Com

para

tive

Heal

th C

are

Syst

ems

Clas

s 4/2

/201

3

Comparative Perspectives on Long Term Care Quality RegulationVincent Mor, Ph.D.Florence Pirce Grant University ProfessorBrown University

Com

para

tive

Heal

th C

are

Syst

ems

Clas

s 4/2

/201

3

Purpose

• Provide a conceptual framework for understanding and comparing regulatory and quality assurance systems pertaining to Long Term Care across the developed and developing world

• Review several “case studies” following a prescribed format selected on the basis of socio-political spectrum

Com

para

tive

Heal

th C

are

Syst

ems

Clas

s 4/2

/201

3

Background• Historically caring for elderly was a family responsibility• Purchasing help to care for elderly was the province of the

wealthy• Like hiring servants, it was assumed that the employer was

discerning and controlled the care provided by the hired help• Residential arrangements were initially informal – placing

older family members to be cared for in someone else’s home• Religious and mutual aide societies emerged to provide care

for members and care of the elderly was among earliest services

• State sponsored care homes largely serving the destitute and those without families emerged from the tradition of poor houses.

Com

para

tive

Heal

th C

are

Syst

ems

Clas

s 4/2

/201

3

Background• As societal aging accelerates, geographic and social mobility

increases, elderly left behind need care solutions • Supply of governmental and sectarian care home solutions

become inadequate• Government grapples with long term care policy agenda• Almost all industrialized and industrializing countries

introduced policies to stimulate supply of care homes• This often implies providing incentives to the private sector to

meet the anticipated demand• Inevitably this entails subsidizing or paying for long term care

for the poor or those who become poor due to high needs• The Challenge is to devise regulatory control systems to assure

the quality of care provided by the private sector

Com

para

tive

Heal

th C

are

Syst

ems

Clas

s 4/2

/201

3

Background• Cambridge University Press Book of Quality Measurement

Systems included a chapter on Long Term Care written by and highlighting interRAI countries: Finland, Canada, Switzerland and US

• Positive reception so series editor at London School of Economics asked for special book on long term care quality

• Specially commissioned chapters on the regulatory structure of long term care (residential or home)

• Outline agreed to and writing reviewed with feedback and comments by Mor and co-editors

14 countries• Austria• Australia• Canada• China• England• Finland• Germany

• Japan• The Netherlands• New Zealand• South Korea• Spain• Switzerland• USA

Demographics

0

5

10

15

20

25

Austra

lia

Austria

Canada

China

Englan

d

Finlan

d

German

yJa

pan

New Zea

land

South

KoreaSpa

in

Switzer

land

The N

etherlan

dsUSA

Population 65+ (%)

Population 85+ (%)

Com

para

tive

Heal

th C

are

Syst

ems

Clas

s 4/2

/201

3

Case Study Question #1• What is the regulatory structure for long term care?

• Which Ministry (Department)?• How do different related Ministries coordinate• How much is in law and how much is included administrative

rules?• What is the relationship between the Central Government and

Regional/Local government? How centralized are the means of regulatory authority and oversight?

Com

para

tive

Heal

th C

are

Syst

ems

Clas

s 4/2

/201

3

Case Study Question #2• Does the Regulatory Structure differ for residential vs.

community based services?• For whom are community and residential services coordinated

and connected?• Is there case management that helps clients move between the

two services?• Which agency (if any) is responsible for this kind of triage.

Com

para

tive

Heal

th C

are

Syst

ems

Clas

s 4/2

/201

3

Case Study Question #3• Does the regulatory apparatus vary by region of the country?

• Are Regions, States, Provinces the basis for implementing regulations?

• Do Regions, etc. add their own regulations, standards and requirements?

• Is there a way to measure variation in the stringency of regulatory enforcement?

Com

para

tive

Heal

th C

are

Syst

ems

Clas

s 4/2

/201

3

Case Study Question #4

• Does the regulatory apparatus vary by who is paying? • Are publicly funded services regulated differently way than

those that are purchased privately? • Are there different regulations applicable to differently funded

individuals?

Com

para

tive

Heal

th C

are

Syst

ems

Clas

s 4/2

/201

3

Case Study Question #5, #6, #7• What is the application, inspection and certification (licensure)

system for long term care services?• Is there a routine monitoring and/or repeat inspection system

for the long term care services? • Are systematic data about patients and/or care processes

collected and used to guide the inspection process? • How is enforcement excercised and how is it documented?

Com

para

tive

Heal

th C

are

Syst

ems

Clas

s 4/2

/201

3

Case Study Question #8, #9, #10

• Is there a way to give “voice” to the consumers’ (clients’/patients’) preferences? e.g. satisfaction with care and with the caregivers of the services received?

• Is there public reporting of inspection results to the public and prospective users of the long term care services?

