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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

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chapter 10 external control of long term care

Chapter 10. External Control of Long-Term Care

Long-Term Care: Managing Across the Continuum

(Second Edition)

learning objectives
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
Government Regulation of Providers
  • Regulation of quality
  • Regulation of payment (cost)
government regulation of quality
Government Regulation of Quality
  • Quality measurements:
    • Process measures
    • Structure measures
    • Outcomes measures
who regulates
Who Regulates?
  • Federal government
  • State government
  • Local government
government regulation of payment
Government Regulation of Payment
  • “Reasonable costs”
  • Prospective payment system (PPS)
  • Channeling funds to come types of providers to influence service delivery patterns
hipaa
HIPAA
  • Health Insurance Portability and Accountability Act:
    • Consumer access to health insurance
    • Privacy of health care data
    • Standardization and efficiency
other regulations
Other Regulations
  • Employee protection (EEOC, OSHA, FLSA)
  • Life safety
  • Tax codes
government licensure of individuals
Government Licensure of Individuals
  • Health care professionals (MD, RN)
  • Long-term care practitioners (CNA)
  • Long-term care administrators
confusing administrator licensing regulations
Confusing Administrator Licensing Regulations
  • Efforts to resolve the fragmentation and confusion:
    • NAB
    • Pew Commission
    • State licensing boards
pros and cons of regulation
Pros and Cons of Regulation
  • Pros:
    • 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 regulation12
Pros and Cons of Regulation
  • Cons:
    • 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
Problems with Uncoordinated Regulations
  • Created at different times, by different entities
  • Often conflict
  • Reliant on documentation
  • Expensive duplication of documentation
policy issues
Policy Issues
  • Balancing regulation and innovation
  • Shifting focus to the consumer
  • Management of care
private control mechanisms accreditation
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
Certification of Individuals
  • Comparable to accreditation of organizations
  • Professionals, administrators
  • Certified by professional organizations
  • Gives prestige, proof of competency
in summary
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.
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