Introduction to Health Care and Public Health in the U.S.

1. Introduction to Health Careand Public Health in the U.S. Regulating Health Care Lecture a This material (Comp 1 Unit 6) was developed by Oregon Health & Science University, funded by the Department of Health and Human Services, Office of the National Coordinator for Health Information Technology under Award Number 90WT0001. This work is licensed under the Creative Commons Attribution-NonCommercial-ShareAlike 4.0 International License. To view a copy of this license, visit http://creativecommons.org/licenses/by-nc-sa/4.0/.

2. Regulating Health Care Learning Objectives - 1 • Describe the role of accreditation, regulatory bodies, and professional associations in health care in the U.S. (Lecture a) • Describe the basic concepts of law in the United States: the legal system, sources of law, classification of laws, the court system, and the trial process.  (Lecture b)

3. Regulating Health Care Learning Objectives - 2 • Describe legal aspects of medicine involving the Affordable Care Act, professional standards in health care, medical malpractice, tort reform, and Medicare and Medicaid fraud and abuse (Lecture c)

4. Regulating Health Care Learning Objectives - 3 • Describe key components of the Health Insurance Portability and Accountability Act (HIPAA) and describe efforts to promote patient safety in the U.S. (Lecture d) • Discuss the need for quality clinical documentation for the use of the health record as a legal document, communication tool and  a key to prove compliance for health care organizations. (Lecture e)

5. Accreditation, Regulation, and Professional Associations • Nonprofit Accrediting Organizations • The Joint Commission (TJC) • URAC (formerly called Utilization Review Accreditation Commission) • National Committee for Quality Assurance (NCQA) • Regulatory Agencies • Food and Drug Administration (FDA) • Professional Associations

6. TJC History - 1 • 1910: The forerunner of TJC was called the “end-result” system • 1951: Joint Commission on Accreditation of Hospitals (JCAH) is created and starts accrediting health care organizations • 1987: JCAH changed its name to Joint Commission on Accreditation of Healthcare Organizations (JCAHO)

7. TJC History - 2 • 2007: Name simplified to The Joint Commission (TJC); currently accredits and certifies nearly 21,000 organizations and programs in the USA • 1994: Joint Commission International (JCI) offers an international accreditation and has touched more than 90 countries since then.

8. TJC’s Mission Statement • “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.” (The Joint Commission, 2016)

9. TJC Accreditation - 1 • TJC accreditation signifies an organization meets TJC’s standards for patient care • Accreditation is earned by an entire health care organization (hospital, nursing home, office-based surgery practice, etc.) • Procedure manual: emergency management, environment of care, HR, infection prevention and control

10. TJC Accreditation - 2 • Tools TJC uses to measure performance • Integrated Survey Process (ISP): An in-person visit to evaluate performance across an organization • Outcome Research Yields Excellence (ORYX): System for health care organizations to report information to TJC about patients with certain conditions (core measure sets) • The core measure sets reported depend on the type and size of the organization

11. ORYX: Core Measure Sets - 1 • Examples • Heart attack • Pneumonia • Inpatient psychiatric care • Children’s asthma • Stroke

12. ORYX: Core Measure Sets - 2 • Specific performance measures are associated with each core measure set • For example, the TJC looks at whether children with asthma received certain drugs in the hospital and were sent home with a management plan

13. TJC Certification • TJC-accredited organizations and providers of health care staffing services can also earn certification for specific programs or services • For chronic diseases and conditions • Examples: asthma, diabetes, heart failure programs • Programs can be within the medical center or in the community

14. TJC Patient Safety Activities • National Patient Safety Goals • Universal Protocol • Office of Quality Monitoring • Speak Up™ Program • Sentinel Event Policy

15. Nonprofit Accrediting Organizations • The Joint Commission • URAC, formerly the Utilization Review Accreditation Commission

16. URAC • Mission: “To promote continuous improvement in the quality and efficiency of healthcare management through processes of accreditation, education, and measurement” • Has more than 30 accreditation and certification programs for various types of health care organizations

17. URAC Privacy & Security Accreditation - 1 • Outlines best practices for maintaining privacy and security of health information • Allows organizations to demonstrate compliance with privacy and security requirements specified by: • Health Insurance Portability and Accountability Act (HIPAA) • Health Information Technology for Economic and Clinical Health Act (HITECH) • See http://www.urac.org

18. URAC Privacy & Security Accreditation - 2 • These health care organizations must comply with HIPAA: • Health plans: Health insurance companies, employer-funded health plans, and government programs that pay for health care, such as Medicare or Medicaid • Health care providers that conduct certain tasks electronically • Health care clearinghouses (organizations that process health information)

19. The National Committee for Quality Assurance (NCQA) • Accreditation body for: • Health plans • Health plan contracting organizations • Accountable Care Organizations • Accreditation process includes assessments of clinical performance and consumer experience • Healthcare Effectiveness Data and Information Set (HEDIS) • Consumer Assessment of Healthcare Providers and Systems (CAHPS) survey

20. Regulatory Agencies • Under the authority of Congress, federal agencies enforce standards in a specific field in the private sector • Agencies create regulations, known as “rules”, to carry out public policy • The goal is consumer protection. Example: Food and Drug Administration (FDA)

