Regulating private hospitals

1. Regulating private hospitals Professor EK Yeoh

2. Harding-Preker Framework Assessment Strategy Grow Issues and Goals Focus Harness Convert • Distribution (equity) • Efficiency • Quality of Care • PHSA • Gather available information • Identify additional needs • In-depth studies Private Sector Instruments • Activities • Hospitals • PHC • Diagnostic labs • Producers / Distributors • Ownership • For-profit corporate • For-profit small business • Non-profit charitable • Formal/ Informal • Policy Tools • Regulation • Contracting • Training/Info • Social marketing • Social franchising • Info. to patients • Demand-side • (incl. Vouchers) • PPP transactions • Enable environment improvement PublicSector Source: Adapted from Harding & Preker, Private Participation in Health Services, 2003.

3. Harding-Preker Framework Assessment Strategy Grow Issues and Goals Focus Harness Convert • Distribution (equity) • Efficiency • Quality of Care • PHSA • Gather available information • Identify additional needs • In-depth studies Private Sector Instruments • Activities • Hospitals • PHC • Diagnostic labs • Producers / Distributors • Ownership • For-profit corporate • For-profit small business • Non-profit charitable • Formal/ Informal • Policy Tools • Regulation • Contracting • Training/Info • Social marketing • Social franchising • Info. to patients • Demand-side • (incl. Vouchers) • PPP transactions • Enable environment improvement Regulation PublicSector Source: Adapted from Harding & Preker, Private Participation in Health Services, 2003.

4. Outline for Presentation • Define regulations • Regulatory strategies and instruments • Regulating quality • Compliance-based • Incentive-based • Self-regulation • Regulatory regime and effectiveness • Key Messages • Further Reading and References

5. Regulation Three basic categories • Regulation as setting forth mandatory rules that are enforced by a state agency • Regulation incorporates all efforts by state agencies to steer the economy… include state ownership and contracting, taxation and disclosure requirements • Regulation to include all mechanisms of both intentional and unintentional social control Saltman and Busse (2002) Baldwin et al (1998)

6. Regulation • Regulation is the range of factors exterior to the practice or administration of medical care that influences behaviour in delivering health care Brennan and Berwick (1996)

7. Dimensions [Purposes] of health sector regulation Saltman and Busse (2002)

8. Social and economic policy objectives • Equity and justice • Social cohesion • Economic efficiency • Health and safety • Informed and educated citizens • Individual choice Harding and Preker (2003) Saltman and Busse (2002)

9. Health sector management mechanisms • Regulating quality and effectiveness • Regulating patient access • Regulating provider behaviour • Regulating payers • Regulating pharmaceuticals • Regulating physicians Harding and Preker (2003) Saltman and Busse (2002)

10. Regulatory strategy • Command and control • Self regulation • Incentive-based regimes • Market harnessing controls • Disclosure • Direct action • Rights and liabilities laws • Public compensation and social insurance Saltman and Busse (2002)

11. Actors Government Professional/ provider organizations Patients’/ Consumers’ organizations

12. Regulatory actors • self-regulators tend to be strong on specialist knowledge but weak on accountability to the public; • local authorities strong on local democratic accountability, • weak on coordination; • parliament strong on democratic authority, weak on sustained scrutiny; • courts and tribunals strong on fairness, weak on planning; • central departments strong on coordination with the government, weak on neutrality; • agencies strong on expertise and combining functions, weak on neutrality; • directors general strong on specialization and identification of responsibility, weak on spreading discretionary powers. Saltman and Busse (2002) Baldwin and Cave (1999)

13. Targets Quality Capacity Price Market structure and levels of services Entitlements Saltman and Busse (2002)

14. Regulatory instruments • Control-based regulation • Licensing • Registration • Incentive-based regulation • Contracts • Accreditation • Market-structure regulation • Encourage desired behaviour Harding and Preker (2003)

15. Control-based regulatory instrument Harding and Preker (2003)

16. Control-based regulatory instrument Harding and Preker (2003)

17. Incentive-based regulatory instrument Harding and Preker (2003)

18. Incentive-based regulatory instrument Harding and Preker (2003)

19. Regulatory instruments by regulatory strategy and target of regulation Harding and Preker (2003) Harding and Preker (2003)

20. Self-regulation • A state-generated mandate that allows certain professionals or enterprises to set standards for the behaviour of its membership • Private self-regulation without state enforcement e.g. some professional organisations or voluntary organisations • Publicly mandated self-regulation e.g. professional self-regulation by physicians, dentists and pharmacists, etc. • Joint self-regulation with non-governmental actors Saltman and Busse (2002) Baldwin and Cave (1999)

