Pioneer ACOs Announced by CMS
Posted by Western PA Hospital News on Dec 23, 2011 in Legal | 0 comments
Mike Cassidy
On December 19, 2011, CMS issued a press release announcing that 32 leading health care organizations across the country will participate in a new pioneer Accountable Care Organization (ACO) initiative. CMS believes that the pioneer ACO initiative will “encourage” providers to deliver better and more coordinated care and expects that this could save up to $1.1 billion over five years.
CMS describes the pioneer ACO model as an initiative complementary to the Medicare Shared Savings Program designed for organizations with existing experience providing integrated care across a variety of health care settings. The pioneer model is intended to test the rapid transition to a population-based model of care.
The pioneer initiative model differs from the Medicare Shared Savings Program in the following ways:
- The first two years of the pioneer ACO model are a shared savings payment arrangement with higher levels of savings and risk than the Medicare Shared Savings Program.
- Starting in year three of the initiative, those organizations that have earned savings over the first two years will be eligible to move to a population based payment arrangement and full risk arrangements that can continue through optional years four and five.
- Pioneer ACOs are required to develop similar outcome-based payment arrangements with other payors by the end of the second year.
- Under the pioneer ACO model, beneficiaries do not enroll in an ACO. Primary care providers and other health care providers make the decision to participate in ACOs, meaning that beneficiaries will not need to take a proactive action to receive the benefits offered through an ACO. Although ACOs are required to notify beneficiares of the ACO participation, insuring the beneficiary is aware of the new arrangement, but the beneficiary maintains complete freedom to visit any health care provider accepting Medicare.
Don’t Count on a Retaliation Loophole
Posted by Western PA Hospital News on Sep 19, 2011 in Legal | 0 comments
Jane Lewis Volk
By Jane Lewis Volk
It is illegal for an employer to retaliate against any employee who voices or files a discrimination complaint, but what about actions taken against the employee’s family or friends who work for the same company?
A recent court case closes the loophole. In the case, the Supreme Court had to decide whether a third party had a right to sue his employer on grounds of retaliation if he was not the one who committed the action that the employer was supposedly retaliating against.
In the case, a female employee filed a gender discrimination complaint with the Equal Employment Opportunity Commission. Three weeks later, her fiancé, who worked for the same employer, was fired from his position. The fiancé then sued the company, claiming that his termination was an unlawful method to punish the employee who filed the complaint. The employer maintained that the termination was performance-based.
U.S. Physician Practices Spend Four Times As Much As Payer Administrative Money As Canadian Counterparts
Posted by Western PA Hospital News on Aug 12, 2011 in Legal | 0 comments
Mike Cassidy
A commonwealth fund supported studies reported some key findings:
1. Physician practices in the United States spent $82,975.00 per physician per year interacting with payers compared with $22,205.00 in Canada.
- If U.S. physicians had similar administrative costs to their Canadian counterparts, the total annual savings would be $27.6 billion dollars.
- U.S. nurses and medical assistants spent 20.6 hours per week on administrative tasks related to health plans, which is nearly 10 times the 2.5 hours spent by Canadian nursing staff.
I have attached a link with a scan of the highlights of the study.
Burns White names Colleen A. Treml new Chief Marketing Officer
Posted by Western PA Hospital News on Jul 12, 2011 in Legal | 0 comments
(From Burns White LLC) Law firm Burns White LLC has named Colleen A. Treml the firm’s new Chief Marketing Officer.
Ms. Treml is a licensed attorney with nearly 20 years of marketing and communications experience. She spent the last five years overseeing a team of communications professionals as Senior Manager of Marketing Communications at Philips Respironics.
Ms. Treml previously worked as an attorney at Tucker Arensberg P.C. in Pittsburgh and spent 13 years in various high-level, corporate marketing and communications positions in the healthcare industry, including roles as National Director of Physician and Medical Services Communications at Aetna Inc., and Assistant Vice President, Physician Communications at U.S. Healthcare.
Healthcare Industry Groups Comment on EHR and Health Reform
Posted by Western PA Hospital News on Jul 11, 2011 in Legal | 0 comments
Mike Cassidy
By Mike Cassidy
In two separate letters, one just by the American Hospital Association and one by a consortium of industry groups, AHA, AMA, AMDIS, CHIME, EHRA, FAH and HIMSS, industry has submitted extensive comments to HHS regarding these issues. Comments focus on five areas of opportunity and challenge:
1. Reduce regulatory complexity;
2. Clarify certification and site certification processes;
3. Address meaningful use issues;
4. Clarify and improve the compliance process; and
5. Evaluate/coordinate the overlapping regulatory time line
Although both letters are instructive, the attachments to the AHA letter provide a useful summary of the issues. Attachment A charts the legal barriers to clinical integration, i.e.
- Antitrust
- Stark
- Anti-Kickback
- Civil money penalties
- IRS tax exemption issues
Attachment B indicates the complexity of the overlapping requirements for transition to ICD-10, meaningful use, health reform and HIPAA 5010.
ACOs and Anti-Trust
Posted by Western PA Hospital News on Apr 13, 2011 in Legal | 0 comments
Mike Cassidy
By Mike Cassidy
In last month’s post entitled “Reform Redux,” I mentioned that one of the foremost issues for the coming year would be the development of Accountable Care Organizations (ACOs). The two most troublesome issues in developing ACOs will probably be the Anti-Trust and the Anti-Kickback/Stark issues. Traditionally, this regulatory structure has made it almost impossible for multiple providers to agree in any joint venture to provide health care services:
- The Anti-Trust laws basically prohibit agreements (affectionately known as conspiracies) among competitors to fix prices, which is evident by the many enforcement actions taken against IPAs, PHOs, etc.
- The combination of the Stark law prohibiting referrals to entities with which physicians have financial relationships, the Anti-Kickback statutes prohibiting payment in exchange for referrals, and the Civil Money Penalties statute prohibiting incentives to withhold care, basically eliminate any meaningful opportunities to operate as anything other than an integrated delivery system, which operates as a single entity.
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