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UnitedHealth Takes a Bold Step Forward in Payment Reform Print E-mail
Written by Bernd Wollschlaeger, MD, FAAFP, FASAM   
Monday, 05 March 2012 10:48

Recently, the Wall Street Journal published an interesting article titled "New Way to Pay Doctors: UnitedHealth, Nation's Largest Insurer, Is Latest to Announce Fee Overhaul."

According to the article, "Under the new plan the carrier is rolling out, part of medical providers' compensation could be tied to goals such as avoiding hospital readmissions and ensuring patients get recommended screenings. UnitedHealth has been trying such efforts on a more limited scale, but now the company says it plans to roll out new contracts nationwide that could include financial rewards for care the company considers high-quality and efficient, and in some cases potentially withhold expected increases if certain standards aren't met."

Under an aggressive projection, costs could amount to as much as $3.27 per member a month by 2015, with savings as high as $7.80, the documents said. Using a less-aggressive scenario, the company said, the costs could amount to 46 cents, and the savings to $1.35, per member a month.

Much of the cost under both projections wouldn't be locked in, since it would be tied to bonuses that providers would get only if they hit certain goals; indeed, those payments may be calculated as a share of the overall savings achieved. According to the released information pieces of the new payments may be in lieu of increases to traditional fees.  Driving the payment reform is the growing realization that the current health-care payment system, with its fees for each service, is flawed. The current system entices quantity but no quality and a value-based reimbursement system would stir healthcare towards prevention, quality and outcome oriented care. Donald Berwick, former administrator of the Centers for Medicare and Medicaid Services, said the initiative "looks promising," but it would be important for the incentives to be strongly enough tied to quality and patient-satisfaction measures, in addition to efficiency goals, to ensure there's no "skimping on care".

In a description of some of its pilot programs, the carrier mentioned potential bonuses of $1 to $3 per member a month for primary-care physicians. For a different provider setup, called accountable care organizations, the document said the bonuses could amount to $1 to $5 per member a month. Accountable care organizations can be built around hospitals or doctor groups, and they generally involve a provider taking overall responsibility for a group of patients.

UnitedHealth also said it could offer "clinical integration" fees for providers that make changes aimed at better tracking patients' conditions and coordinating their care. This would include the model known as "patient-centered medical homes," which are typically set up by primary-care doctors, but the fees could also be available to other providers making similar efforts.

In my opinion physicians can and should play a proactive role in the payment reform initiative. We have to reorganize our practices, implement efficiency measurements and form groups organized along the Patient-Centered Medical Home concept. We cannot expect that insurance companies will provide us with the panacea for our economic woes. Now is the time to act!

Dr. Wollschlaeger is a frequent contributor to FHIweekly and Specialty Focus.  You can read more of his articles by visiting
http://floridadocs.blogspot.com/
Last Updated on Saturday, 24 March 2012 16:35
 
Noncompetes Are Once Again Relevant For Recruited Doctors Print E-mail
Written by Jeffrey L Cohen, J.D.   
Friday, 24 February 2012 11:52

When the Stark II (Phase III) regulations were released in August, 2007, they clarified that when a hospital recruits a physician to a medical practice, the employment agreement between the medical practice and the newly recruited physician may contain practice restrictions as long as they do not "unreasonably restrict" the recruited physician's ability to practice medicine within the recruiting hospital's service area. This stymied many medical practices which were reluctant to hire a new physician without a noncompete and nonsolicitation provision. A 2011 CMS Advisory Opinion (No. CMS-AO-2011-01) changed this.

The Advisory Opinion involved a pediatric orthopedist who was recruited by a hospital to a medical practice. The medical practice wanted to hire the new doctor, but was not willing to do so without a noncompetition provision and other restrictive covenants. The practice asked CMS for guidance because the Stark regs suggested that perhaps a noncompete could not be contained in the employment agreement of a physician recruited by a hospital to join a local medical practice. In fact, a prior version of the Stark regs was clear that noncompetes were not permitted in the employment agreements of physicians recruited by hospitals.