Financing of LTCCountry Designated public

LTC insurance (Y/N)

Cash allowance/personal budget paid to recipient to pay for LTC servicesb

Cash allowance/payment to carer for informal care by family member or other

Austria No Yes. Both cash benefits and in-kind services No Finland No Yes. Both cash benefits and in-kind services Yes Japan Yes No. In-kind home and institutional services No Spain No Yes. Both cash benefits and in-kind services No England No Yes. Both cash benefits and in-kind services Yes Germany Yes Yes. Both cash benefits and in-kind services No The Netherlands Yes Yes. Both cash benefits and in-kind services No China No Services bought privately No South Korea Yes Yes. Both cash benefits and in-kind services No Switzerland LTC part of

compulsory health insurance

Yes. Both cash benefits and in-kind services No

Australia No No. In-kind home and institutional services Yes New Zealand No No. In-kind home and institutional services Yes Canada No No. In-kind home and institutional services Yes, at provincial level USA No No. Mainly In-kind home and institutional

services for public programmes (Medicare and Medicaid). Cash benefits under voluntary (private)insurance

No

Com

para

tive

Heal

th C

are

Syst

ems

Clas

s 4/2

/201

3

Components of a Regulatory Control System

• Certification standards and the standard setting process, including how providers apply, are reviewed, inspected and determined to meet specified criteria

• Ongoing monitoring of compliance with standards; oversight and inspection & complaint investigation

• Enforcement of the regulations in the form of fines, prohibition on new admission and final de-certification or revocation of licensure

• Publicly reporting quality monitoring results to help consumers and their advocates select providers ; using market forces to stimulate competition

Com

para

tive

Heal

th C

are

Syst

ems

Clas

s 4/2

/201

3

Regulatory Dimensions

• Governing the physical space, minimal professional resources and available services

• Governing the educational achievement and minimum training standards for people caring for long term care clients

• Governing the processes of care provided• Governing the outcomes clients experience

Com

para

tive

Heal

th C

are

Syst

ems

Clas

s 4/2

/201

3

Inter-relationship between Regulatory Control & Purchasing Standards• Licensing and minimal quality standards apply to the provider

• Government or purchaser’s role can be passive or more active

• As “purchaser” Government can set higher standards OR “steer” patients to facilities with superior quality since regulations set minimum standards

• Even in the absence of “market” forces purchaser can make a market – however, rarely done

Com

para

tive

Heal

th C

are

Syst

ems

Clas

s 4/2

/201

3

Comparative Regulatory Perspectives• Standards setting and Inspection Indepedence

• Reliance on “professionalism” and training of provider staff

• Reliance on Measurement of Residents’ Care Processes and Outcomes

• Public Reporting to Stimulate Market Forces

• Not necessarily independent; a matter of relative emphasis and compatability with cultural norms

Com

para

tive

Heal

th C

are

Syst

ems

Clas

s 4/2

/201

3

Categories of Regulatory Approach • Professionalism Based Regulatory System• Inspection Based Regulatory System• Empirical Data & Reporting Regulatory System• Developing Country Approach

Com

para

tive

Heal

th C

are

Syst

ems

Clas

s 4/2

/201

3

Com

para

tive

Heal

th C

are

Syst

ems

Clas

s 4/2

/201

3

Regulatory Structure

• Centralized• National Authority• Limited Local Discretion

• Decentralized• Local Government rules OR• Inspection teams

Com

para

tive

Heal

th C

are

Syst

ems

Clas

s 4/2

/201

3

Com

para

tive

Heal

th C

are

Syst

ems

Clas

s 4/2

/201

3

Com

para

tive

Heal

th C

are

Syst

ems

Clas

s 4/2

/201

3

Com

para

tive

Heal

th C

are

Syst

ems

Clas

s 4/2

/201

3

Com

para

tive

Heal

th C

are

Syst

ems

Clas

s 4/2

/201

3

Regulatory Functions• Licensure• Structural Standards• Professional Standards• Professional Associations• Minimum Care Process Standards• Resident/Client Outcome Status Measurement• Routine Inspections• Random Unannounced Inspections• Data Driven Inspections• Sanctions and Warnings• Legal Appeals Process• Complaint collection and Monitoring• Public Reporting

Com

para

tive

Heal

th C

are

Syst

ems

Clas

s 4/2

/201

3

Com

para

tive

Heal

th C

are

Syst

ems

Clas

s 4/2

/201

3

Com

para

tive

Heal

th C

are

Syst

ems

Clas

s 4/2

/201

3

Exemplars of Inspection Variation• All US states have adopted Federal quality standards

• State officials and staff conduct inspections in accordance with the Federal standards

• Considerable inter-state variation in the frequency and severity of “deficiencies” (departures) from established standards as perceived by inspectors

• Although many other countries have similar national to regional or local delegation of inspection and monitoring functions, few other countries make this kind of data available

Com

para

tive

Heal

th C

are

Syst

ems

Clas

s 4/2

/201

3

Com

para

tive

Heal

th C

are

Syst

ems

Clas

s 4/2

/201

3

Summary• Quality Regulation in the form of Quality Assurance and

Protection of the Public is a fundamental Government function

• Considerable cross-national variation in the philosophical underpinnings of the long term care regulatory system

• Variation likely due to;• perception of government• “Trust” in non-governmental institutions• Historical Idiosyncracies

• Range of regulatory functions and “tools” is broad• How well (strigently) applied may not be related to the

regulatory approach countries have developed.