21. FDA Overview Categories of FDA regulated products: 6.1 Figure: As part of Department of Health and Human Services, the FDA is charged with oversight of these areas. (FDA, 2016)

22. FDA Mission • Protect public health • Regulates drugs • Performs drug approvals • Provides drug safety information • Spreads the message about medication errors • Helps speed up product innovations • Helps public obtain accurate, science-based information

23. Centers for Medicare & Medicaid Services (CMS) • Under U.S. Department of Health & Human Services • CMS regulates reimbursement for health care products and services, including: • Medicare • Medicaid • Children’s Health Insurance Program (CHIP)

24. CMS - Medicare • Federally funded health care program for individuals who: • Are over age 65 • Are under age 65 with certain disabilities • Have permanent kidney failure requiring dialysis or transplant

25. CMS – Medicaid and CHIP • Medicaid and CHIP provide health care for low income adults and children. • Programs are administered by individual states

26. Office of the National Coordinator for Health Information Technology (ONC) • ONC a federal entity within the Department of Health & Human Services • Coordinates nationwide efforts to implement and use electronic health records • Promotes the exchange of electronic health information across care settings

27. Professional Associations - 1 • Nonprofit organizations that support: • A particular profession • The interests of individuals engaged in that profession • Physicians • Hospital administrators • The public interest

28. Professional Associations - 2 • Sets requirements: • For entry into the profession • May require license or certificate • For maintaining membership in the profession • Members generally have a significant amount of education, training, or experience

29. American Board of Medical Specialties (ABMS) - 1 • Mission: “to serve the public and the medical profession by improving the quality of health care through setting professional standards for lifelong certification in partnership with Member Boards.” • Board certification differs from licensure, which sets minimum competency for physicians

30. American Board of Medical Specialties (ABMS) - 2 • Member boards certify specialist physicians • Also subspecialists; for example, adolescent medicine is a subspecialty of family medicine

31. American HospitalAssociation (AHA) • Nearly 5,000 organizational members • 43,000 individual members • Major programs • Advocacy • Lobbying and media campaigns to influence political and economic policies • Resource center • Database of information on health planning and admin. • Annual survey of U.S. hospitals • Reports and studies

32. American MedicalAssociation (AMA) • Nearly 225,000 members • Physicians with an MD or DO degree, or a recognized international equivalent • Resident physicians and fellows • Medical students • Major programs • Resources for physicians • Advocacy • Publishing medical journals

33. American NursesAssociation (ANA) • Nonprofit professional organization that represents the interests of the USA’s 3.4 million registered nurses • Focus areas • Fostering high standards of nursing practice • Promoting a safe and ethical work environment • Bolstering the health and wellness of nurses • Advocating for nurses and the public

34. Regulating Health CareSummary – 1 – Lecture a • Hospitals and other health care organizations are accredited by TJC • TJC also certifies specific health care programs and conducts patient safety activities • URAC accredits and certifies a wide range of health care organizations, and it has an accreditation program for IT professionals

35. Regulating Health CareSummary – 2 – Lecture a • Regulatory agencies such as the FDA protect consumers by setting and enforcing standards • Professional associations establish standards for their members to enhance the safety and quality of health care

36. Regulating Health Care References – 1 – Lecture a References American Board of Medical Specialties. http://www.abms.org. Accessed January 26, 2017. American Hospital Association. http://www.aha.org. Accessed January 26, 2017. American Medical Association. http://www.ama-assn.org. Accessed January 26, 2017. Center for Medicare & Medicaid Services. https://www.cms.gov/Medicare/Medicare-General-Information/MedicareGenInfo/index.html. Accessed January 26, 2017. Medicaid. https://www.medicaid.gov/. Accessed January 26, 2017. Office of the National Coordinator. https://www.healthit.gov/newsroom/about-onc. Accessed January 26, 2017. Robeznieks A. AMA saw membership rise 3.2% in 2012. May 9, 2013. http://www.modernhealthcare.com/article/20130509/NEWS/305099950. Accessed January 26, 2017. Regulatory agency (definition). Encyclopedia Britannica. http://www.britannica.com/EBchecked/topic/496265/regulatory-agency. Accessed January 26, 2017.

37. Regulating Health Care References – 2 – Lecture a References The Joint Commission. http://www.jointcommission.org/facts_about_the_joint_commission/ Accessed January 26, 2017. The Joint Commission International. http://www.jointcommissioninternational.org/about-jci/who-is-jci/. Accessed January 26, 2017. U.S. Department of Health & Human Services. Health information privacy. http://www.hhs.gov/hipaa/index.html. Accessed January 26, 2017. U.S. Food and Drug Administration. http://www.fda.gov. Accessed January 26, 2017. URAC. http://www.urac.org. Accessed January 26, 2017. Charts, Tables, Figures Figure 6.1: Part of Department of Health and Human Services, charged with oversight of the areas displayed. http://www.fda.gov/. Accessed January 26, 2017.

38. Introduction to Health Careand Public Health in the U.S.Regulating Health CareLecture a This material was developed by Oregon Health & Science University, funded by the Department of Health and Human Services, Office of the National Coordinator for Health Information Technology under Award Number 90WT0001.