Describe health care regulation in your own words. What costs are related? Who is affected?
Healthcare regulation encompasses the oversight and standard of practice that is established to ensure the safe delivery of care is provided to those in need. Regulations put in place by governing and accrediting agencies that oversee the appropriate application of procedures and practices routinely monitor organizations for compliance. Joint Commission and CMS are to examples of regulatory bodies that are responsible for ensuring enforcement of regulations. Violations in practice can incur fines, reduced reimbursement, and also cost the organization in other ways by damaging the reputation of the facility. The US Centers of Medicare and Medicaid Services (CMS) publishes the Hospital Compare report of hospital quality and patient satisfaction data (Chen et al, 2020).Public records of violations can deter potenti al patients from seeking care at an organization that has been known to provide suboptimal care to their patrons. Regulations are beneficial in setting practice guidelines to help support the delivery of safe care. When organizations are known for providing superior care and good outcomes these positive results can impact patient satisfaction scores, employee engagement, and organizational viability.
Chen, H., Cates, T., Taylor, M., & Cates, C. (2020). Improving the US hospital reimbursement: How patient satisfaction in HCAHPS reflects lower readmission. International Journal of Health Care Quality Assurance, 33(4/5), 333-344. https://doi.org/10.1108/ijhcqa-03-2019-0066
Healthcare regulations are rules put into place by credentialing bodies, and state and federal governmental agencies with the intention of improving healthcare. The intention of these regulations is to assure that patients have fair access to care, healthcare costs are contained and healthcare organizations are held to a standard to provide safe quality care to patients (Legers, 2021). There are many costs that are related to these regulations. Healthcare organizations must employ multiple people to take responsibility for meeting all of the requirements for each of these regulatory agencies. These associates are responsible for reviewing, auditing and documenting that all requirements are met. Many regulations dictate the number of providers or practitioners that must be available for certain certifications. Likewise many of these certifications have a price tag connected with them. There are also millions of dollars spent annually to employ all of the personnel at these governmental agencies and administer these programs. Some information states that more than $38 billion is spent on administering and monitoring compliance with these regulations (Legers, 2021).
Who is affected by these regulations? All members of the healthcare team along with patients and their families are affected by these regulations. Healthcare workers must receive extensive training on various processes and standards that must be met to remain in compliance with these regulations. Patients are also affected as many healthcare organizations struggle to continue to be able to provide the services that they have in the past due to financial constraints.
There have been many good things to come out of many of these regulations, like the expectation of high quality care and improved patient outcomes but we have also seen some organizations have to eliminate services due to the financial constraints of meeting some of these regulations.
Chen, H., Cates, T., Taylor, M., & Cates, C. (2020). Improving the US hospital reimbursement: How patient satisfaction in HCAHPS reflects lower readmission. [Improving the US hospital reimbursement] International Journal of Health Care Quality Assurance, 33(4), 333-344. doi:https://doi.org/10.1108/IJHCQA-03-2019-0066
Leger, M. (2021) Financial management for nurse managers: Merging the heart of the dollar (5th ed.) Jones and Bartlett, ISBN-13:9781284230932
It was interesting to learn that healthcare systems in the U.S. must comply with about 629 regulatory requirements across nine domains (Leger, 2021). This makes the American healthcare system one of the most heavily regulated sectors of the U.S. economy. Field (2008) said that healthcare professionals may feel as if they spend more time complying with rules that direct their work than actually doing the work itself. Regulation can be defined as a form of government intervention designed to shape the behavior of an economic entity, whether organizations or individuals (Leger, 2021, p.38). Regulations come from federal, state, local, and private organizations. Healthcare providers and hospitals are directly affected by the regulations. For example, it is California state law that hospitals have interpreters 24 hours a day at no cost to the patient (Department of Managed Health Care, n.d.). As a result of this law, our hospital has interpreters available via telephones and videos 24/7. Nursing staff must offer and use certified medical interpreters while providing care to patients who have limited proficiency in English. Billions of dollars each year are spent by healthcare organizations to comply with regulatory requirements (Leger, 2021). The compliance is monitored by numerous surveyors and extensive reporting requirements. As an example, the California Department of Public Health, as the state survey agency for the Centers for Medicare and Medicaid Services, certifies facilities to receive Medicare and Medi-Cal reimbursements by ensuring that hospitals comply with state licensing laws and federal certification regulations.
Department of Managed Health Care (DMHC). (n.d.). Language Assistance. https://www.dmhc.ca.gov/healthcareincalifornia/yourhealthcarerights/languageassistance.aspx#:~:text=State%20law%20requires%20that%20hospitals,Patients%20should%20not%20be%20charged.
Field R. I. (2008). Why is health care regulation so complex? P & T: a peer-reviewed journal for formulary management, 33(10), 607–608. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2730786/
Leger, M. (2021). Financial management for nurse managers: Merging the heart of the dollar (5th ed.). Jones and Bartlett. ISBN-13: 9781284230932