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impact of federal nursing home regulation, but

sure; nursing home accreditation and licen-

again, it is difficult in these studies to isolate

sure (including COPs, the Nursing Home

the pure effect of regulatory changes from

Reform Act of 1987, and state regulations);

other factors that were changing during the

and licensure for all other health facilities.

same time period. The available evidence sug-

Also included is peer review, encompassing

gests a historical decline in the inappropriate

Quality Improvement Organizations and the

use of physical and chemical restraints, along

Health Care Quality Improvement Act of

with declines in rates of urinary incontinence,

1986; the Clinical Laboratory Improvement

catheterization, and hospitalization, at least

Act of 1967 as amended; and other quality-

some of which can be attributed to the

related facilities regulations such as FDA regu-

Nursing Home Reform Act of 1987.40 These

lation of blood banks, blood-borne pathogen

requirements imposed by the Occupational

effects are difficult to translate into dollar

terms. In my analysis, based on a single study,41

Safety and Health Administration, and health

outcomes reporting systems mandated by

I have credited these regulations with produc-

states. (Note that medical malpractice is dis-

ing hospital savings that effectively offset the

cussed as a completely separate category on

significant costs associated with regulating

grounds that it affects facilities, professionals,

nursing homes ($22,000 per nursing home).

Quality-related

and even insurance plans to some extent.)

However, it is worth noting these same regula-

facilities

Collectively, these quality-related facilities reg-

tions also have been shown to reduce access to

care for those on Medicaid,42 an adverse impact

ulations imposed a cost of $21.8 billion and

regulations

provided benefits amounting to $4.0 billion.

I had no good way of monetizing. Thus

imposed a cost of

Hospital accreditation/licensure (net cost $8.6

whether on balance these nursing home regu-

$21.8 billion and

billion), the Clinical Laboratory Improvement

lations have produced any net benefit depends

Act (net cost $3.2 billion), and peer review (net

on the weight that is attached to quality

provided benefits

cost $2.1 billion) are the three largest contrib-

improvements relative to lowered access.

amounting to

utors to this cost.

CLIA is another good example of well-

Medicare and the majority of state health

intentioned regulations that impose sizable

$4.0 billion.

departments that license or certify hospitals

costs resulting in an inherent trade-off

rely on the Joint Commission on Accreditation

between any potential gains from the stan-

of Healthcare Organizations to certify quality.

dards themselves and health losses associat-

Yet a recent assessment concluded, "it is appar-

ed with patients who elect not to be tested

ent that the JCAHO is not associated with

due to higher prices. One simulation found

improving the quality of care."38 There have

the benefits of improved cancer screening

were completely offset by the reduction in

been relatively few studies of the impact of

the number of people screened as a result of

state nursing home regulation, in part because

higher prices that resulted from CLIA.43

virtually all such facilities are regulated, and

hence the absence of a plausible comparison or

control group limits such studies to examining

Health Professionals

whether changes in regulation have been asso-

Regulation

ciated with changes in quality over time. It too

often is not possible to unravel whether

observed differences really reflect differences in

There is even more variety among health

actual quality or merely differences in the qual-

professionals, most of whom are subject to

ity of reporting.39 For example, an apparent

varying degrees of health services regulation.

Health professionals include physicians/dentists,

decrease in quality postregulation may not

such as professionals with a doctoral degree,

really mean that care has gotten worse, but

including doctors of medicine (MDs), doctors

instead that more of what was happening pre-

of osteopathy (DOs), and doctors of dental

regulation is now being reported. There have

science or dental surgery (DDSs); mid-level

been more concerted efforts to measure the

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