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U.S. Spends More on Healthcare Than Other High-Income Nations But Has Lower Life Expentancy, Worse Health Has the Tide of Practice Acquisition Ebbed? Are Medicare ACOs Working? Experts Disagree
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C O N T E N T S
4 U.S. Spends More On Health Care Than Other High-Income Nations but Has Lower Life Expentancy, Worse Health 5 Has The Tide of Practice Acquisition Ebbed? 9 Are Medicare ACOs Working? Experts Disagree 11 18 Health Technologies Poised For Big Growth 12 N Rise of ‘Telemedicine’ Drives Move Toward Multi-State Nursing Agreement 13 Final Stage 3 EHR Rule is Out, but HHS Signals More Changes Ahead 15 Nine Steps to Outsource Medical Practice Services 15 In-House vs. Outsourced Medical Billing: Pros and Cons 16 In Maryland, A Change in How Hospitals Are Paid Boosts Public Health 18 Dartmouth-Hitchcock Pulls Out of Medicare Pioneer ACO Initiative 18 AmSurg Seeks to Merge with TeamHealth in $7.8B Deal 19 Toumey Will Pay U.S. $72.4 Million to Duck $237 Million False Claims Verdict
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US Spends More on Health Care Than Other High-Income Nations But Has Lower Life Expectancy, Worse Health New Report Finds Americans Have Fewer Doctor and Hospital Visits Than People in Other Nations; Outsized Spending Likely a Result of More Technology, Higher Prices For Care and Prescriptions Drugs The U.S. spent more per person on health care than 12 other high-income nations in 2013, while seeing the lowest life expectancy and some of the worst health outcomes among this group, according to a Commonwealth Fund report out today. The analysis shows that in the U.S., which spent an average of $9,086 per person annually, life expectancy was 78.8 years. Switzerland, the second-highest-spending country, spent $6,325 per person and had a life expectancy of 82.9 years. Mortality rates for cancer were among the lowest in the U.S., but rates of chronic conditions, obesity, and infant mortality were higher than those abroad. “Time and again, we see evidence that the amount of money we spend on health care in this country is not gaining us comparable health benefits,” said Commonwealth Fund President David Blumenthal, M.D. “We have to look at the root causes of this disconnect and invest our health care dollars in ways that will allow us to live longer while enjoying better health and greater productivity.” Using data from the Organization for Economic Cooperation and Development (OECD) and other sources, the report, U.S. Health Care from a Global Perspective: Spending, Use of Services, Prices, and Health in 13 Countries, compares health care spending, use of services, prices, and health outcomes in the U.S. with those in Australia, Canada, Denmark, France, Germany, Japan, the Netherlands, New Zealand, Norway, Sweden, Switzerland, and the United Kingdom. Most of the data are for 2013, and so predate the major insurance provisions of the Affordable Care Act. Commonwealth Fund researchers found the U.S. to be a substantial outlier when it comes to health spending. Health care consumed 17.1 percent of the nation’s gross domestic product (GDP) in 2013, about 50 percent more than any other country. Despite being the only country in the study without universal health care coverage, government spending on health care in the U.S.—mainly for Medicare and Medicaid—was high as well, at $4,197 per person in 2013. By comparison, the U.K., where all residents are covered by the National Health Service, spent $2,802 per person. Americans Get Less Health Care, Spend More for It According to the study, health care spending per person is highest in the U.S. not because Americans go to doctors and hospitals more often, but because of greater use of medical technology and health care prices that are higher than in other nations. When looking at health service pricing and use, the report finds: • People in the U.S. visit doctors an average of four times per year; only residents of Switzerland, New Zealand, and Sweden have fewer visits. Americans also go to the hospital relatively infrequently, with 126 visits per every 1,000 people, compared to 252 visits in Germany, where the rate is highest. • Americans receive the most diagnostic imaging exams, including MRIs, CT scans, PET exams. The average U.S. adult also takes more prescription drugs than adults in all the other countries except New Zealand. • Prescription drugs are most expensive in the U.S., with prices twice as high as in the U.K., Australia, and Canada. • Prices for health services are considerably higher in the U.S. than elsewhere. On average, heart bypass surgery costs $75,345 in the U.S., compared to $15,742 in the Netherlands, where the procedure is least expensive. “When you look more deeply at how countries spend on health care, it is very clear that in the U.S. we are paying higher prices but not getting more,” said David Squires, senior researcher at The Commonwealth Fund and coauthor of the report. “And because we spend so much on health care, there is less to spend on other important needs and investments.” Additional Findings • U.S. does well on cancer care. The U.S. appears to have comparatively good health outcomes when it comes to cancer care. Rates of cancer deaths were lower in the U.S. than in most other nations—164 for every 100,000 people, compared to 220 in Denmark, 196 in the Netherlands, and 193 in the U.K. Cancer deaths in the U.S. also declined faster between 1995 and 2007 than in the other countries. • Health care spending growth slowed in the U.S. and globally. Per capita health care spending growth in the U.S. has slowed in recent years, from 2.47 percent in 2003–09 to 1.50 percent in 2009–13. This slowdown occurred in other countries as well, with spending growth even turning negative in Denmark and the U.K. • U.S. spends the least on social services. The U.S. spends only 9 percent of GDP on social services like disability benefits or employment programs. It is the only country studied where health care spending accounts for a greater share of GDP than social services spending. In contrast, France and Sweden spent 21 percent of GDP on social services. Moving Forward High health spending in the U.S. has far-reaching economic consequences, affecting wages and personal financial well-being
4 AFFILIATED PRACTICE
while worsening budget deficits, the report’s authors say. New health care models like accountable care organizations, which base provider pay on patient outcomes, could encourage higher-quality, lower-cost care. These models, they say, could also help bring about a shift toward proportionally greater spending on social services, as health care organizations are incentivized to think more broadly about what their patients need to be healthy.
