BLOG: Fighting Words
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CMS will give providers flexibility on MACRA requirements
By Virgil Dickson | September 8, 2016 (Story updated at 5:11 p.m. ET)
The CMS on Thursday announced it will allow providers to choose the level and pace at which they comply with the new payment reform model aimed at emphasizing quality patient care over volume. The announcement comes after intense pressure from industry stakeholders and policymakers to ease implementation of the Medicare Access and CHIP Reauthorization Act, which is set to start Jan. 1, 2017. Two months ago, CMS Acting Administrator Andy Slavitt said the agency was considering delaying the start date.
Next year, eligible physicians and other clinicians will be given four options to comply with new payment schemes such as the Merit based Incentive Payment System (MIPS) or an alternative payment model such as accountable care organizations.
Read more here.
By Heather Caspi | September 8, 2016
Although details of the settlement in this doctor-health system monopoly case are under seal, one fact is clear: Independent doctors' voices were heard, and they were taken seriously.
Physicians Score Antitrust Settlement
With Health System
Medscape Medical News | August 19, 2016
By Robert Lowes
In a David-vs-Goliath court battle, a collection of independent physicians has scored a settlement with a Central Florida health system accused of anticompetitive actions that allegedly hurt physicians' ability to practice medicine.
The case highlights some of the challenges facing independent medical practices in the era of Big Box healthcare.
The health system in question is Rockledge-based Health First, which encompasses four hospitals, a multispecialty medical group, outpatient services, such as home and hospice care, and health insurance plans, including some for Medicare Advantage. In 2013, Health First and related defendants were sued in federal court for antitrust violations by a multispecialty medical group called Omni Healthcare, three other medical practices, seven individual physicians, a physician assistant (PA), and a PA services company.
These practitioners claimed that Health First, enjoying market power, pressured them to refer patients exclusively, or nearly so, to the system's hospitals, physician specialists, and ancillary services. Those who didn't "play ball" found themselves dropped from Health First's insurance provider panels and its hospital medical staffs as well as boycotted by compliant physicians, according to the lawsuit. Noncompliant practices lost patients and revenue as a result. Health First also allegedly lured their physicians to join the system empire.
To gain further control of referrals, the plaintiffs said, Health First 3 years ago acquired the largest independent physician group in the area, which was ordered to admit patients in house. This attempt to monopolize physician services restrained competition and drove up costs, the argument went.
Omni Healthcare and other plaintiffs also accused Health First of attempting to monopolize the local market for Medicare Advantage plans.
The plaintiffs asked the court to unwind its medical practice acquisition, divest its health plans, and pay close to $350 million in monetary damages.
"Disgrunted Cries" From Fee-for-Service Relics
Health First countered in court filings that the plaintiffs lacked sufficient evidence to support their claims. It described itself as a "pioneering" integrated delivery network that provided coordinated, wellness-oriented patient care at competitive costs, in contrast to the "archaic" fee-for-service model advanced by the plaintiffs. Their lawsuit, Health First said, represented "the empty cries of disgruntled doctors upset with the evolution of modern healthcare delivery networks." More to the point, the plaintiffs were disgruntled by the "downward pressure" that Health First put on reimbursement rates.
"[Health First's] refusal to accommodate plaintiffs' practice models is the result of competitive market forces, not antitrust violations," the system said.
The system also contested the claim that it was trying to take over the local Medicare Advantage market, arguing in part that there is no separate market for these plans because they compete with traditional Medicare. That's the same position taken by health insurer Aetna in its tussle with the Department of Justice (DOJ) over its proposed merger with Humana. The DOJ sued Aetna and Humana on July 21 to stop the merger on the grounds that, among other things, it would reduce Medicare Advantage competition in more than 350 counties in 21 states, home to more than 1.5 million Medicare Advantage customers.
The DOJ pronouncement that there are separate markets for traditional Medicare and Medicare Advantage — and to make a fight over it — did not appear to bode well for Health First as its antitrust case proceeded through federal court.
