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Chapter 10. External Control
of Long-Term Care
Long-Term Care: Managing
Across the Continuum
(Second Edition)
1
Learning Objectives
1.
2.
3.
4.
5.
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
2
Government Regulation of
Providers
Regulation of quality
Regulation of payment (cost)
3
Government Regulation of
Quality
Quality measurements:
Process measures
Structure measures
Outcomes measures
4
Who Regulates?
Federal government
State government
Local government
5
Government Regulation of
Payment
“Reasonable costs”
Prospective payment system (PPS)
Channeling funds to come types of
providers to influence service
delivery patterns
6
HIPAA
Health Insurance Portability and
Accountability Act:
Consumer access to health insurance
Privacy of health care data
Standardization and efficiency
7
Other Regulations
Employee protection (EEOC,
OSHA, FLSA)
Life safety
Tax codes
8
Government Licensure of
Individuals
Health care professionals (MD, RN)
Long-term care practitioners (CNA)
Long-term care administrators
9
Confusing Administrator
Licensing Regulations
Efforts to resolve the
fragmentation and confusion:
 NAB
 Pew Commission
 State licensing boards
10
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
11
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
12
Problems with Uncoordinated
Regulations
Created at different times, by
different entities
Often conflict
Reliant on documentation
Expensive duplication of
documentation
13
Policy Issues
Balancing regulation and innovation
Shifting focus to the consumer
Management of care
14
Private Control Mechanisms:
Accreditation
Voluntary
JCAHO, CARF, NCQA
Measure against optimal standards, not
minimally-acceptable levels
Give provider prestige, stamp of
approval
15
Certification of Individuals
Comparable to accreditation of
organizations
Professionals, administrators
Certified by professional organizations
Gives prestige, proof of competency
16
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.
17
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