Has the tide of practice acquisition ebbed? By David N. Gans, Is there a place for the independent practice in tomorrow’s healthcare system? The demise of the private practice appears to have been grossly exaggerated. During the past few years many writers and policy wonks predicted that independent practices cannot survive, and the future of healthcare will be controlled by large health systems in which doctors are well-paid employees. This might have seemed like a logical conclusion based on a belief that only the largest systems will have the financial means to survive. However, this does not seem to be the case. Their perception resulted in articles that incorrectly cite a statistic that half of all doctors are employed by hospital systems and forecast the inevitable extinction of the private practice. However, the truth contradicts this prediction. Statistics maintained by the American Medical Association (AMA) indicate that 60% of physicians practice in organizations that are owned by doctors, and that only 20.3% of doctors work in practices owned by hospitals or are direct hospital employees as described in the article, "Of particular interest: Available data about medical practices." MGMA’s membership parallels the AMA national data. As shown in the graph below, in 2014, 68% of MGMA member organizations were physician-owned and 20% were part of a hospital or integrated delivery system (IDS). The remaining 12% were academic practices or operated by a federal, state or city government, owned by an insurance company, health maintenance organization or industry, such as DaVita HealthCare Partners Inc., Denver. The number of hospital-/IDS-owned physician practices has increased in recent years, and hospital-/IDS-owned practices have increased in average size as hospital systems acquire new practices and employ additional doctors. The previous AMA survey was based on a 2007-2008 survey, which indicated that only 16.3% of physicians were hospital employees. The strategic rationale for hospitals to employ physicians has evolved over time. Creating a hospital-owned medical practice used to be viewed as a strategy to compete with other hospitals by having employed physicians direct admissions and referrals to hospital services. However, with the advent of value-based payment and government and commercial insurance companysponsored accountable care organizations (ACOs) there is new value to having primary care and specialist physicians employed by a hospital/health system because it enables common medical records, a single signature contract with insurance payers and the coordination of bundled and global payments, all of which are critical to succeeding in a value-based payment environment. We have observed that different health systems have created different strategies to acquire physician practices depending on the actions of competing health systems, whether the system has or plans to sign a government or commercial ACO contract and the health system’s relationship with its medical staff among other factors. The annual “Medical Practice Today: What members have to say” survey of MGMA members which should be arriving in your inbox soon, asks respondents to describe their organizational alignment in the past two years as well as future plans. The data reported in the July 2014 issue show that while 7% of respondents integrated with a hospital or health system by selling practice ownership (and 1% had dissolved such a relationship) in the past two years, many more MGMA members (11%) had integrated clinically with a hospital but retained independent ownership. The jump in the percent of practices that achieved clinical integration while retaining independence may be indicative of the next trend in organizational alignment, a scenario in which physicians’ entrepreneurial attitude increases productivity in the joint venture while they retain a significant degree of autonomy and self-governance. Examining plans for the future shows that while only 3% intend to integrate with a hospital or IDS, 8% intend to remain independent while achieving clinical integration. Also, 1% plan to dissolve their contractual relationship with hospitals or health systems. While it is still relatively rare, other types of healthcare organizations besides hospitals are looking closely at purchasing physician practices. Commercial insurers are exploring how they can acquire provider components that might enable the payer to better control healthcare expenditures for its beneficiaries. This model has worked well for Kaiser Oakland, (Calif.) Health Plans and in recent years four of the larger payers1 have followed suit with group acquisitions. Similarly, in 2013 Highmark Blue Cross/Blue Shield, Pittsburgh, Pa., acquired the West Penn Allegheny Health System, Pittsburgh, Pa. (eight hospitals with 2,100 affiliated doctors); and earlier this year, DaVita purchased Colorado Springs (Colo.) Health Partners, a 100-doctor multispecialty group, adding it to practices in California, Florida, Nevada and New Mexico that are managed by DaVita’s subsidiary HealthCare Partners, LLC, Torrance, Calif. Even anticipating the continued growth of physician groups that are part of hospital system, insurance companies and OCTOBER 2015
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publically-traded corporations, a significant majority of medical groups expect to remain independent, physician-owned enterprises. The clinical integration trend is expected to continue, but the opportunity to remain autonomous should outweigh the economic benefits of mergers. Also, an independent, physician-owned medical group can be much more adaptable to the evolving economic and regulatory environment. An independent practice has less capital investment tied up in brick and mortar compared with a hospital, and an independent practice can more easily align the interests of its governance, management and providers to a common goal. Will some physician practices be purchased by hospitals, insurance companies or business corporations? Undoubtedly. However, the predicted tsunami that was supposed to push all doctors into employment arrangements appears to be a mistaken forecast as the wave of practice acquisition seems to have ebbed.
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Are Medicare ACOs working? Experts disagree One of the missions of the 2010 federal health law is to slow the soaring cost of health care. A key strategy for Medicare is encouraging doctors, hospitals and other health care providers to form accountable care organizations to coordinate beneficiaries' care and provide services more efficiently. Under this experimental program, if these organizations save the government money and meet quality standards, they can be entitled to a share of the savings. Participation is voluntary. In August, Medicare officials released 2014 financial details showing that the so far the ACOs have not saved the government money. The 20 ACOs in the Pioneer program and the 333 in the shared savings program reported total savings of $411 million. But after paying bonuses, the ACOs recorded a net loss of $2.6 million to the Medicare trust fund, a fraction of the half a trillion dollars Medicare spends on the elderly and disabled each year. To help put this development in perspective, Kaiser Health News posed this question to several ACO experts: Three years in, the ACO program has many success stories, but it's not yet saving Medicare money. Is it working? Here are their answers, edited for clarity and space. Richard Barasch Chairman and CEO of Universal American Corp, whose subsidiary, Collaborative Health Systems, operates 25 Medicare ACOs The program started off slowly. Changing the behavior of doctors from fee-for-service to a value-based environment involves changing in some cases 30, 40 years of behavior and doesn't happen overnight. It's very, very hard work. The doctors who embrace it find it very challenging. Think about how it affects their entire practice. For these things to work, it has to be not just a value-based conversation but it also has to be about how the practice is actually managed. For example, the program wants us to encourage Medicare beneficiaries to get annual wellness visits. Most doctors don't think of their enterprise as a business with customers. They think of it as a practice with patients. And things like the marketing work to get people in for an annual wellness visit is something new to them. It's not something that they would typically do. So the notion of once a year, calling their members and asking them to come in--not just sending a little three by five inch card – but proactively getting them into the practice turns out to be a new exercise for many. Nine of our ACOs earned $27 million in shared savings. There's another thing going on here too, and this is sort of interesting from the non-financial, behavioral viewpoint. The doctors want to do the right thing. We're seeing a generational shift in how physicians view their practices--again with a little selfselection. They know that pay for performance is coming. Now they are being measured, and they want their scores high. They understand that the world is changing and there's a little bit of self-selection in our group with doctors who want to change along with the system. And what we found remarkable in the 2014 reporting period, even the doctors who did not earn bonuses were quite happy with the quality scores that were generated around their practices. They work hard to get their quality scores where they think they should be--and when they're not, the doctors are very, very chagrined. Hospitalizations in 2014 decreased on average by 11 percent for beneficiaries with chronic obstructive pulmonary disease, for example, and