Settlement Ends Trial on Second Day
Health First failed in its attempts to keep the lawsuit from going to trial. US District Judge Roy Dalton Jr, in Orlando, ruled that there was enough evidence for the case to proceed.
However, on August 16, the second day of the trial, just after the opening arguments, the settlement was struck. It covered all the plaintiffs' claims against the defendants, according to a joint statement issued Wednesday by both sides. They said that they had agreed to give a former federal judge the authority to "mediate and to resolve any disputes that may arise in the preparation of final settlement documents." No other terms of the settlement were disclosed.
It is not known whether the settlement will reinstate physicians who were dropped from Health First insurance provider networks or from the medical staffs of system hospitals on account of allegedly anticompetitive actions by the system. Likewise, it's not clear whether Health First will divest itself of the medical practice it acquired or the health plans it formed, or pay any money to the plaintiffs.
Medscape Medical News did not receive answers to specific questions about the settlement from either Health First or an attorney for the plaintiffs.
Settlements of court cases often stipulate that none of the parties admit any wrongdoing or claim either legal victory or defeat.
Follow Robert Lowes on Twitter @LowesRobert
Naseem S. Miller Contact Reporter
Group of medical practices and doctors in Brevard County allege that Health First is running a monopoly.
A trial expected to last three weeks began Monday in an antitrust lawsuit filed by a group of Brevard County medical practices and doctors against Health First health system.
The group alleges that by owning hospitals, physician practices and health insurance plans, Health First has created a monopoly in southern Brevard County, negatively affecting their finances and business relationships, and leading to higher prices and lower quality of care for patients.
"There's no place where competition is more important than in health care," Joe Whatley, one of the plaintiffs' attorneys told the jury in his opening statement.
Health First, which says it's a positive competitive force and a fully integrated community-based, health-care delivery system, denies all allegations.
Read full story here.
SVN COMMERCIAL ADVISORY GROUP SUPPORTS
INDEPENDENT DOCTORS WITH $10,000 SPONSORSHIP
In a move that underscores its support for the independent doctors of America, The Gail Bowden Team of SVN Commercial Advisory Group, a commercial real estate firm specializing in medical office property, became the newest corporate sponsor of the Association of Independent Doctors, the two groups announced today.
AID is a national nonprofit trade association that is fighting the consolidation of hospitals and medical groups, a trend that is driving up health-care costs, reducing quality and harming small business. Based in Winter Park, Fla., AID has 1,000 members in 16 states coast to coast.
“Independent doctors are the most important part of patient care,” said Gail Bowden, a senior investment advisor, who spearheaded the $10,000 sponsorship. “We need to keep them in business.”
Last year, Bowden ranked No. 1 in Florida and No. 3 internationally out of all SVN’s commercial real estate advisors.
Together Bowden and associate advisor Jessica Fleming have more than 40 years of
experience helping doctors find, negotiate and finance the best medical real estate arrangements possible.
“We can be a true asset to independent physicians negotiating a fair market lease or purchase contract anywhere in the United States or Canada,” said Bowden.
“We are always looking for partnerships that add value to our doctor members,” said Marni Jameson Carey, AID’s executive director. “This was a perfect fit, as both of our organizations are committed to helping independent doctors stay that way.”
In becoming a corporate sponsor of AID, SVN joined other AID partners which include Allyne Health, a provider of custom financial solutions for medical practices; Kareo, a cloud-based medical billing and technology platform; and McKesson, the world’s largest provider of medical supplies.
Read how one doctor and Obama advisor could no longer ignore the evidence: Independent doctors generate savings and improved quality far more often than large hospital systems do.
How I Was Wrong About ObamaCare
The law's drafters wanted consolidation: 112 mergers last year. But smaller practices have improved care better.
WALL STREET JOURNAL
Opinion | Commentary
By BOB KOCHER
July 31, 2016 4:35 p.m. ET
I was wrong. Wrong about an important part of ObamaCare.
When I joined the Obama White House to advise the president on health-care policy as the only physician on the National Economic Council, I was deeply committed to developing the best health-care reform we could to expand coverage, improve quality and bring down costs. We worked for months to pass this landmark legislation, and I still count celebrating the passage of the Affordable Care Act with the president one balmy spring night in 2010 as one of my greatest Washington memories.
