government agencies, and preventing fraud and abuse in government funding programs as is given to protecting quality.

·         Medicare and Medicaid are the preeminent sources of regulations when it comes to controlling payment for long-term care.

·         Government agencies regulate payment by channeling it from provider groups that they see as high-expense to those who are less costly.

Health Insurance Portability and Accountability Act - the purposes of HIPAA are threefold:

·         To provide consumers with greater access to health care insurance,

·         To protect the privacy of health care data,

·         To promote more standardization and efficiency in the health care industry

Other Regulations – fall into two primary categories

·         Regulations protecting employees

·         Regulations protecting the environment

Licensure of Individuals

·         Are licensed by the states rather than by the federal government.

Health Care Professionals

·         Are licensed to practice (in most cases) throughout the continuum of care, not just in long-term care.

Practitioners Specific to Long-Term Care  

·         Certified Nursing Assistants – not licensed, but certified.

·         Long-Term Care Administrators – nursing facility administrators (and increasingly assisted living administrators) must be licensed by the state(s) in which they work.

Efforts to Resolve the Confusion over Licensure

·         There has been significant progress toward increasing the uniformity of state licensing regulations, removing some of the confusion, duplication, and fragmentation.

·         In some cases, it is also making them more strenuous.

·         This progress has primarily been the result of efforts by several organizations, including both government and private, federal and state.

Regulation: Pros and Cons

·         Regulation of long-term care has its supporters and its critics.

·         Those who favor regulation cite the need to protect consumers from historic abuses and from excessive costs.

·         Critics argue that the current system of regulation is ineffective.

Problems Associated with Uncoordinated Regulations

·         They have been created at many different times, by many different agencies, for many different purposes.

·         One regulation may conflict with another.

·         There is need for coordination.

Finding a Happy Medium

·         It is an extremely complicated and difficult issue that does not lend itself to quick fixes.

Policy Issues - there are several policy issues relating to regulation, including:

·         Need for a balance between regulation and innovation 

·         Shifting the focus to the consumer – a good thing?

·         Management of care – who should be the gatekeeper?

Private Control Mechanisms - there are several private organizations involved with controlling providers of long-term care

·         Accreditation

·         Joint Commission

·         CARF International

·         Private Certification

·         There are numerous private organizations involved in certifying the competency of individual health care professionals and practitioners.

·         They measure against standards set well above minimum acceptability.

·         They ensure that certified professionals are competent in their areas of specialization and are well-qualified to practice their professions

LECTURE OUTLINE

A.  Identify learning objectives for the session

B.  Introduce the lecture topic

C.  Public (Government) Control Mechanisms: Identify and discuss public (government) control mechanisms, including which government agencies regulate long-term care providers and why.

D.  Quality Regulation: Briefly discuss the issues pertaining to government regulation of quality. [The topic will be discussed in more detail in Chapter 12.]:

      1.   Who regulates quality and why?

2.   How is quality defined and measured?

            a.   Process measurements

            b.   Structure measurements

            c.   Outcomes measurements

3.   What are the different types of quality regulation?

            a.   Federal

            b.   State

            c.   Local

E.   Regulation of Payment: Briefly discuss the forms of payment regulation [the topic will be covered in detail in chapter 11.]

F.   HIPAA. Discuss the Health Insurance Portability and Accountability Act (HIPAA) and its influence on long-term care:

a.       Consumer access to health insurance

b.      Protecting the privacy of health care data

c.       Promoting standardization and efficiency

G.  Other Regulations: Discuss the fact that long-term care providers are also subject to many regulations that do not pertain only to long-term care.

H.  Regulation (Licensure) of Individuals: Identify and discuss which individuals working in long-term care are licensed or certified:

      1.   Health care professionals in general

      2.   Practitioners specific to long-term care

      3.   Long-term care administrators

I.    Confusion Over Licensure: Discuss the efforts of various groups to resolve some of the confusion and fragmentation surrounding licensure:

      1.   NAB

      2.   Pew Commission

      3.   States

J.    Regulation Pros & Cons. Discuss the pros and cons of long-term care regulation, including identifying and resolving problems associated with uncoordinated regulations.