by 8 percent for those with congestive heart failure. They cared a lot about that, even though the money wasn't there in this marketing period. Robert Murray President of Global Health Payment, a consulting firm that works on health reform initiatives, and former executive director of the Maryland Health Services Cost Review Commission The recent results on ACO performance indicate that it hasn't been successful. A lot of people have characterized the results as lackluster at best, and I think things are even worse than that. Medicare's performance data ignores the fact that each of these ACOs made very substantial investments in infrastructure: new data systems, care management and care coordination systems that probably run anywhere between 1 and 2 percent of their target budget. If you apply that to the results of the ACOs, you would find that even a significant proportion of those meeting Medicare's goals would be underwater financially. The problems are largely based on design flaws. Because the formation of an ACO requires substantial levels of risk and large upfront infrastructure costs, they have been largely dominated by deep-pocketed health systems, hospital networks, large multispecialty physician groups or other combinations of specialists and hospitals. However, these providers are unlikely to make aggressive attempts to control costs because the hospital and specialists are still being reimbursed under traditional fee-forservice payment model. For hospitals, which have high levels of fixed costs, the way to cover costs and earn profits is to generate more volume. Their incentives run directly counter to the goals of the ACO program, which are to reduce costs, to reduce unnecessary use of hospitals and high-priced professionals. The ACO model for these groups is akin to asking an overweight patient to eat his or her own flesh to become thinner. CMS could correct these deficiencies by developing a new ACO model that features groups of primary care physicians (PCPs) as the key organizational building blocks. PCPs are at the center of care management activities for most Medicare beneficiaries and primary care is generally under-provided. Because PCPs account for a small share of total expenditures, it is possible to provide OCTOBER 2015
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large financial incentives with modest shared savings proportions, perhaps 20 to 30 percent. However, because they account for a small share of total costs, PCPs are unable to assume financial risk. Therefore, a PCP-led ACO must include a mechanism to pay for reasonable infrastructure costs while retaining the upside-only risk characteristic of the current Medicare Shared Savings Program (MSSP). Each PCP group should also be eligible for a shared savings payment if it generates savings, regardless of the performance of the entire ACO. Jeff Goldsmith Associate professor of public health sciences at the University of Virginia and president of Health Futures, Inc., a health analytics firm We are actually ten years in, not three. The ACO model was first tested in the Physician Group Practice demonstration, which began in 2005. The results of that demo greatly resemble those of the past three years: less than a fifth of the ACOs generate the vast majority of savings, and those failing to generate bonuses outnumber bonus winners three or four to one. Prominent among the "failures" are respected provider systems with decades of successful managed care experience in both the commercial market and Medicare Advantage. This isn't a new idea. You can make any program "work" if you employ Lake Wobegon accounting. Hire a friendly consultant to do your program evaluation, instead of a respected independent evaluator (how about the HHS Office of Planning and Evaluation?). Count the "savings" but ignore the overruns. Don't count the bonus payments as a "cost." Don't count ACO set-up or operating costs (so we cannot determine the return on investment from participation). Don't share the savings with Medicare beneficiaries. And voila, it "works." The CMS Innovation Center is a young agency with a very full plate. It has an audience, including Congress, health service research experts and the provider community. Its leadership needs to establish its credibility in order for its innovations to take hold. Picking the ACO as its lead project was a bad decision, and one that has not enhanced the center's credibility. Michael Chernew Professor of health care policy and director of the Healthcare Markets and Regulation Lab in the Department of Health Care Policy at Harvard Medical School The existing data unambiguously shows that overall the Pioneer program saved a little bit of money for CMS. There should be two separate questions: One of them is before health care providers shared the savings, did they save Medicare any money? And is after they shared the savings, did they save Medicare any money? I actually think the first question is more important because it speaks to the long run savings and sustainability of the model. Mike McWilliams and I, along with other colleagues published a paper that found the first year of the Pioneer program saved money by cutting spending by about 1.2 percent. But it saved money even after savings were shared. We don't have enough data yet on the MSSP program to make judgments, but I wouldn't conclude that they haven't saved money. I also speculate that over time we will see bigger savings and more organizations participate. Medicare has tweaked the rules to make the program more attractive to providers. In addition, ACOs can help providers get beyond the Affordable Care Act's productivity adjustments that will reduce the rate of growth in fee-for-service payment rates to hospitals and other providers. The ACO model allows these organizations to transfer some of the efficiency gains they make into bottom-line savings. If they reduce admissions, if they reduce readmissions, if they reduce wasteful use of diagnostic services, they can keep some of those savings. When they keep those savings, it doesn't look great if Medicare's spending is higher than it would have been if the savings were not shared. On the other hand, the incentives of sharing helped generate the savings in the first place and they might allow those providers to survive. We need to put the health system on a sustainable spending trajectory. Even though the Pioneer plans saved a relatively modest amount, we seem to be moving in a reasonable direction. You don't expect to get a lot of the savings early, but if you can get providers to do things that will control the rate of spending growth, over time you will get a payoff. What we need to do now is not worry about 2016, but worry about the health care system in 2025. I believe that looks better if we continue on this path. Moreover, the alternatives are not great. I don't mean that success is easy and I don't mean to imply that all organizations will succeed. This is not without risk. I am personally a bit optimistic. But I don't think success is a foregone conclusion. It is very hard for many organizations. Undoubtedly, some will fail. Sean Cavanaugh Deputy administrator and director of the Center for Medicare at the Centers for Medicare & Medicaid Services CMS' ACO initiatives are off to a successful start because beneficiaries are receiving measurably better care and the trust funds are saving money. In the Pioneer Model and the Medicare Shared Savings Program, which collectively provide care to more than 8 million Medicare
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beneficiaries, ACOs improved care from one year to the next and consistently outperformed fee-for-service providers in areas where there are comparable quality measures. In the third performance year, Pioneer ACOs showed improvements in 28 of 33 quality measures and experienced average improvements of 3.6 percent across all quality measures. Shared Savings Program ACOs that reported quality measures in 2013 and 2014 improved on 27 of 33 quality measures. In addition, Shared Savings Program ACOs achieved higher average performance rates on 18 of the 22 Group Practice Reporting Option Web Interface measures reported by other Medicare fee-for-service providers reporting through this system. In addition, an independent evaluation report for CMS found that the Pioneer Model generated more than $384 million in savings over its first two years, while the CMS Office of the Actuary has certified that an expansion of the Pioneer Model would be expected to save the trust funds additional funds. While the actuary has not opined officially on cost savings in the Medicare Shared Savings Program, the program's financial results are in line with those that we expected. And early results show that ACOs with more experience in the program tend to perform better over time. Among ACOs that entered the Shared Savings Program in 2012, 37 percent generated shared savings, compared to 27 percent of those that entered in 2013, and 19 percent of those that entered in 2014. Another sign of success has been the growth in interest in the ACO model. The Shared Savings Program now includes more than 420 Medicare ACOs serving more than 7.8 million Americans with original Medicare. The Shared Savings Program continues to receive strong interest from both new applicants as well as from existing ACOs seeking to expand and continue in the program for a second agreement period starting in 2016. Next year, CMS will launch the Next Generation ACO model, which has also garnered significant interest among providers. ACOs are a part of our vision of a system that delivers better care, spends our dollars in a smarter way, and puts patients in the center of their care to keep them healthy.
