2009 boc athletic trainer regulatory conference

A State Regulator A State Regulator Looks Ahead: Looks Ahead:

Issues and Trends in Issues and Trends in Professional LicensureProfessional Licensure

David A. MontgomeryDavid A. MontgomeryNebraska Department Nebraska Department of Health and Human of Health and Human

ServicesServices

July 10, 2009July 10, 2009

2009 BOC Athletic Trainer Regulatory Conference

WHAT IS LICENSURE?

Licensure is:• A public policy exercise of the

State’s police powers

• Designed to protect the public

• A legalized monopoly to practice a profession

• A system of standards for entry into a profession

• A system of standards for maintaining licensure

• A system for removing impaired or incompetent providers from practice.


Licensure is:• A legal way to deter entry into a

profession

• A mechanism to protect licensees from competition

• A means to gain access to third-party reimbursement

• A means to establish and enhance the prestige of a profession

• A means to create a market for new academic disciplines.


Drivers of licensure and of changes in licensure:

• Cost containment○ Costs of health care

○ Access to reimbursement

• Professional identity○ Relationship of licensure to

professional identity

○ Relationship of licensure to professional education

• Public protection


LICENSURE AND

COST CONTAINMENT

Issues:•Access to reimbursement is a primary

driver for licensing a profession

•Licensure is expensive○ Cost of administrative functions

(accounting, HR, legal, investigations, etc.)

○ These drive up licensure fees, especially for small professions

•Licensure costs can become a barrier to entry and limit access


Possible Futures:• New payment systems may weaken or sever

link between licensure and reimbursement○ This might render licensure undesirable for

some professions

• Increased sharing of expenses among licensing boards

○ Agreements among autonomous boards

○ Umbrella boards

○ Umbrella agencies

• Cost-shifting away from individual licensing fees

○ Public financing of some/all activities

○ Distributing costs over a larger body of licensure


LICENSURE AND

PROFESSIONAL IDENTITY

Issues:•Licensure often driven by desire to

show “maturity” or “worthiness” of a profession

•Licensure sometimes becomes a means to create a market for evolving academic disciplines

•Both these tendencies are encouraged by emphasis on specialization rather than generalization


• Professional identity and academic curricula are intertwined with licensed scope of practice

○ Academic disciplines focus on mastery of a body of knowledge and theory

○ Most scopes of practice are based on functions or acts

○ Many professional scopes of practice include duplicative acts – H&P, diagnosis/assessment, therapeutic modalities, prescribing

○ Scopes of practice typically fall beyond patterns of practice and disciplinary knowledge

• The public is often clueless as to nuances of scopes of practice and academic identity


•Most professions insist on hiring members of their profession as regulators

•Most boards are totally or primarily composed of members of the profession (self-regulation)


Possible Futures:• Cost-containment may change paradigm to

generalization rather than specialization

• Re-thinking of licensing by scope of practice “packages”

○ Ontario model – licensed to perform acts, not to be a

○ Practice defined more as application of specialized knowledge than as performance of acts

○ Possible mergers of groups of related professions and disciplines

○ Administration by non-licensed professional regulators

○ Increased use of umbrella boards and public members on boards


LICENSURE AND

PUBLIC PROTECTION

Issues:• Licensure often continues to protect the profession

more than the public

• Many licensed professions have minimal ability to do significant harm to the public

• Disciplinary actions occupy an increasing share of licensing boards’ time

○ Most cases involve the “Big 3” – sex, drugs, alcohol

○ Very few cases deal with incompetence or gross negligence

○ Many cases are technical or involve minor violations of regulations

• Most licensing boards lack jurisdiction over unlicensed practice

• Few major investigations due to public comments


Possible Futures:• Legislatures will become more reluctant to

grant licensure on demand○ Greater use of “sunrise” programs

○ More use of regulatory alternatives (institutional regulation, supervisory requirements, public disclosure statements, etc.)

○ Some current professions may be deregulated or merged

• Licensing boards may seek greater jurisdiction over unregulated practice (although legislators often skeptical)

• Greater sharing of investigative and prosecutorial resources


•Possible public financing of

investigative and prosecutorial functions

•Greater use of mandatory reporting by licensees to uncover offenses

•Streamlining of regulations to focus on serious issues of potential harm

•Greater education of licensees in requirements of practice


THREE OBSERVATIONS

Our present professional regulatory “system” is a patchwork resulting from centuries of unsystematic legislation, band-aid fixes, and ad-hoc changes. It is marginally effective, but also inefficient, needlessly expensive, inconsistent and confusing to the public.


As part of health care reform, a major national conversation is needed over the effectiveness and efficiency of this “system”, including licensing, private certification, and enforcement. Such a conversation could lead to reforms that would streamline and modernize licensing practices.


At present there is no sign that this will occur.


Contact Information

For Questions Regarding this Presentation:

David A. MontgomeryNebraska Department of Health and Human

ServicesDivision of Public Health – Licensure Unit

301 Centennial Mall SouthP.O. Box 95026

Lincoln NE 68509-5026Phone: 402-471-6515

Email: [email protected]

Thank YouThank You


2009 boc athletic trainer regulatory conference

Documents

licensure undesirable

licensure fees

patterns of practice

prescribingscopes of

professional identity

professional licensuredavid

cost containment issues

new academic disciplines