What I got wrong about ObamaCare was how the change in the delivery of health care would, and should, happen. I believed then that the consolidation of doctors into larger physician groups was inevitable and desirable under the ACA. I joined my White House health-care colleagues— Ezekiel Emanuel and Nancy-Ann DeParle—in writing a medical journal article arguing that “these reforms will unleash forces that favor integration across the continuum of care.” We added that “only hospitals or health plans can afford to make the necessary investments” needed to provide the care we will need in a post-ACA world.
Well, the consolidation we predicted has happened: Last year saw 112 hospital mergers (up 18% from 2014). Now I think we were wrong to favor it.
I still believe that organizing medicine into networks that can share information, coordinate care for patients and manage risk is critical for delivering higher-quality care, generating cost savings and improving the experience for patients. What I know now, though, is that having every provider in health care “owned” by a single organization is more likely to be a barrier to better care.
Over the past five years, published research, some of it well summarized on a Harvard Medical School site, has indicated that savings and quality improvement are generated much more often by independent primary-care doctors than by large hospital-centric health systems.
Look at accountable-care organizations (ACOs), in which doctors and health-care providers come together to provide complete care for an individual and are compensated for keeping them healthy and generating savings. Based upon the latest data the Centers for Medicare and Medicaid Services has released,from 2014, independent physician-led ACOs, like the Rio Grande ACO on the Texas border, are outperforming ACOs from many of the most famous health systems. Johns Hopkins Hospital in Baltimore has been ranked as one of the top three health systems in the nation, but its ACO failed to achieve shared savings in 2014.
Small, independent practices know their patients better than any large health system ever can. They are going up against the incumbent and thus are driven to innovate. These small businesses can learn faster without holding weeks of committee discussions and without permission from finance, legal and IT departments to make a change.
More often than not, one of the most important changes these practices make is embracing technology. The ability to store, analyze and make sense of data has now become so easy and inexpensive that all physicians can use “big data.”
In my White House days, we believed it would take three to five years for physicians to use electronic health records effectively. We were wrong about that too. At every opportunity, organized medicine has asked to delay and lower thresholds for tracking and reporting basic quality measures; yet they have no reason to delay.
In the ACOs run by Aledade, which advises small medical practices (I sit on its board), we have found that independent primary-care doctors are able to change their care models in weeks and rapidly learn how to use data to drive savings and quality. For small practices, it does not take years to root out waste, rewire referrals to providers who charge less but deliver more, and redesign schedules so patients can see their doctors more often to avert emergency-room visits and readmissions.
Recognizing the strength in the small practices, the federal government needs to write rules that make it easier for them to thrive under ObamaCare and don’t tip the scales toward consolidation. That means introducing payment models that limit losses for small providers to the Medicare dollars they receive rather than total spending, and which rely on multiyear benchmarks instead of single-year swings. It also means comparing small practices to other small ones—instead of to large health systems with large balance sheets—when determining if a practice deserves bonus payments for savings.
Large health systems deliver “personalized” care in the same way that GM can sell you a car with the desired options. Yet personal relationships of the kind often found in smaller practices are the key to the practice of medicine. They are the relationships that doctors want to forge with patients, and vice versa. It may sound old-fashioned, but what I have learned is that we do not need to sacrifice this unique feature of our health-care system as we move forward in adapting new value-based payment models and improving the health of patients.
Dr. Kocher was special assistant to President Obama for health care and economic policy from 2009 to 2010. He is now a partner at Venrock, the venture-capital firm.
Block that trend! This is EXACTLY why AID is working with the FTC to block two hospital system mergers in Pennsylvania and Illinois, and why our founder met with the FTC in Washington last week.
Mergers on the rise as hospitals optimize for value-based care
By Jeff Lagasse
Healthcare IT News | July 25, 2016
The first half of 2016 has seen more healthcare organization M&A activity that the same timeframe in 2015 as providers are figuring out how to navigate rapid industry change and emerging payment models, Kaufman Hall said.
