Chapter 10. External Control of Long-Term Care Long-Term Care: Managing Across the Continuum (Second Edition)

Learning Objectives Understand why there is need for external control and inherent problems Discuss ways in which quality and cost are controlled, and by whom Identify and discuss the respective roles of federal and state governments Understand which individual practitioners are subject to control, and by whom Identify and define nongovernment controls, such as accreditation and certification

Government Regulation of Providers Regulation of quality Regulation of payment (cost)

Government Regulation of Quality Quality measurements: Process measures Structure measures Outcomes measures

Who Regulates? Federal government State government Local government

Government Regulation of Payment “Reasonable costs” Prospective payment system (PPS) Channeling funds to come types of providers to influence service delivery patterns

HIPAA Health Insurance Portability and Accountability Act: Consumer access to health insurance Privacy of health care data Standardization and efficiency

Other Regulations Employee protection (EEOC, OSHA, FLSA) Life safety Tax codes

Government Licensure of Individuals Health care professionals (MD, RN) Long-term care practitioners (CNA) Long-term care administrators

Confusing Administrator Licensing Regulations Efforts to resolve the fragmentation and confusion: NAB Pew Commission State licensing boards

Pros and Cons of Regulation Need to protect consumers Their decisions not always rational They are vulnerable Access to services is inequitable Need to protect those who pay

Pros and Cons of Regulation Consumers can make good decisions if given good information Regulation lowers care to common level Regulations stifle innovation Regulations are confusing, contradictory

Problems with Uncoordinated Regulations Created at different times, by different entities Often conflict Reliant on documentation Expensive duplication of documentation

Policy Issues Balancing regulation and innovation Shifting focus to the consumer Management of care

Private Control Mechanisms: Accreditation Voluntary JCAHO, CARF, NCQA Measure against optimal standards, not minimally-acceptable levels Give provider prestige, stamp of approval

Certification of Individuals Comparable to accreditation of organizations Professionals, administrators Certified by professional organizations Gives prestige, proof of competency

In Summary: Long-term care provider organizations and staff are regulated by various government agencies, and may also be accredited or certified by private organizations. Regulations are necessary, but are often fragmented and uncoordinated, causing problems for both providers and consumers.