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to Summit ProceedingsQuestion 1
What types of structures, policies and processes should be put into place to
co-ordinate within each state all health professions regulation in regard to
cost, quality, safety, accessibility of health care at the state level?
Groups made reference to the Ontario Health Professions Regulatory Advisory Council, which was viewed as keeping professional regulatory bodies at a greater distance from the government than is characteristic of the American system. It was remarked that under the model professions act to establish scopes of practice, provide advisory counsel, are totally self-funded, and made up of fifty percent public members. One of the groups remarked that scopes of practice in Ontario seem more open and professions more willing to collaborate with one another. Another example of "over-arching" departments cited by those present was the New York Board of Regents, which has 28 advisory boards
Attendees also referred to the Virginia Department of Health Professions, which oversees 12 boards. Each board has policy responsibility, rule-making authority and collects fees (each being self-funded). The department shares an "Administrative Proceedings Division" which is not legal counsel, but serves to write up all notices, conduct informal hearings, help secure prosecutors, consent orders, and drafts regulations and proposed legislation on behalf of the individual boards. Other attendees mentioned a program in Washington which licenses mental health professionals but also requires all non-licensed health professionals to register and to share their training and background. This current program serves to register the individual for disciplinary activity.
Attendees were concerned that were public members to become the majority then the courts would increasingly challenge the decisions due to the lack of professional expertise. Other perceived barriers to change were issues of "turf" protection and reimbursement protection. It was suggested that there is an unwillingness to stop looking at differences between states rather than concentrating on similarities. Attendees also noted that any change would need to involve third-party payers with whom data would need to be shared. Some attendees felt that the drawback of establishing a coordinating body would be that it would add another level of bureaucracy.
Question 2
What structure and/or policies should be implemented to co-ordinate the above
initiatives with policies associated with the regulation of health institutions
and third party payers/insurance agencies?
Some attendees believed it would be valuable to share health plan data, although they noted that this idea could be resisted and it could provide a barrier to change. A further suggestion was to keep regulatory functions separate from outcome data.
Question 3
How should public members be better utilized in the regulatory process? How
should public members increase the credibility and accountability of boards?
What proportion of a licensure board should public members represent?
Groups noted the current Pew recommendation that boards consist of at least one-third public members and agreed on the value of public members. Some present suggested that the visibility of state boards should be increased in order to attract stronger public and professional membership. Other suggestions were to develop mentoring programs for new public and professional members with overlapping terms as well as developing selection criteria to recruit better matches for new members. A further suggestion was to provide potential board members with job descriptions and an idea of the time commitment involved.
Question 4
What type of relevant practice information should be available to the public to
strengthen consumer protection? What are the best means to make it available to
the public? Who should control it?
Attendees noted the following programs, structures and policies that are currently in place or which soon will be:
Attendees felt that ideas for the future would be to make the National Practitioner Database open to the public (which, it was pointed out, would require an Act of Congress). Other suggestions were to use hospital and hospital plan report cards as models for displaying information about practitioners, and that context for disciplinary decisions and an explanation of any sanction must be provided.
It was felt that barriers to these changes taking place were the following: a threat to confidentiality; variations among states (regarding state procedure acts) as to what should be open to the public and in differences in defining what constitutes a "complaint." Some attendees felt that the suggestions did not follow due process, while others pointed out that the use of alternate dispute resolution (ADR) leads to certain complaints against practitioners not being included in the official record.
Asked what initial action steps should be taken, attendees suggested clearly defining what constitutes a complaint and working towards a consensus. Those present felt that more savvy and demanding consumers would drive change. Attendees noted that some reported data is currently widely available on the Internet. It was suggested that as much information as possible should be collected but that certain data (such as social security numbers, home addresses, non-final action, patient names) should not be made available.
Some expressed concern that information regarding continuing education might be viewed by the public as being indicative of competency, when this is not necessarily the case. A suggestion for the future was to provide the public with information about professions' scopes of practice to allow a better understanding of the various professions. The establishment of a consumer focus panel to determine what information would be most valuable for the public was a further suggestion.
Question 5
What types of structure, policies and processes should be put in place to
facilitate the mobility of health professionals across state borders?
Attendees felt that barriers to the concept are fear of losing one's job, differences in criminal background check requests and procedures and that an attitude of provincialism exists that means states are opposed to closer co-operation. Furthermore attendees felt that the initiative would not be a priority for all boards, and that there is a(n incorrect) belief that standards vary tremendously. Other attendees felt that there are real differences in some standards, while others added that any new procedures might mean the loss of dollars to states and agencies, and still others noted that the educational requirements differ from state to state.
It was suggested that initial action steps should include the elimination of financial incentives to maintain the status quo, and also to standardize professional curricula. Driving the change would be the redundancy of checks, the desire of professionals and consumers to be mobile, the federal government's interest in helping to expand mobility, and the use telemedicine and telehealth.
Those present also asked who would be responsible for the policy-making policy? Who has policy authority and who would assume policy authority?
It was felt that the answers to these questions would depend on the law in individual states.
Attendees felt that solutions would be to remind boards of their roles, noting that some (including North Carolina) boards are required to work together. Those arguing for these changes should be aware of different levels of policy-making and that leadership guides who shall make policy. It was also felt that an objective entity is necessary to resolve inter-board conflict. Others suggested that professional associations, rather than boards, may be guilty of instigating turf battles. Another suggestion was to make boards financially autonomous which, it was suggested, would make them more responsive to consumers.
It was felt that barriers to change would be money, the variety of actors and players, and the fact that individuals rather than facilities need to be regulated. Some attendees felt that an approach worth considering was the direct regulation of professions by a department rather than a board. Examples given were the Colorado Department of Regulatory Agencies which directly regulates without needing a separate board for all professions. Another example cited was Washington State - where no new boards have been created since 1983. The advantages of such an approach were perceived to be cost-saving, less politics, more direct regulation and a consistency of policy.
Some favored the separation by profession of certain functions of the department/board such as disciplinary action. It was noted that the District of Columbia's Health Occupations Revision Act regulates 20 professions together and has responsibility for investigations, administration, and standard scopes of practice. Critics of consolidation felt that it would mean professions no longer being as involved in their own regulation. Attendees felt that any changes would require education of administrators and board members and that financial and political resources would need to be brought to bear to support change.
One group stated that given the mobility of health professionals multiple jurisdictional licenses were absurd. Their discussion focused on the retail concept of Petsmart and the requirement for vets to cover retail outlets in multiple jurisdictions. It was also suggested that mutual acceptance of standards be established for professions to ensure reciprocity/mutual recognition.