Hospital recruitment transactions involve bringing a physician into a new area and funding the start up period (usually a year). The nice thing for a medical practice is that the dollars given by the hospital to the practice (the difference between salary and benefits and collections) can run into the hundreds of thousands of dollars! The down side was that the medical practice could not tie the recruited physician's hands with a noncompete or other similar restriction. The Advisory Opinion is, however, a game changer because it allowed the medical practice to impose a noncompete on the recruited physician.

As mentioned, the practice would not hire the recruited physician without the noncompete. The noncompete had a 25 mile radius, and the Opinion cited the following relevant facts: 

1. The recruited doctor would remain on one of five hospitals within the 25 mile zone;
2. The recruiting hospital's service area extended beyond the 25 mile zone, in which there were at least three other hospitals within a one hour driving range;
3. The noncompete complied with applicable state law.

Based on these facts, the OIG permitted a one year noncompete because it did not "unreasonably restrict" the doctor's ability to practice in the recruiting hospital's service area. Certainly, many other medical practices can be sure to follow suit.

Physicians interested in nocompetes must be familiar with state law. Getting to the bone of the issue, noncompetes are enforceable in Florida if:

Click HERE to read the rest of the story. 

With almost 25 years of healthcare law experience following his experience as legal counsel for the Florida Medical Association, Mr. Cohen is board certified by The Florida Bar as a specialist in healthcare law. With a background and expertise in transactional healthcare and corporate matters, particularly as they relate to physicians, Mr. Cohen's practice involves him in regulatory, contract, corporate, compliance and other healthcare law related matters. As Founder of the Florida Healthcare Law Firm, Mr. Cohen can be reached at 888-455-7702 or online at jcohen@floridahealthcarelawfirm.com.
Last Updated on Monday, 05 March 2012 11:00
 
MGMA Chief Calls for Further Delay of 5010 in Letter to HHS Secretary Print E-mail
Written by Jeffrey Herschler   
Monday, 13 February 2012 09:34

"The Medical Group Management Association (MGMA) requests that you take immediate action to address the payment disruption issues that have occurred as a result of the federally mandated transition to HIPAA Version 5010 electronic transactions on Jan. 1. Medical practices throughout the nation are experiencing significant challenges implementing these new transactions, a situation that has led to considerable cash flow problems for physicians and their practices. Problems are being reported with both Medicare Administrative Contractors (MACs) and commercial plans.  

Should the government not take the necessary steps, many practices face significantly delayed revenue, operational difficulties, a reduced ability to treat patients, staff layoffs, or even the prospect of closing their practice. As the transition to Version 5010 is a mandatory step toward ICD-10 implementation, this raises even more concerns, understanding the magnitude of ICD-10 is exponentially greater than Version 5010."

Click HERE to read the entire letter.
 
Med Mal Litigation Results in Questionable Justice Print E-mail
Written by Jeffrey Herschler   
Friday, 03 February 2012 11:12

According to author Philip K. Howard in his book LIFE WITHOUT LAWYERS - Restoring Responsibility in America:

"Overall, including settlements, about 25 percent of medical malpractice payments are made on claims, without merit..." 

He goes on to point out that "The error works in the other direction as well...25% of meritorious claims got nothing."

Mr. Howard, by the way, is an attorney.

Last Updated on Friday, 03 February 2012 11:15
 
AMA Writes to Speaker Boehner, Recommends a Stop to ICD-10 Implementation Print E-mail
Written by Jeffrey Herschler   
Friday, 03 February 2012 10:59

"The implementation...will create significant burdens on the practice of medicine with no direct benefit to individual patient care..."

James L. Madara, MD, Executive VP and CEO of the American Medical Association recently wrote a letter to John Boehner, Speaker of the House, urging him to "put a stop to the Health Insurance Portability and Accountability Act (HIPAA) required implementation of ICD-10". Citing the burden of coping with "with 68,000 codes - a fivefold increase from the current 13,000 codes" and issues in Canada involving "high risk for claims processing and payment disruptions" associated with ICD-10, he recommends a "call on stakeholders to assess an appropriate replacement for ICD-9." Dr. Madara estimates the cost of transitioning to the new coding system as between $83,290 to more than $2.7 million per healthcare practice.

Click HERE to read the letter.
Last Updated on Monday, 06 February 2012 07:49
 
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