Encouraged by this move that curbs hospital’s appetite for independent practices, saves Medicare $500M a year.
Medicare to Pay Independent, Hospital-Owned Practices the Same
Medscape Medical News
Ken Terry | July 11, 2016
The Centers for Medicare & Medicaid Services (CMS) has proposed regulations that would implement "site-neutral" Medicare payments to ambulatory care practices owned by hospitals and give them less of a reason to employ physicians.
Following a law Congress passed in 2015, the CMS would no longer classify certain employed physicians as being part of a hospital outpatient department (HOPD) that can add facility fees to its charges. As a result, the hospital would receive a lower payment for their services than it does now, because the doctors would be paid under the Medicare fee schedule, just like physicians in private practice.
Besides payments for office visits, the site-neutral approach would also affect tests that are often performed in physician offices, such as echocardiograms. Medicare pays far more for these tests when they're done in an HOPD than when they're performed outside of a hospital. The same is true for chemotherapy when it is provided in an HOPD rather than a physician's office.
The proposed regulations, part of the CMS' 2017 Hospital Outpatient Prospective System (OPPS) proposal, provide these three key exceptions:
All items and services furnished in a dedicated emergency department.
Items and services furnished in a hospital department within 250 yards of a remote location of the hospital.
Items and services that were furnished and billed by an off-campus hospital department prior to November 2, 2015.
If any one of a hospital's grandfathered ambulatory care sites has changed its location since November 2, 2015, or does so in the future, it would be subject to the site-neutral payment, the proposed rules say. But the OPPS payment status of an off-campus practice would continue, the CMS proposes, if it changes ownership and the new owner adopts the practice's existing Medicare agreement.
New York Times
JULY 25, 2016
A wave of mergers in many sectors of the economy over the last several decades has significantly reduced competition and hurt consumers. That’s why the lawsuits filed last week by the Department of Justice and state attorneys general in federal court challenging two big health insurance mergers were so important.
Antitrust officials say Aetna’s $37 billion acquisition of Humana and Anthem’s $54 billion purchase of Cigna will reduce the number of large national health insurers to three, from five today. That would lead to fewer choices and higher premiums for individuals and employers in places like New York, Los Angeles and Kansas City, Mo. The mergers could also hurt doctors and hospitals, because they would have less bargaining power against the larger insurers when negotiating reimbursement rates.
AAPS Physicians Threaten to Leave Medicare Because of MACRA
BECKER'S HOSPITAL REVIEW
Written by Emily Rappleye (Twitter | Google+) | July 07, 2016inShare
The Association of American Physicians and Surgeons warns physicians may make like the British and leave Medicare Brexit-style due to the "imposition" of new payment methods.
At issue specifically with the national group is the Medicare Access and CHIP Reauthorization Act, which replaced the Sustainable Growth Rate formula, and will determine physicians' Medicare payment adjustments beginning in 2019. This law would burden independent physicians specifically, AAPS said, citing data from CMS that predicted 87 percent of solo practice physicians would be penalized in 2019 under the law's Merit-based Incentive Payment System.
"Physicians need to withdraw from Medicare or any other program that subjects them to this rule," AAPS executive director Jane Orient, MD, said in a statement.
The AAPS takes issue with the rule's compliance score, which is tied to resource use and mandatory government-certified EHR use. This will pressure physicians to weigh the cost of resources against what is best for the patient, and the EHR mandate would give the government increased access to patient medical records, AAPS argued.
"It is impossible to practice medicine under this rule, for ethical and practical reasons," Dr. Orient said in the statement. "The rule makes it impossible to protect confidentiality, and one is in a constant conflict of interest: What is best for the patient may be bad for the financial viability of the practice. It would take a dedicated team of legal specialists to even attempt compliance. Full compliance is probably impossible even with such a team, which is beyond the means of a small practice."
The group also warned that the rule is not just for Medicare — it also allows all payers to be phased into the payment models, which AAPS calls "harmful."
Address: 400 N. New York Ave., Suite 213 | Winter Park, FL 32789
The Association of Independent Doctors (AID) is a 501(c)(6) non-profit organization.