Long Term Care Administration Analysis - Essay Example

? LTC210-Introduction to Long Term Care Administration-Unit 3 Aedric Frechelle of the Explain why the long-term care field is now experiencing much more competition than was the case in the past. According to the Global Burden of Disease Study 2010 (GBD 2010), which was published on December 13, 2012, even though the life expectancy has increased for men and women worldwide by more than ten years, they spend more years living with injury and illness (Wang et al., 2012). The baby boomers are expected to keep that growth cycle going, most likely at faster rate, which is expanding the demand for services and is also heightening the expectations from service providers (Study Notes, p. 2). From the economists and the business perspectives, when the demand increases, the supply will also increase to meet the increasing demand. In this particular scenario, as the demand for services by the population increases, and when the reimbursement is available, the providers for services will also increase. For a long time, Medicare and Medicaid were the most significant buyers of long-term care services. However, with the introduction of Managed Care Organizations (MCO), the pressure and the competition has increased. MCOs have the option to choose which providers they will do business with since many of them do not cover long-term care. This directly increases the amount of providers looking to provide the services, resulting in opening up the opportunity for competition between the providers (Pratt, 2010, p. 215). Our system allows competition due to a firm belief that the customer will benefit from competition as better quality will be offered in order to gain more customers. Since the customers are also better informed due to higher education and ability to compare services, their expectations are higher and they give their ‘businesses’ to only those health care organizations that meet their needs. The health care facilities are also susceptible to pressure from payers and regulatory agencies to provide quality and cost-effective services. The providers that follow the requirements will be given incentives on top of their reimbursements. These institutions are the most favorable to increase their customer base, to have a solid financial relationship with managed care organizations (MCO), and with the Federal and State agencies. 2. Explain, using examples, the differences between licensure and accreditation. The health care industry is highly regulated. It is natural for them to be so as they deal with life and death situations. It is not like other industries where mistakes can be rectified or losses can be repaid. With the health care industry, the mistakes cost lives and hence, they must be prevented at any cost. For that purpose we have two types of external controls. One deals with governmental regulations, licensing of facilities and individuals (public), and the other deals with voluntary accreditation and certifications (private) (Study Notes, p. 6). One of the most important differences between public and private agencies is that “public agencies have a dual purpose—to control both quality and costs—while the private organizations have a single purpose—to measure, evaluate, and ensure the quality of care” (Pratt, 2010, p. 258). Another difference is that the “government programs seek to ensure a minimum level of quality or competency, while the private organization set standards that measure and ensure more of an optimum level” (Pratt, 2010, p.p. 258-259). Licensure is provided by the State and it is basically a “permission to a qualified individual or entity to perform certain specified activities that would be illegal without a license” (Pozgar, 2006, p.273). For example, in the health care industry we find practitioners like Registered Nurses (RN), Licensed Practical Nurses (LPN), Physicians (MD), Registered Dietician (RD), Licensed Physical Therapist (PT), and many others who, in order to practice their profession, need a license from the State. The exam for Registered Nurses is very interesting as it is not just about answering the test correctly. It is the level of difficulty of the test that determines if the individual will pass or fail the test. For example, a person may answer only 75 questions, but if the level of difficulty of those questions is high, then he will pass the test. On the other hand, if a person answers 100 questions and that too correctly, but if the level of difficulty of those questions is low, then that person will fail the test (in the case of a Registered Nurse the minimum of questions is 75 and the maximum is 265). When the State grants a license, it ensures that the individuals are qualified to practice their profession. However, an individual has the restriction of practicing only that profession for which the licensure is granted. The individual cannot practice other skilled profession unless he is licensed by the State. For example, a Registered Nurses cannot practice Physical Therapy (or be hired as one) unless they have the license to practice that profession. If an individual practices without license, then it would be considered as a violation of the law and any entity that hires that individual could/will face penalties. Accreditation, on the other hand, is different from licensure. It is not required by law for an institution to be accredited. There is no mandated penalty for providers who do not participate as it is completely voluntary. It is typically made up of the organizations representing the providers that are covered by that process, and the evaluation of providers is against predetermined performance standards widely accepted in the health care industry (Pratt, 2010, p. 259). Even though they are voluntary, some accreditations might give the impression that they are not, as they could provide a “deemed status” for Medicare. For example, this is the case with the accreditation granted by the Joint Commission on Accreditation of Health Organizations (JCAHO). When the deemed status is conferred by that agency, it means that the institutions do not have to be surveyed separately by Medicare, as it meets all the standards of Centers for Medicare & Medicaid Services (CMS). This means that Medicare does not have to conduct a separate survey, saving time and money to that Federal agency. The institution with the JCAHO accreditation can do business with Medicare, thus receiving reimbursements from that agency as well as from Medicaid, as most States recognize that accreditation as meeting or exceeding their standard for licensure and granting them deemed status (Pratt, 2010, p.p. 259-260). Most of the hospital and long-term care providers opt to have JACHO accreditation as the deemed status gives them an advantage over their competitors. The prestige of having such accreditation also impacts the consumer’s decision while determining which institution to choose. Differences between Licensure and Accreditation: Licensure Accreditation Applies to? Organizations & Individuals Organizations Mandatory or Voluntary? Mandatory Voluntary Operated by? Government Agencies Private Organizations Measures Against? Minimal Performance Standards Optimal Performance Standards Source: Study notes, unit 3. 