Regulatory Aspects of Healthcare

• Major Function: Responsible for regulating the health care industry
• General Organizational Structure: 11 Operating Divisions, 10 Regional Offices

Main Function: Administers the Medicare/Medicaid Programs

Responsible for administration of programs provided by the Social Security Act of 1935

• Responsible for administering programs provided by the Occupational Safety and Health Act
   
• Promotion of safe and healthful working conditions
   
• Use and storage of hazardous materia
• Use of protective wear
   
• Sharps disposal

• Responsible for administering programs provided by Environmental Protection Act
• Establishment & enforcement of environmental protection standards
• Research on effects of pollution
  
• Regulation of hazardous waste disposal

Regulate packaging, storage, usage and disposal of radioactive materials

• Licenses health care facilities
  
• Administers CMS rules and regulations on a local basis
  
• Serves as a clearing house for various state agencies
  
• Operates public health department clinics

• A state function
  
• In Texas, licensure of healthcare facilities is under the direction of the Texas Department of State Health Services
• Usually renewable annually
  
• Fee charged
  
• Based on compliance with
  
• legal requirements
  
• life and safety codes
  
• necessity (in certain cases)

• A voluntary process which is intended to demonstrate that a facility or institution meets or exceeds an expected level of quality
  
• Basis for health care accreditation:
• Standards of care- Established measures that represent expected levels of performance
  
• Results of on-site visits
  
• Accreditation fee is charged to the facility

• The process by which a healthcare facility is approved to receive federal and/or state funding for the care provided to Medicare,Medicaid and TriCare patients
  
• Mandatory in order for a healthcare facility to receive payment for MC/MC/TC patients
  
• *Administered by CMS
• Delegated to DSHS in Texas

Major Role: To advance the philosophy and practice of osteopathic medicine by promoting excellence in education, research, and the delivery of quality, cost-effective healthcare

Major Role: To continuously improve health care for the public, in collaboration with other stakeholders, by evaluating health care organizations and inspiring them to excel in providing safe and effective care of the highest quality and value

• Non-insured
  
• Person receiving care is responsible for paying the bill
  
• Payment is due at the time of discharge
• Arrangements may be made in most facilities

The recipient is not able to pay and is not covered by insurance

• An entity other than the person receiving services is responsible for paying all or part of the bill
  
• Types
  
• Private insurance companies
  
• Government-funded insurance
  
• Managed care organizations

• Funding: 100% federal
  
• Age 65+ or Qualifying condition

• Funding: federal and state (states may pay up to 50%)
  
• Based on income eligibility

• Inpatient hospitalization
  
• SNF (limited)
  
• Home health (limited)
  
• Hospice (limited)

• Physician services
  
• Outpatient services
  
• DME (Durable Medical Equipment) 
• PT, OT, ST

Parts A & B coverage through private HMO plans

Prescription Drug Plan

• Coverage is based on income eligibility, regardless of the type of facility / level of service
• Coverage varies by state
  
• Texas- Inpatient; Outpatient; Physician services; Family planning; Long term care

Inpatient Services

Outpatient Services

Physician Services

• In network physicians only!
• Can't go out of network
• PCP gives referrals to specialist

• Allowed to go out of network, but pay a percentage
• Preferred providers list, no need for referrals

• Costs are managed through
  
• Gatekeeper- PCP 
• Approval mechanism-

An independent agency of the United States federal government that administers Social Security, a social insurance program consisting of retirement, disability, and survivors' benefits. To qualify for these benefits, most American workers pay Social Security taxes on their earnings; future benefits are based on the employees' contributions.

Created in order to reduce the budget gap by generating revenue through closure of tax loopholes and introduction of tougher enforcement of tax rules, as opposed to changing marginal income tax rates

• 1. Regulates the availability and breadth of group health plans and certain individual health insurance policies
• 2. Defines policies, procedures and guidelines for maintaining the privacy and security of individually identifiable health information as well as outlining numerous offenses relating to health care and sets civil and criminal penalties for violations. It also creates several programs to control fraud and abuse within the health care system

• Law that gave hospitals, nursing homes and other health facilities grants and loans for construction and modernization.
• In return, they agreed to provide a reasonable volume of services to persons unable to pay and to make their services available to all persons residing in the facility’s area

• Known as the “Patient Antidumping Law"
• Insurance program giving some employees the ability to continue health insurance coverage after leaving employment

It requires hospitals to provide care to anyone needing emergency healthcare treatment regardless of citizenship, legal status or ability to pay

Created Medicare Part D- prescription drug improvement plan

• PPACA is aimed primarily at decreasing the number of uninsured Americans and reducing the overall costs of health care.
• PPACA requires insurance companies to cover all applicants and offer the same rates regardless of pre-existing conditions or gender.

• Reduced federal & state payments
• Reduced services
• Shorter length of stay
• Cutting staff
• Longer waiting period

Materials that are potentially infectious with disease-carrying microorganisms

Payment is based on a pre-determined fixed rate

• Payment is based on actual charges
  
• Charge for a particular service
  
• Rate x LOS

a primary care physician, with a role of rationing patient access to specialized medicine

A company or an agency that purchases health services

Government Insurance Program- Medicare

Government Insurance Program- Medicaid

Texas Department of State Health Services

Emergency Medical Treatment and Active Labor Act