18 health technologies poised for big growth By now, everyone's got an EMR. And most providers are also making use of ancillary technologies to help harness patient data toward more efficient care and better outcomes. But many species of health IT are still surprisingly underused in the U.S. hospital market. "While the EMR market itself is pretty saturated, and usage has really improved since the HITECH Act, the challenge for hospitals and health systems is, now that you have all this data, what do you do with it?" says Matt Schuchardt, director of market intelligence solutions sales at HIMSS Analytics. There's no shortage of technologies out there to help hospitals improve operations. But it may surprise you to realize how relatively untapped they often still are. HIMSS Analytics' hospital database keeps tabs on all manner of IT products, and its list of the tools with biggest positive growth potential points to where the market will be heading in the coming years. It tracks technologies that have seen growth of 4 percent to 10 percent since 2010 – but have yet to be adopted by more than 70 percent of hospitals. In many cases, the percentage of potential customers far exceeds those that have a given product installed. The reasons for this are varied, says Schuchardt. In some cases, the tools have just recently become sufficiently well-developed to make a difference. Some are still fairly new technologies. Some are more sophisticated than smaller hospitals really need. Some require significant shifts in strategy and workflow, and providers may not yet be willing to take the plunge. But all offer the potential to help achieve the big goals: better care for more people at lower cost. "I think the opportunity for vendors to provide solutions is now," he says. "There are technologies in place now that can really help, and hospitals need to be aware of them." With EMRs by now well-established, he adds, "the next step of optimization is going to require analysis and utilization of all these large data sets, and really clear insights on best practices." We asked Schuchardt to weigh in on the HIMSS Analytics list, offering his thoughts on the potential of each. Bed Management Remaining first-time buyers: 49.7 percent It's surprising to think how few hospitals "know how their beds are used, and where they're in use," says Schuchardt. "Think about how expensive beds are getting: you have to staff them, of course, but the beds themselves are extremely expensive and you can't have them be empty." As such, "this is one technology that "has big growth potential." New software programs "are so much more sophisticated in terms of the data they're tracking," he says. "Knowing how many beds are empty, most hospitals probably do that on a spreadsheet. But really knowing how they're utilized – and which beds are the most expensive – is going to be incredibly helpful, in terms of the cost-cutting and savings people are hoping to get from these structural changes." Business Intelligence Remaining first-time buyers: 40.3 percent OCTOBER 2015
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Financial BI is fairly well-used, at least at larger institutions. But "clinical BI is still very lightly adopted, and there are lots of plans to purchase those tools," says Schuchardt. "You need the data, but once you have it, what do you do with it? You're going to need a tool to really analyze it. BI connects really well to population health, too: Population health is a series of components – it's integrating all those disparate data sets together to make the right decisions for patient care and from a business perspective." Data Warehouse Remaining first-time buyers: 39.7 percent An EMR, too, is a series of components, "with a clinical data repository being the hub of that spoke," he says. But in its most basic form that only means the data inside that system – "it's not all of the external data that's available – pay data, etc. You need all of that to really start doing BI." That's a massive amount of data that needs a place to live and a means with which to be fed into clinical and business intelligence platforms. And that's saying nothing of all the new data sources emerging onto the scene. "Now there are intelligent medical devices that are able to load your blood pressure into your record when you're at the hospital or the doctor's office," says Schuchardt. "There's a ton, a ton, a ton of data, and machine learning is going to start letting us make hay of that sooner, rather than later – but only if you have access to that kind of processing power." Dictation with Speech Recognition Remaining first-time buyers: 44.4 percent "This is another one where it's just a technology issue," he says, suggesting that many hospitals just have other competing priorities for their tech budgets. But the capabilities exist. "You can have Dragon at your house now. Everyone has Siri on their phone, although she's not very smart. You think about the kinds of words people use in healthcare it just increases the complexity. It's not, 'Hey, how do I get to here…' It's very technical and jargony – you need to make sure there aren't translation errors." Enterprise Master Person Index Remaining first-time buyers: 39.6 percent "EMPI is sort of like the next level of CDR," says Schuchardt. "It's like putting patient data in an easily sharable manner. The data sets in different EHRs aren't even necessarily correlatable. One may have your birthday as three fields and another might have it as an eight-digit code. Those two data sets are never going to talk. In that format, they're going to say, this isn't the same person – or you're going to have to build a very complicated query to connect those two data sets. It's getting to some standardization across vendors, and making the data much more sharable. Or allowing you to pull data into the EMPI as an interim step between connecting a physician office that's on one EMR to a hospital that's on another."
