The Affordable Care Act is heading back to the Supreme Court this Spring. The issue presented to the Supreme Court on this occasion is whether the IRS is authorized promulgate regulations to extend tax credit subsidies for coverage purchased through Federal Government’s Health Care Exchange.
The Affordable Care Act allows individuals who purchased health coverage through State-established Health Care Exchanges to subsidize a portion of that coverage through the form of refundable tax credits. The United States treasury directly pays each eligible taxpayer to offset the cost of the taxpayer’s insurance premium. However, a majority of States (including Florida) have elected not to establish their own Health Care Exchanges. In order to provide coverage to persons in these States, the Federal Government set up its own Health Care Exchange marketplace.
We’re past the tipping point and are proceeding headlong into new market-driven accountability for quality, cost and value. As these large-scale changes progress, physicians who want to thrive and be positioned for long-term success will have to embrace new ideas and approaches in their practices.
A few years ago physicians in Ohio created their own physician-owned company to assist themselves with success in the changing world of healthcare. Via their company, The Medical Group of Ohio (MGO), they created a clinically integrated physician network comprised of nearly 2,100 physicians. The vast majority of these physicians are in small independent practices. Being clinically integrated means the physicians are working together, using proven physician-created protocols and measures, to demonstrably improve patient care, decrease cost, and deliver value.
The US Department of Health and Human Services, Office of Civil Rights is the chief enforcer of HIPAA. The Office’s recent enforcement of HIPAA with respect to a Massachusetts derm practice is illustrative of how the government views HIPAA and how vulnerable medical practices are.
Now that we’re on other side of the holidays and solidly planted in 2014, it’s a great time to chart a new course. Here are 8 things you can do that will make you money or save you money:
Hire someone. If you are a solo practitioner, are responsible for generating the revenue and also for leading your business, you will learn one clear thing: it’s impossible! It’s simply impossible to do both. In business, if you are not growing, you’re sinking. There is no such thing as maintaining the status quo. If you can’t see how you can afford to do it, then you need to meet with your financial advisors, since at least some part of the work of your new hire will come off your plate. It may even make sense to ask a local hospital to assist you in bringing in a new doctor.
H.R. 2914 is a bill filed by Congresswoman Speier that is intended (among other things) to prohibit medical practices providing the following sorts of medical services (“Non-ancillary Services”) to their own patients—
*The technical or professional component of (i) surgical pathology, (ii) cytopathology, (iii) hematology, (iv) blood banking, or (v) pathology consultation and clinical lab interpretation services
*Radiation therapy services and supplies
*Advanced diagnostic imaging studies (which include for instance MR and CT)
Since its passage in 1989, the now ubiquitous federal law known as the Stark Law has driven the business behavior of health care providers of many kinds. Recent developments, however, make us wonder whether the end of Stark is near, and if so, whether that’s a good thing.
By way of background, the Stark law has two components: part one, a self referral prohibition, generally forbids physicians from referring to a provider of any “designated health service” (DHS) (e.g. MRI, PT, clinical lab) if the physician or his/her immediate family member has a financial relationship (including ownership interest) with the provider of the service. Part two mandates that certain compensation arrangements between healthcare providers meet certain requirements. Things like medical director agreements, management agreements, employment and independent contractor arrangements have been regulated by the law since its inception. Most notably, for purposes of this article, one provision (the “In Office Ancillary Services” exception or “IOAS”, also known as the “Group Practice Exception”) has allowed medical practices to provide all sorts of “ancillary services” to their own patients. That is the key aspect of the law that is lately coming under serious attack.
Hospitals, particularly those heading ACO development efforts, are quick to say things like “One day, all physicians will be employed by hospitals.” Though there is clearly some wisdom under that statement, it’s also a remarkable leap of faith.
Three things are clear in this era of healthcare reform: (1) healthcare will be provided to more, but with less; (2) there will be a growing move over time to pass financial risk to providers; and (3) those businesses in a position to control both costs and quality (and some say patient satisfaction) are in a position to both survive and even do better than ever.
This leaves the door wide open as to the form of the business that can succeed. Is it a single specialty mega practice? Is it a multi specialty medical practice? How about a hospital?
Healthcare professionals today are constantly faced with views of what’s changing in healthcare, and all of them seem equally convincing. “One day, everyone will be employed by a hospital” is one of the favorites. Not surprisingly, the proponents of that perspective tend to be….hospitals. “Everyone has to merge their practices” is another favorite. The proponents? Large super practices, of course.
How does one sort through this? Who’s right? The truth is that everyone is seeing part of the whole and is “right.” But being “right” doesn’t mean right for you. My opinion?
Has your practice implemented a compliance program or considered improving an existing one? Is it really necessary? Prior to the Patient Protection and Affordable Care Act (ACA), the necessity for physician practices to develop compliance plans was merely voluntary. However, the ACA will now require physician practices to have a fraud and abuse compliance plan in place as a condition of continuing to participate in Medicare or Medicaid programs. Because the government first published guidelines in the year 2000 for the voluntary use of compliance plans in physician practices and has subsequently enacted a mandate in the ACA for compliance plans, many physician practices are proactively implementing them. While this compliance plan mandate may be viewed by physicians as yet another administrative burden and expense to the practice, it can have many benefits as well. Implementing an effective compliance program can have the result of not only reducing liability risks, but can also allow a practice to reap monetary benefits. In fact, it could be more costly for the practice not to have one!
The popular conception in healthcare is that (1) a new law was passed, (2) it changed everything, and (3) in a bad way. Over time, however, it should get clearer that, while there was a law passed, the law alone is not driving changes to our healthcare system: it’s our own demographics and behavior. Most of the tax dollars currently fueling our healthcare system (and arguably our economy) are tied to an aging Boomer population that are soon to drop off the income producing cliff into the Medicare population. Bye bye income earners; hello ridiculous public healthcare expenditures. Though it is true that the timing for expanding public spending on healthcare (with the federal mandates aimed at employers and Medicaid eligibility expansion) could not be more poorly timed, the situation is more of a “Perfect Storm” than a surgical strike.
The financial stress of our changing population and of a historic utilization based healthcare system is causing our healthcare system to morph in every way. “Health insurance,” with increasing cost, copays and deductibles and reduced benefits, is quickly ceasing to look like your father’s 80/20 major medical plan and starting to look more like catastrophic coverage. Fee for service compensation is fast becoming “spoken” out of existence. There are more “pay for performance,” “case rate” and other outcome and risk based compensation models than you can shake a stick at. The simple truths are: payers have to deliver more with less; and patients have to bear more and more of their healthcare expenses.
Health law is the federal, state, and local law, rules, regulations and other jurisprudence among providers, payers and vendors to the healthcare industry and its patient and delivery of health care services; all with an emphasis on operations, regulatory and transactional legal issues.