3. What are “public/private partnerships?” The concept of public/private partnership is when private investors provide the funding for public services that otherwise would be funded by the public sector. The major source of funding for long-term care is Medicare (skilled needs) and Medicaid (non-skilled needs). It is well known that the Federal and State governments are having problems due to increase in cost. It has been suggested and demonstrated through projects done by the Robert Wood Johnson Foundation that public/private partnerships could alleviate the Federal and State budgets by offering to the consumer to purchase private long-term care insurance. “They were designed to provide incentives to increase private participation in long-term care financing, with an ultimate objective of reducing the demand in public funding” (Pratt, 2010, p.54). This initiative is beneficial to the governmental budget but is confronting resistance from the consumer. Among the objections is the concern that as time passes by and the consumer gets older, the premium rates will escalate greatly if people have to wait until they are likely to need it before making the initial purchase. The targeted age groups are young adult and middle-aged population. More than worrying about something as far off as long-term care, most of the demographic is beset by many other financial demands such as meeting daily needs, putting their kids through college and taking care of their own parents, which they consider as more pressing and urgent (Pratt, 2010, p.p. 54-55). Last but not the least, most of the population believes that the government will take care of them. They think that since their taxes were paid for those benefits, they are not obliged to pay for those services again. Additional education about long-term care benefits and about what to expect from the government in order to gain support for any initiatives in the future, is the need of the hour. 4. Describe how Quality Assurance (QA) and Continuous Quality Improvement (CQI) are different. Continuous Quality Improvement (CQI) is “a holistic approach based on a desire by the staff and administration to achieve excellence” (Pratt, 2010, p. 303). In other words, it is about everyone in the organization and what they do, and is not relegated to a specific group. CQI focuses on improving the system, seeks to prevent errors and strives to improving quality (Pratt, 2010, p. 303). Quality Assurance (QA) focuses more on the issue (or problem) than on the process and the outcome (U.S. Department of Health, n.d.). For example, it focuses on who was responsible for issues, the errors that were made, what was done and how it was done (U.S. Department of Health, n.d.). Quality is monitored periodically and relies on inspections to identify errors (Pratt, 2010, p. 302). Other differences are given in the following table of comparison. Comparison of Quality Assurance and Continuous Quality Improvement: Quality Assurance Continuous Quality Improvement Seeks Improvements in Quality of Care Seeks Improvements in Quality of Care Mandated by Government Voluntary Concentrates on Problems Concentrates on Consumers Focuses on Problem Focuses on Why Problem Occurred Emphasizes Record-Keeping Emphasizes Interdisciplinary Problems-Solving Sets Targets Seeks Continuous Improvement Source: Study notes, unit 3. 4. Discuss the “spend down” provision of Medicaid and why it is controversial. The Medicaid Excess Income program (commonly known as “spend down” or “surplus income” program) is a process established by the State to reduce the individual financial assets (or actives) because they have too much income (New York State, 2009). This process is done for individuals that otherwise would not qualify for Medicaid long-term care benefits (New York State, 2009). It is considered controversial as it does not seem fair that after life long sacrifices, savings, being fiscally responsible and paying taxes, the middle class is penalized by having to give up everything either to the State or to the family. Upper class do not need the ‘spend down’ because they can easily cover long-term care, and lower class is already covered by default. Therefore, the middle class (many call it the “sandwich class”) seems to be paying for the consequences. Another allegation is that the long-term care benefits should already be covered after a lifetime of paying taxes. Individuals are expected to pay or incur the medical expenses equal to the monthly ‘spend down’ before Medicaid covers additional medical expenses in the month. This opens the doors for critics to question the rationale of saving, when at the end, it has to be spent in order to be qualified for Medicaid long-term care benefits. The question is, if people know that ultimately their savings are going to be taken away by the government, then how will they get encouraged to save (Pratt, 2010, p. 327)? Those opposed to pay for the services do not think there is much logic in this (Pratt, 2010, p. 327). The government response is that it is not ethical to force the State to pay for someone who has those savings. Another allegation is that if they continue to pay for long-term care benefits, then their savings might disappear altogether leaving the future generation without a provision to fall back on in case it is needed. As both parties have logical rationale and reasonable arguments, the ethical dilemma and disagreements will most likely continue. Reference New York State (2009). Medicaid Excess Income (“Spenddown” or “Surplus Income”) program. Retrieved from: http://www.health.ny.gov/health_care/medicaid/excess_income.htm Pozgar, G. (2006). Legal Aspects of Health Care Administration. Sudbury, MA: Jones and Bartlett Publishers. Pratt, J.R. (2010). Long-Term Care: Managing Across the Continuum (3rded). Sudbury, MA: Jones and Bartlett Publishers . U.S. Department of Health and Human Services (n.d.).What is the difference between Quality Improvement and Quality Assurance? Retrieved from: http://www.hrsa.gov/healthit/toolbox/HealthITAdoptiontoolbox/QualityImprovement/whatarediffbtwqinqa.html Wang, H., Dwyer-Lindgren, L., Lofgren, K.T., Rajaratnam, J.K., Marcus, J.R., Levin-Rector, A. …Murray, C.JL. (2012). Age-specific and sex-specific mortality in 187 countries, 1970-2010: A Systematic Analysis for the Global Burden of Disease Study 2010. The Lancet, 380(9859) 2071-2094, doi: 10.1016/S0140-6736(12)61719-X Read More