Rise of ‘Telemedicine’ Drives Move Toward Multi-State Nursing Agreement Andrew Kitchenman State lawmakers, nursing groups want to make sure NJ health-safety standards are maintained
This scenario could happen as soon as next year: A nurse is treating a patient in New Jersey, and the nurse isn’t even in the room – or even in New Jersey. There’s a nationwide effort underway to make it easier to provide healthcare by telephone or over the Internet, in what is known as “telemedicine.” New Jersey lawmakers are weighing whether to join the Nurse Licensure Compact, which would allow registered nurses and licensed practical nurses to practice across state lines. The compact has drawn interest from New Jersey nursing groups and legislators from both parties. But it also presents challenges before New Jersey can sign onto it. For one thing, the state law requiring criminal background checks for nurses is more rigorous than such laws in other states. In addition, the New Jersey Board of Nursing’s license database hasn’t been compatible with those of other states. Nurses can be involved in interstate phone consultations during emergencies, such as helping with patients who must be transported by helicopter to a hospital in another state. As the number of such cases has grown, the state-based system for regulating nurses’ licenses has become an issue. New Jersey nearly joined an earlier version of the Nurse Licensure Compact in 2001, but the state’s criminal-background checks and database incompatibility derailed the effort. Sen. Robert W. Singer (R-Monmouth and Ocean) wants to ensure that the same problem doesn’t recur. “The other states that we’re entering this compact with have a lesser requirement for nursing,” Singer said. At the same time, Singer said he sees the advantages of making it easier for out-of-state nurses to work in New Jersey. He recalled that during superstorm Sandy, different licensure rules were a roadblock to having nurse volunteers from Delaware and Pennsylvania help at overburdened clinics set up at shelters near the Jersey Shore. “I think it’s a great idea,” Singer said of the compact.
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The New Jersey State Nurses Association, the largest nursing group in the state, has mixed feelings about the bill. Association CEO Judith Schmidt said her organization supports the “concept of the multistate compact,” but asked legislators to delay action on a bill that would make New Jersey a party to the compact. “We would like to have some time to see what the other states are experiencing,” Schmidt said, adding that association members are concerned that other states will make changes to the compact that would require New Jersey to also make changes to state law. If such changes are made after New Jersey has passed the bill, it could delay New Jersey’s participation for several years, Schmidt explained. Bill sponsor Sen. Jim Whalen (D-Atlantic) said New Jersey legislators could keep an eye on what is happening in other states before passing a final version of the bill. If other states enact laws that are in synch with New Jersey’s, “fine, we move it on the floor,” Whalen said. “If they don’t, we hold it until the next session -- at least we’re one step in.” The next legislative session begins in January. Regarding Singer’s concern that other states have lower standards for licensing nurses, Whalen noted that the compact is intended to create universal standards that are similar to those in states with rigorous licensure. But Singer expressed skepticism, saying “There’s always an intent,” but adding that it may not play out in practice. Sen. Joseph F. Vitale (D-Middlesex), also a sponsor, noted that the bill must undergo more steps before becoming law, including having the nonpartisan Office of Legislative Services review its impact on the state budget. Jeanne Otersen, chief of staff for the Health Professionals and Allied Employees labor union, suggested amending the bill to add a provision that it wouldn’t go into effect until the other states' licensing standards are compatible with New Jersey's –and until New Jersey's database is compatible with the others. Under the terms of the compact, it will go into effect and become binding on the participating states when a majority of the states have joined it. Twenty-five other states, including Delaware and Maryland, have passed laws to join the compact, so it will go into effect when the next state signs on. The Senate Health, Human Services, and Senior Citizens Committee unanimously released the bill on Monday. It now goes to the Senate Budget and Appropriations Committee for a hearing. The Assembly version has been referred to the Assembly Health and Senior Services Committee.
Final Stage 3 EHR rule is out, but HHS signals more changes ahead By Joseph Conn
The Obama administration, under pressure from Congress and the healthcare industry to ease its mandates for the use of electronic health records, issued regulations for the current and final stages of its incentive program for the technology. But officials also acknowledged the new rules are almost guaranteed to be revised in the coming months. Changes are likely to be needed to accommodate federal legislation passed earlier this year and to slow the tempo of change that has repeatedly required federal officials to delay deadlines and add flexibility to the $31.5 billion program as EHR vendors and healthcare providers struggled to keep up. The CMS and the Office of the National Coordinator for Health Information Technology issued the new testing and certification criteria for EHR vendors and the final regulations outlining the requirements for providers to meaningfully use the technology in a single 752-page document (PDF). In a press statement accompanying the release of the rules, the CMS announced “a 60-day public comment period to gather additional feedback about the EHR incentive programs going forward, in particular with the Medicare Access and CHIP Reauthorization Act of 2015 (MACRA)." MACRA, which Congress passed earlier this year to replace the sustainable growth-rate formula, establishes a merit-based incentive payment system designed to prod physicians to move more of their patients into risk-based payment models. Achieving meaningful use will be a component of physicians' compensation under the MACRA pay scheme. “We will use this feedback to inform future policy developments for the EHR incentive programs, as well as consider it during rulemaking to implement MACRA, which we expect to release in the spring of 2016,” the CMS said. Dr. Patrick Conway, deputy administrator for innovation and quality at the CMS, said during a call with reporters that the rule offers flexibility to providers still trying to achieve Stage 2 goals this year. The new rule reduces the reporting period this year from one year to 90 consecutive days of meeting meaningful-use requirements. It also will provide some wiggle room for providers who had not yet upgraded to an eligible EHR system. “Even if they were to deploy it tomorrow, they could report that performance in 2016 and avoid a penalty,” Conway said. Conway asked for patience from critics calling on the administration to wait until 2017 to set the Stage 3 criteria. At this point, O C T O B E R 2 0 1 5 13
Conway said, the existing and future rules for the program could not be separated. “It's quite likely we would have penalized hundreds of thousands of providers” if those changes had been made. The agency will collect comments for the next 60 days so officials can make changes to the Stage 3 rule next year, an approach Conway suggested would allow the CMS "to get to a similar place" as delaying the rule. It's not clear how much patience the industry is ready to give. Physicians and hospitals weren't completely satisfied by the CMS' stated intent to modify the regulations to reflect their feedback. American College of Cardiology President Dr. Kim Allan Williams, for example, said the rule “does not account for the reality of the situation faced by the medical community.” Williams pointed out that many providers have tried, failed and given up meeting the current requirements of the program. “That is why it is vital that CMS consider participation data from the current stage to see what is working and what isn't before outlining an upcoming stage.” A recent Modern Healthcare analysis of program data indicated physician participation dropped by 12% in 2014 compared with a year earlier. Most of the critics who argued for a delay in Stage 3 until 2017 similarly asked for a period of assessment of Stage 2 achievements and failures first. The American Medical Association, however, thanked the feds for granting a hardship exemption for providers who are unable to clear the bar this year. The AMA added that it hopes the additional comment period will yield further improvements. The American Hospital Association called the rules “a mixed bag for hospitals and health systems and the patients they serve.” The AHA said it appreciated the 90-day reporting period this year, but the simultaneous release of the Stage 3 rules was “deeply disappointing” and “too much too soon.” “Despite the urging of hospitals, physicians and Congress, the Stage 3 final rule includes many new and more challenging requirements,” the AHA said. “More than 60% of hospitals and about 90% of physicians have yet to attest to Stage 2.” Sen. Lamar Alexander (R-Tenn.), who has taken up the cause of provider who want the government to put the brakes on the program, issued a statement Thursday threatening legislation to alter it. Alexander, who chairs the Senate Health, Education, Labor and Pensions Committee, said the Obama administration “rushed ahead with a rule against the advice of some of the nation's leading medical institutions and physicians.” Members of the College of Health Information Management Executives, however, is on the bus with where the CMS is heading with the meaningful use regulations. The organization, which represents about 1,700 hospital CIOs, also said provisions of the ONC's new requirements for EHR vendors will “lead to greater transparency regarding vendor products; improved testing and surveillance of health IT, and an improved focus on user-centered design.” Dr. Karen DeSalvo, head of the ONC, said those 2015 edition rules governing the functionality of EHRs will make data more available to consumers by requiring vendors build in application programming interfaces, or APIs, into their systems, which she called “doorways to data.” The regulations also improve cybersecurity and add tools intended to stop providers and vendors from engaging in practices the ONC has dubbed "information blocking." The ONC also issued a final draft Tuesday of its road map for achieving interoperability of health information technology.
