Hcs 545 - Health Law and Regulations

Health Law and Regulations

Tiffany Langham

HCS/545

September 17, 2012

Matt Frederiksen

Health Law and Regulations

Regulation plays a major role in the health care industry at both the state and federal levels. There are various federal regulations governing health care with the objective to protect the health interests for the public, especially the elderly, the low-income, and the disabled. The United States Congress passes federal legislation. The state government agencies implement and enforce the federal laws and regulations. In addition, the state agencies develop and enforce state specific standards to regulate health care organizations, health care professionals, and protect consumers seeking health insurance.

Role of Federal Government Regulatory Agencies and Analysis

The U.S. Department of Health and Human Services (DHHS) has 11 operating divisions with eight public health agencies and three human service agencies. According to the U.S. Department of Health and Human Services (2012), "The agencies perform a wide variety of tasks and services, including research, public health, food and drug safety, grants and other funding, health insurance and many others" (HHS Operating & Staff Divisions). Examples of these divisions are the Agency for Healthcare Research and Quality (AHRQ), Centers for Disease Control and Prevention (CDC), Centers for Medicare and Medicaid Services (CMS), Food and Drug Administration (FDA), etc (U.S. Department of Health and Human Services, 2012).

The Affordable Care Act of 2010 established The Center for Medicare and Medicaid Services Innovative Center. The CMS Innovation Center's mission is better care, better health, and lowering health care costs by using the Institute of Medicine's domains of quality (safety, timeliness, effectiveness, efficiency, equity, and patient-centered care), promoting preventative care, living a healthy lifestyle, improving the coordination of care between entities, and efficient use of health care resources, thus reducing beneficiaries cost of health care (Centers for Medicare and Medicaid Services, 2012). A part of the beneficiaries high cost of care is readmissions to the hospital. Many patients are re-admitted to the hospital within 30 days of discharge for the same diagnosis. The re-admitting diagnosis is often a health care-associated infection, such as clostridium difficile, methicillin resistant staphylococcus aureus, ventilator associated pneumonia, and vancomycin resistant enterococci. Clostridium difficile alone is "linked to 14,000 American deaths each year. C. difficile infections cost at least one billion dollars in extra health care costs annually" (Centers for Disease Control, 2012, para. 1). Improving the quality of patient care, patient assessments, flow of information, and communication between hospitals, nursing homes, assisted livings, and other entities will decrease hospital readmissions and health care costs. Regulator and payers are scrutinizing hospital-acquired infections (HAIs) as the "result of unacceptable lapses in the quality of care" ("Hospital perspectives on reducing and preventing readmissions," 2011, p. 1) and the HAIs also "contribute to substandard patient outcomes that may result in hospital re-admissions" ("Hospital perspectives on reducing and preventing readmissions," 2011, p. 1). Starting October 2012, hospitals will receive a reduction in Medicare payment for high re-admission rates for patients with certain conditions ("Hospital perspectives on reducing and preventing readmissions," 2011, p. 1). In personal interviews with nursing home staff and hospital staff separately, both blame the other for developing the infections. The improvement in communication and more accurate patient health assessments will alleviate that blame.

A state mandated universal transfer form in New Jersey accompanies patients when transferring between health care providers, e.g., hospitals, and nursing homes with the purpose of improving the continuity of care. The form is one page but captures the needed patient information, including health care-associated infection (Edelstien & Moles, 2012).

Role of State Governmental Regulatory Agencies and Analysis

Federal laws regulate the oversight of the Medicare and Medicaid programs. Although the programs are voluntary, it is essential for the majority of providers to participate to continue business operations. To receive Medicare and Medicaid payments for services, providers have regulations and requirements to follow in protecting patients' rights (Harris, 2008, p. 62). The state government enforces federal laws and state specific standards in regulating health care organizations and health care professionals. Health care organizations require a license to operate. Health care professionals, such as physicians require a license to practice. Furthermore, state governments regulate health insurance companies ensuring the companies do not employ in practices such as price fixing, misleading marketing, or violating privacy (Jaffe, 2009).

The Texas Health and Human Services Commission has four component agencies, the Department of Aging and Disability Services (DADS), the Department of State Health Services (DSHS), the Department of Assistive and Rehabilitation Services (DARS), and the Department of Family and Protective Services (DFPS). These state agencies administer programs, such as Medicaid, disaster planning, food stamps, and family violence services. Examples of the agencies functions are developing policy and rule-making, fraud and abuse prevention and detection, ombudsman services, etc (Texas Health and Human Services Commission, 2012).

The Texas Department of Aging and Disability Services Regulatory Division manages the Nursing Facility program that provides institutional care to Medicaid benefactors requiring routine skilled licensed