K.  Policy Issues. Discuss policy issues concerning government regulation:

      1.   Balance between regulation and innovation

      2.   Shifting the focus to the consumer

      3.   Management of care

L.   Private (Nongovernment) Control Mechanisms: Discuss accreditation and certification as control mechanisms.

M.  Accreditation:

1.   Identify the major accreditation agencies:

            a.   Joint Commission

            b.   CARF International

            c.   Others

2.   Explain the difference between facility licensure and accreditation.

N.  Certification of Individuals

      1.   Discuss the types of agencies that certify individuals.

      2.   Explain the difference between individual licensure and certification.

O. Summarize the discussion, recapping the key points

 

VOCABULARY TERMS

Accreditation - the granting of approval to a health care provider by a private review organization after it has met specific standards.

American College of Health Care Administrators (ACHCA) - professional organization representing long-term care administrators.

CARF International - an organization that accredits rehabilitation and human services providers.

Centers for Medicare & Medicaid Services (CMS) - The government agency overseeing operation of the Medicare and Medicaid programs - formerly the Health Care Financing Administration.

Certification - a term usually used to indicate that a professional has met a standard of performance capability.

Code of ethics - a set of standards determining ethical behavior, such as the Code of Ethics of ACHCA.

Deemed status - provision in Medicare regulations stating that provider entities accredited by CMS-approved accrediting organizations are deemed to be in compliance with Medicare conditions for coverage.

Domains of practice - determined by NAB to be areas of knowledge or skill required of long-term care administrators; including: resident care and quality of life, human resources, finance, physical environment and atmosphere, and leadership and management.

Endorsement - the process by which one state licensing jurisdiction accepts a license from another jurisdiction.

Equal Employment Opportunity Commission (EEOC) - federal agency that monitors employment to prevent discrimination.

External controls - control over an organization by outside agencies or organizations, usually involving regulation.

Gatekeeper - term used to describe the person or organization that directs a consumer to particular kinds/types of care.

Health Care Financing Administration (HCFA) - former name for the Centers for Medicare and Medicaid Services (CMS).

Health Insurance Portability and Accountability Act of 1996 (HIPAA) - designed to provide consumers with greater access to healthcare insurance, to protect the privacy of healthcare data, and to promote more standardization and efficiency in the healthcare industry.

Joint Commission - an organization providing voluntary accreditation for health care providers.

Law -set of rules or principles passed by an elected body, dealing with a specific area of a legal system.

Legislation - a single law or collection of laws.

Licensure - the process whereby a government jurisdiction assures that individuals or organizations meet minimally acceptable levels of qualification.

National Association of Long-Term Care Administrator Boards (NAB)  - national organization that assists state jurisdictions in the licensing of nursing home administrators.

National Committee on Quality Assurance (NCQA) - organization that accredits managed care organizations.

Occupational Safety and Health Administration (OSHA) - federal agency that monitors employee safety and health conditions in business and industry.

Omnibus Budget Reconciliation Act (OBRA) - Also known as the 1987 Nursing Home Reform Act, it established stringent new rules for nursing facilities.

Patient Self-Determination Act - 1990 act requiring health care providers to inform all consumers of their right to participate in care decisions.

Pew Commission - the commission that issued a report outlining a series of recommendations for improving the existing regulatory system.

Private controls - external control of long-term care providers by organizations that are not government-based.

Public controls - external control of long-term care providers by government agencies.

Quality assurance (QA) A quality control mechanism mandated by Medicare, based on an institutional committee whose duties include monitoring quality, quantity, and necessity of services provided and recommending changes in policies or procedures.

Regulation - government rule created for the implementation of a law.

Social Security Act (SS) - passed in 1935, this act created a social/financial safety net for Americans without adequate resources to care for themselves, primarily providing income for elderly and retired individuals.

Voluntary - acting willingly, as opposed to regulatory mandates.