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Nine Steps to Outsource Medical Practice Services Judy Capko These are challenging times with new and unexpected changes and demands being placed on practices that seek to be among the best. These expectations often result in practice leaders feeling a bit overwhelmed and (sometimes) understaffed. How can you manage all that is expected in your medical practice today and still run an efficient and profitable practice? Outsourcing just might be the ticket to help you divide and conquer some aspects of the workload. There are many service companies that specialize in specific areas of practice operations, such as managing payroll, transcription, coding audits, and even the entire billing and collection process. Because their focus is narrow, these companies can concentrate on developing and maintaining a high level of knowledge and expertise in their field. They can also afford to make capital investments in technology that would not be within the price range of the average practice.Perhaps there's an opportunity for your practice to think about enjoying the potential benefits of outsourcing? It is a big decision and one that will require diligent thought and analysis. Here are a few things to consider before making a decision to shift any service over to a vendor :1. Select an established vendor Explore only service companies that have a stable history and a proven track record .2. Know your expectationsBe clear on exactly what your expectations are and compare them to the services being offered and the promised deliverables. 3. Ask about data sharingUnderstand what information the practice must share with the vendor and what will be required of you and your staff. 4. Discuss communicationDiscuss how communication will flow back and forth, and if there is a point person or account rep. that will be assigned to your practice. 5. Know what it will costKnow exactly what the upfront and ongoing costs will be. 6. Contact outside referencesConduct reference checks of long-term clients. Find out how responsive the vendor is to clients; if it continually improves products and services; and how committed support staff are to both improving quality and excelling in customer service. 7. Ask about performance measuresClarify what measurable outcomes will be achieved so performance can be monitored against a benchmark. 8. Conduct a site visitOnce you identify a service company you'd like to work with, consider visiting one of its clients to gain additional perspective on how it operates and the value of the service it provides. 9. Retain an attorneyWhen you have chosen a vendor and are ready to finalize an agreement, there will be confidentiality statements and contracts to be signed. It's time to call in a lawyer to protect your interests. Ensure you understand the agreement and have a suitable escape clause should either party want to terminate the arrangement.
In-House vs. Outsourced Medical Billing: Pros and Cons The question of whether to outsource medical billing operations or keep the process in-house is one that weighs heavily on many doctors and practice managers. The right answer differs from practice to practice based on a multitude of factors: age of the business, size of local labor market, and state of practice finances, among other considerations. Aside from clinical services, billing and revenue cycle management are the most important processes of your practice. Your cash flow depends on them, so the decision of how to handle these services shouldn’t be taken lightly. You should do thorough assessments of your practice’s cost, staffing, and volume metrics to determine what’s right for you. In the preliminary stages of the decision-making process, however, you’ll need to take a generalized look at what most doctors and administrators consider to be the major advantages and disadvantages that the in-house and outsourcing options each present. In-House Medical Billing Pros Retaining Control: Especially when trusted, long-term employees are executing medical coding and RCM duties, doctors and administrators appreciate having hands-on control of financial operations through in-house billing. Return on Investment: Once a practice has invested in training medical billers and purchasing billing technology, moving to an outsourced solution means losing lots of time and money spent. When there’s a valid infrastructure in place, it’s worthwhile to just refine existing processes to generate the best ROI. Close Proximity: Should issues arise, the accessibility of your in-house billing department is a major advantage, since all it takes to observe the billing process and address any problems is a walk across the office floor. OCTOBER 2015
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Cons Higher Costs: It’s generally accepted that the expenses of paying billers’ salaries, covering employee benefits, and purchasing technology systems add up to more than is commonly paid out to a third-party billing solution. Liabilities: Medical billing departments can be hotbeds for embezzlement, and general employee neglect (think ignored encounter forms, discarded superbills, and unappealed claim denials) can go largely unnoticed if managers don’t keep a stringent eye on billing operations. Support Issues: If your billing department consists of only two or three staffers, your operations – and cash flow – can be majorly stalled when even just one employee gets sick, goes on vacation, takes a leave of absence or quits altogether. Outsourced Medical Billing Pros Less Expensive: Especially if you’re starting up a new business or transitioning because of an employee’s resignation, outsourcing makes the most financial sense. Check out this hypothetical cost analysis on the topic from Physicians News Digest. Transparency: A medical billing company should be able to supply you with comprehensive performance reports automatically or upon request. This capability grants you unparalleled visibility into your billing operations without requiring you to micromanage – or even oversee – any staffers. Enhanced Consistency: Your outsourcer will be contractually obliged to perform certain services, such as appealing denials, for you with a certain level of success. Plus, you never have to worry about staffing, since it’s their job to support your needs yearround. Cons Hands-Off: While many consider it an advantage that outsourcing makes the management of billing someone else’s problem, it’s tough for more hands-on managers to relinquish control of the process to another entity. Variable Cost: Most medical billing companies charge a percentage of collections, so the more you bring in, the more you’ll pay out. This can make it hard to budget your practice’s expected billing expenses, since costs differ widely between slow and busy months. Hidden Fees: Read any outsourcing contract very carefully. Are there startup charges? Fees for things like printing statements or sending reports? What happens if you cancel your membership? Make sure the money you save by outsourcing isn’t offset by a multitude of “fine-print” charges.