21. Self-regulation Harding and Preker (2003) Baldwin and Cave (1999)

22. Regulatory body in Hong Kong • The Medical Council of Hong Kong • Hong Kong Academy of Medicine • Hong Kong Hospital Authority

23. The Medical Council of Hong Kong Empowered by the Medical Registration Ordinance, Cap. 161, Laws of Hong Kong, the Medical Council maintains a register of eligible medical practitioners, administers the Licensing Examination, issues guidelines and a Professional Code and Conduct, exercises regulatory and disciplinary powers for the profession, and answers general enquiries from doctors and the public. http://www.mchk.org.hk

24. The Medical Council of Hong Kong • Standards of practice • Licensing • Entry to the professions • Re-certification not required • Continuing medical education not required • Clinical audit and quality assurance not required • Accreditation of specialties • Code of practices and ethics

25. The Medical Council of Hong Kong • 24 medical members, 4 lay members • Preliminary Investigation Committee • Licentiate Committee • Education and Accreditation Committee • Ethics Committee • Health Committee

26. Hong Kong Academy of Medicine (HKAM) In recognition of the need for essential postgraduate medical education and training in Hong Kong, the Hong Kong Academy of Medicine was formally established under the Hong Kong Academy of Medicine Ordinance (Cap 419) with the statutory power to organise, monitor, assess and accredit all medical specialist training and to oversee the provision of continuing medical education. http://www.hkam.org.hk

27. Role of HKAM • To maintain the standard of specialist training and specialist continuing medical education (CME) and continuous professional development (CPD) in the territory • To assists the Medical Council of Hong Kong, the Registration body, in the maintenance of the Specialist Register (SR) since its inception in 1997 (Medical Registration Ordinance)

28. Specialist training • Standard 6-year format for basic and higher specialist training leading to Fellowship • Examinations and assessment • Require continuing medical education and continuous professional development to maintain specialist status

29. Hong Kong Hospital Authority • Public hospitals were corporatized in 1991 under the holding of a single statutory nonprofit public corporation, the Hospital Authority, independent of the government bureaucracy and established with the mandate to manage all public hospitals. http://www.ha.org.hk

30. Hong Kong Hospital Authority Under the Hospital Authority Ordinance, the Hospital Authority is responsible for: Advising the Government on the needs of the public for hospital services and of the resources required to meet those needs; Managing and developing the public hospital system; Recommending to the Secretary for Food and Health appropriate policies on fees for the use of hospital services by the public; Establishing public hospitals; Managing and controlling public hospitals; and Promoting, assisting and taking part in education and training of persons involved in hospital or related services. 30

31. Management structure • Functions: • Clinical effectiveness and technology management • Patient safety and risk management • Patient relations and engagement • Quality and Standards • Infection, emergency and contingency • Chief Infection Control Office • Infectious Disease Control Training Centre

32. Quality assurance/ clinical audit • Monitoring, audit and inspection • Implement pilot hospital accreditation program, which includes defining the quality of hospital services in line with international standards and review by an international accrediting agent • Key performance indicators • Satisfaction survey

33. Regulating quality • Structure • Facility licensing • Healthcare personnel licensing • Process • Facility accreditation • Clinical practice guideline • Outcome • Performance reporting • Clinical audit

34. Complementary/ synthetic role of regulatory instrument • Licensing/ professional standards • Compliance/ control based • Self-regulatory • Specialist practice • Self-regulatory • Non-financial incentive-based

35. A framework for comprehensive regulatory assessment Harding and Preker (2003)

36. Regulatory decision-making OECD (2002)

37. Regulatory activity • Legislation • Implementation • Monitoring • Evaluation • Enforcement • Judicial supervision Saltman and Busse (2002)

38. Regulating legitimacy • Acceptability • Political • Social • Regulated • Process • Communication • Transparency • Independent creditability of regulatory body • Legal foundation

39. Regulatory cycle Decide to regulate Regulation Evaluate system performance Secure legal authority Impose penalties for violators Write rules Monitor compliance Peter Berman

40. Key Messages Regulations is an inherently complex and political process. Regulation is a strategic, dynamic and on-going process. Control/Compliance based regulations needs to be complemented with other instruments (e.g. (purchasing, self-regulations) to be effective. Legitimacy and wide awareness of quality regulations are critical for effectiveness.

41. Reading and References Busse R, Hafez-Afifi N and Harding A (2000). “Chapter 4: Regulation of Health Services.” Private Participation in Health Services Handbook. Washington, DC: The World Bank Saltman R, Busse R and Mossialos Elias (2002). European Observatory on Health Care Systems Series: Regulating entrepreneurial behaviour in European health care systems. Open University Press. World Health Organization http://www.ps4h.org/hospital_documents http://www.ps4h.org/Bali_documents