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

2. 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

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

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

5. Who Regulates?
Federal government
State government
Local government

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

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

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

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

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

11. 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

12. 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

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

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

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

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

17. 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.