In Maryland, A Change In How Hospitals Are Paid Boosts Public Health Audie Cornish Joshua Sharfstein (center), secretary of the State of Maryland Department of Health and Mental Hygiene testifies at a hearing in 2011. Chris Maddaloni/CQ-Roll Call, Inc./Getty Images Think for a moment about what would happen if you upended the whole system of financial incentives for hospitals. What if you said goodbye to what's known as fee-for-service, where hospitals are paid for each procedure, each visit to the emergency room, each overnight stay? What if, instead, hospitals got a fixed pot of money for the whole year, no matter how many people came through the door? Would a change like that make hospitals rethink the way they care for patients? Would they think more creatively about how to keep people healthier so they wouldn't come to the hospital at all? Those very questions are being asked in Maryland, where an experiment in how hospitals are paid has been underway since early last year. The experiment came about under an agreement between the state of Maryland and the Centers for Medicare and Medicaid Services. It was championed by Dr. Joshua Sharfstein, who was then Maryland's Secretary of Health and Mental Hygiene. Sharfstein came into office in 2011, around the time the Affordable Care Act was being rolled out. Along with the expansion of health coverage for the uninsured, there was a lot of talk about improving health outcomes while cutting costs. The ACA created opportunities to test new ways of paying for and delivering care. Maryland was poised to act. That's because for nearly 40 years, Maryland had a unique system that set the rates, or the prices, that hospitals charged. Those rates were essentially the same for Medicare as they were for private insurers. In other states, Medicare pays less than private insurers, Sharfstein says. Medicare's participation in this system was contingent upon Maryland keeping price growth down.
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But in recent years, the system was starting to crumble. Prices were rising, and overall expenditures were also up, as hospitals tried to make up in volume what they were losing on price. Maryland had some of the highest hospital readmission rates in the country. "There were incentives built into the old system for volume," Sharfstein says. "If you can only make $2 on a pair of pants, you have to sell a lot of pants." With prices on the rise, Medicare's continued participation was in question. Rather than scrap the whole system, Sharfstein and his colleagues promised Medicare that Maryland would find a way to keep overall expenditures down while improving the quality of care and outcomes for patients. The plan hinged on ending fee-for-service payments to hospitals and moving to something called global budgeting. Instead of being paid per admission, hospitals would get a set amount of money for the entire year for patient care, regardless of how many MRI tests, ER visits or hip replacements there were. At the end of the year, if there was money left over, the hospitals could keep it. "Whereas before, hospitals could really only make money by keeping their beds filled, now they can actually do better if their community is healthier and they're preventing admissions," Sharfstein says. The state tested the approach in 10 rural hospitals. Those hospitals had to think in a new way about how to serve people outside their wards and ERs. The hospitals hired care coordinators to check with patients after they were discharged to make sure they were taking their medications and eating right, for example. Some hospitals created primary care centers in their communities, so patients had an easier way to see a doctor instead of making repeated trips to the emergency room. The hospitals also looked to partner with community groups working on issues as basic as housing. The pilot worked, and in January 2014, after 18 months of negotiations between Maryland and the federal authorities, global budgeting went statewide. It was voluntary for hospitals, but within six months every hospital in the state had signed up. Now, nearly two years into the five-year agreement, the Centers for Medicare and Medicaid Services says that hospitals are well on track to hit targets. Under the deal, Maryland has to save $330 million for Medicare over five years and reduce hospital readmission rates all while improving the overall health of residents. The Maryland Hospital Association says in the first year alone, cost savings topped more than $100 million, and hospital readmissions were down at a rate faster than the national average. Dr. Leana Wen, Baltimore's health commissioner, is eager to see hospitals in the city pitch in on public health. Meredith Rizzo/NPR "To a certain extent in the United States of America, a healthier community may mean a financial problem for the hospital, but no longer is that the case in Maryland," says Sharfstein. "And that creates a great opportunity for public health." That's because a hospital's bottom line now is directly connected to its ability to reduce preventable illnesses, a core mission of public health. "Is it a game changer? Probably," says Dr. Leana Wen, health commissioner in Baltimore. "It definitely is a game changer in concept. Because before, we were reimbursing for everything that we did to patients, not actually the care that we were providing to help patients not end up in the hospital in the first place." Wen wants to come up with a city-wide strategy that would bring together hospitals, treatment providers, community groups and others. She believes getting everyone on board is key to attracting state, federal and private dollars for projects that would yield big savings. And if hospitals see the dollars flowing, she hopes they'll chip in too. One such project is a stabilization center, a place where people who are drunk and high on the street can go to sober up and get into treatment. "If a hospital were to agree to provide nurses and nurse practitioners, that would be fantastic," Wen says. "Perhaps they provide funding. Perhaps they provide transportation." In return, the city would be relieving hospitals of a costly population of patients – people who routinely show up in emergency rooms with underlying substance abuse and mental health problems that cannot be addressed on the spot. The city is also working on some data-driven projects that Wen and others believe hospitals would also be willing to invest in. One is a database that identifies "high utilizers," the people who turn up in emergency rooms most often or call 911 repeatedly. Another is a Web-based dashboard that will show in real time the availability of mental health and substance addiction treatment slots across the city. OCTOBER 2015
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Dr. Cynthia Buchman Webb, chair of the emergency department at MedStar Union Memorial Hospital, says having such a tool would be a big help for hospitals, which often struggle to figure out where to send patients. "Right now, that is the problem," she says. "It's on all of our providers at every different institution to do that ourselves, to make sure we have the most up-to-date information. That's where Baltimore City can really play a big role." At the moment, the health department has a $30,000 grant to start building that dashboard, but more money and more buy-in from providers are needed to make it work. For the stabilization center, the health department has secured just over $3.5 million from the Maryland state legislature to cover capital costs, but they need another $3.5 million to operate it. They're piecing together funding from a number of sources and hope hospitals will be among them.
