Healthcare

Hospitals are investing more in creating outpatient service departments to meet rising patient demand while simultaneously reducing inpatient surgical procedures and generating new sources of revenue. In many cases, the creation of these departments involves the acquisition of private physician practices’ ancillary service lines. Often, the hospital enters into an employment arrangement with the physicians of the once physician-owned private medical practice.

As discussed in a previous post, Practice "Bifurcation" Can be Risky Business, the Stark law is implicated in these post-acquisition employment arrangements because physician compensation is required to be consistent with fair market value.

Leadership at health care organizations is being tested like never before. The move away from fee-for-service (FFS) to a patient outcome based model means management has to get clinical care teams collaborating in a whole new way. Your leadership style and the culture you help create within your organization will be the deciding factor in determining whether your facility survives, and potentially thrives, in this new dynamic.

So, no pressure. Just the success of your organization riding on your shoulders.

The good news is that if you are reading this it means that you recognize the importance of being a great leader and seek out information to build your skills. Half the battle is being aware that you have a management style and committing to building on what is working and improving what is not.

Leaders in the hospital field are already pursuing integration to improve patient outcomes and reduce the ballooning cost of health care. The Centers of Medicare and Medicaid Services' quality initiatives, and now the Affordable Care Act, demand a new health care model that brings hospitals and physicians together to coordinate the continuum of care for improved patient care. One emerging trend to enhance care coordination is clinically integrated networks, or CIN.

On August 14, 2014, the U.S. Department of Justice reported a $1.3 million settlement between New York Heart Center, a New York cardiology group practice, and the United States government to resolve allegations that the practice violated the Physician Self-Referral (Stark) Law and the False Claims Act by "knowingly compensating its physicians in a manner that violated federal law."

The unique nature of services furnished by health care professionals and the possible conflicts of interest arising from financial arrangements between providers has resulted in laws and regulations that differ dramatically from other industries, like the Stark Law. The law was intended to ensure that a physician’s medical judgment is not compromised by improper financial incentives that encourage internal referrals of certain services known as Designated Health Services for Medicare patients.

For twenty years, the 340B program administered by The U.S. Department of Health and Human Services administration (HHS) has helped safety-net providers to stretch scarce Federal resources as far as possible, reaching more eligible patients and providing more comprehensive services. Over the past few years, with the passing of the Affordable Care Act (ACA), the number of qualifying health care entities (and patients) has grown. So have the number of contract pharmacies that can disperse 340B drugs to patients.

The program expansion has caused pharmaceutical companies to lobby for changes and clarifications to 340B. This has resulted in much political upheaval and the promise of mega changes to the program that were supposed to materialize this summer. That didn’t happen. But the program is definitely under scrutiny, so that means it’s important to document your 340B  transactions and understand the compliance requirements around this program.

Here’s what you need to know now about 340B to make sure your hospital or clinic is in compliance:

Are you wondering about the status of your Medicare Disproportionate Share Hospital (DSH) payments in light of the recent Allina DSH court ruling? You’re not alone.  An April 2014 ruling from a U.S. Court of Appeals for the District of Columbia Circuit upheld a previous ruling that a Health and Human Services (HHS) rule change in 2004 (codified in 2007) was procedurally defective. The lawsuit had to do with a rule change the HHS made to determine DSH payments in 2007. The hospitals claimed there was not proper notification. Although the court ruled favorably for the hospitals, what happens next is still unknown. 

The appeals court included instructions in the ruling that gave the HHS room to reach the same policy decision through administrative adjudication. The bad news for providers is that adjudicatory findings can be applied retroactively. The Centers for Medicare and Medicaid Services (CMS) has not yet issued a definitive guideline on how to retrofit the reimbursement fractions for the years in question. 

Given the continued flurry of activity in hospital-physician financial arrangements and increased enforcement activity, hospital system CEOs and in-house and outside counsel all have a vested interest in getting optimal value from the working relationship between the health care valuation analyst and legal counsel.

Earlier this month, the Journal of Accountancy published a detailed article about the shared-responsibility provisions of Section 4980H of the Affordable Care Act. The 3200-word article, titled "The Sec. 4980H assessable payment for large employers," demonstrates how time-consuming and complex traversing the provision can be, and time is running out for employers to determine if they are "applicable large employers" and, more importantly, put the necessary payroll systems in place to comply with the provision.

Most hospital system acquisitions of physician practices are structured as asset purchases, with the former physician-owners and employed physicians of the acquired practice subsequently employed by the purchasing hospital or a hospital-controlled entity. Because of the financial and referral relationships in arrangements such as these, the Stark law and federal anti-kickback statute are nearly always implicated, and compliance with these laws dictates that the financial arrangements be consistent with fair market value. Exceeding fair market value can expose the parties to potentially staggering fines and penalties if found liable as part of a qui tam or government enforcement action. Yet, as discussed in a recent post, New White Paper Doesn't Settle the Workforce Valuation Debate, diversity of opinion exists on certain valuation issues in these types of transactions. 

Now that we have easier access to Electronic Health Records (EHR), it should be easier than ever to use data to find best practices and reduce variations in care that hurt patient outcomes. Right? 

In theory, that’s right. In practice, it’s a whole other ballgame. EHR is a great repository of information but it does not magically perform analytics. Also, how do you grade the usefulness of data and how and when it is collected? 

Here are 3 areas to evaluate whether the data you are accumulating can drive better health care decisions for the patient and improved processes and efficiency for hospitals and providers: 

In this spotlight series we will explore changes to care delivery driven by the Affordable Care Act (ACA) and the increasing sophistication of patients who want health care that is affordable, transparent, and accessible. 

Today the spotlight is on retail medicine. 

Retail medicine is increasing its presence in the U.S. and a variety of health care organizations and analysts are taking notice. First the stats: 

Many rural hospitals are struggling in the new health care marketplace. Reimbursement from government and (soon) private payors is now more dependent on providing a collaborative and leaner process that rewards reducing variations in patient care and treatment in the appropriate setting. Additionally, hospitals in states that have opted out of receiving Affordable Care Act (ACA) funding face increased costs with no funding to cover them. 

Team-Based Care – Part III

For health care organizations to successfully implement any type of team-based approach to patient care there are some things to consider. The culture will have to change to encourage adoption of this new approach and patients, just as physicians, will need to change.

In a field where every position already feels they are working as hard as they can, being passionate about new responsibilities can be difficult.