Dartmouth-Hitchcock pulls out of Medicare Pioneer ACO initiative
Dartmouth-Hitchcock Medical Center has pulled out of the Medicare Pioneer accountable care organization initiative, which has lost nearly half of its 32 original participants. The Lebanon, N.H.-based center lost money during the Pioneer ACO initiative, which requires participating providers to repay Medicare for failing to meet performance targets on quality and savings. Dartmouth-Hitchcock CEO Dr. James Weinstein said his system is at a disadvantage under formulas that cost the ACO $3.6 million in its third year. Pioneer cost-saving targets reward improvement, meaning providers that are the least efficient can make the greatest gains and earn the biggest rewards. But his system already operated efficiently. “You're asking organizations that are already running really well to run a two-minute mile,” he said. “It's not possible.” To create incentives for everyone to improve, the CMS Innovation Center could minimize potential penalties for the most efficient ACOs and limit the potential bonuses for the least efficient, he suggested. Another issue, he said, is that quality performance is not given the same weight as financial savings. Dartmouth-Hitchcock may enter Medicare's Next Generation ACO program, a new test of the payment model that will begin in January. But Weinstein said that model also has flaws.
AmSurg seeks to merge with TeamHealth in $7.8B deal
Nashville-based AmSurg Corp. announced Tuesday that it wants to merge with Team Health Holdings in a $7.8 billion stock-andcash deal that will create the largest physician ambulatory service in the country. AmSurg and TeamHealth together will comprise a network of more than 1,200 healthcare facilities and approximately 20,000 clinicians, according to a news release announcing the deal. TeamHealth so far has resisted the overtures. Amsurg also released a letter sent to TeamHealth's board of directors after a Sept. 30 meeting. "We are disappointed to learn that you chose not to engage with us based on what appears to be a very cursory analysis of our specific proposal and key deal terms. Our goal here is to ask you to reconsider," wrote Christopher A. Holden, President and CEO of AmSurg. The company would dominate the areas of ambulatory surgery, anesthesia, emergency services, hospitalists, radiology and neonatology. “Our proposed combination will be transformational for both AmSurg and TeamHealth shareholders as well as for the physician services sector as a whole," said Holden, who proposes remaining CEO of the combined company. Holden added that the combined company will have significantly enhanced free cash flow and expanded opportunities to accelerate growth. Under the terms of the proposed merger, the combined company would assume the TeamHealth name, and TeamHealth would continue to operate out of its headquarters, according to the press release. The Board of Directors would include representatives from AmSurg and TeamHealth. The AmSurg and Sheridan operations would retain their brands. In August TeamHealth said it would acquire IPC Healthcare in a $1.6 billion deal. TeamHealth rejected rumors at the time that it was pursuing that deal to fend off a takeover.
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Tuomey will pay U.S. $72.4 million to duck $237 million False Claims verdict By Lisa Schencker
Tuomey Healthcare System has agreed to settle with the government for $72.4 million—less than a third of the $237 million that a federal appeals court said it would have to pay for illegal compensation arrangements with doctors. The sum required by the verdict would otherwise have been the largest levied against a community hospital and would have exceeded the Sumter, S.C., system's annual revenue. As part of the settlement, Tuomey will also be sold to Palmetto Health, a system based in Columbia, S.C. Tuomey previously signaled it planned to partner with Palmetto. Attempts to reach Tuomey for comment were not immediately successful Friday afternoon. Tuomey said in a statement Friday that the settlement will bring its decadelong struggle with the U.S. Justice Department to an end once the partnership with Palmetto is finalized Jan. 1. “We are now able to close this chapter and look to the future,” said Tuomey CEO Michelle Logan-Owens in a statement. She said she was elated to share news of the agreement with Palmetto and “moved beyond words with joy as I report today, we also signed a settlement with the Department of Justice.” Before agreeing to settle the case, Tuomey had already lost three times in federal court. In 2013, a federal jury concluded that Tuomey violated the False Claims Act by submitting tens of thousands of illegal claims to Medicare. The jury found that Tuomey paid doctors in ways that rewarded them financially for referring patients to the hospital in violation of the Stark law, tainting the Medicare claims. A federal appeals court upheld that decision in July. Tuomey had argued in the appeals court that it had relied on the advice of its lawyers regarding its physician compensation arrangements. The court, however, noted that Tuomey should have taken more seriously concerns raised by one of the lawyers with whom it consulted over the contracts. The not-for-profit Tuomey system is anchored by Tuomey Regional Medical Center, which has 252 staffed beds, according to the American Hospital Association. It's the only hospital in Sumter, a city of about 40,000. Legal experts said it's not surprising Tuomey agreed to settle, given the appeals court's decision and the huge verdict levied against it. “Tuomey didn't really have any other options, I think, but to settle,” said J.D. Thomas, a partner at Waller Lansden Dortch and Davis. The decision by the 4th U.S. Circuit Court of Appeals didn't leave much legal wiggle room, and the case would have been a long shot for consideration by the U.S. Supreme Court, he said. The settlement allows the hospital to keep its doors open and the government to get paid. It otherwise would have likely been tough for Tuomey to cough up $237 million, which exceeds its annual revenue. “They want to reach a result that allows the government's claims, or the damages they believe they suffered, to be paid back while at the same time allowing a healthcare operator to continue to operate,” Thomas said. Reed Stephens, a partner at McDermott Will & Emery, said the settlement and case itself indicate the high stakes involved in cases alleging violations of the Stark law and False Claims Act. “The outcome is a reflection of how challenging it is for hospitals to manage the risk that they run under the highly complex Stark law regulations,” Stephens said. The Stark law, which governs financial relationships between physicians and other providers, has been widely criticized for its complexity, including by federal appellate Judge Albert Diaz, who recently upheld the verdict against Tuomey. “It seems as if, even for well-intentioned healthcare providers, the Stark law has become a booby trap rigged with strict liability and potentially ruinous exposure—especially when coupled with the False Claims Act,” Diaz wrote in his decision. Under the False Claims Act, those found guilty are liable for three times the amount of actual damages as well as financial penalties for each false claim. Increasingly, alleged Stark violations have been brought to court as False Claims cases, a trend Stephens said he doesn't see ending any time soon because of the large potential payouts for the whistle-blowers who bring such cases. The case was originally filed in 2005 by a whistle-blower, Dr. Michael Drakeford, who declined to enter into an agreement offered by the hospital. In successful False Claims Act cases, whistle-blowers are entitled to a percentage of whatever money the government is able to recover. Drakeford will receive $18.1 million from the settlement. OCTOBER 2015
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