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Commercial Reasonableness: Why It Matters to an ACO's Board
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As described in the first and second installments of this three-part Health Capital Topics series on commercial reasonableness and Accountable Care Organizations (ACOs), many Medicare Shared Savings Program ACO boards of directors have relied on the temporary waivers from the Centers for Medicare and Medicaid Services (CMS) to protect their organization from fraud and abuse penalties. Considering the potentially finite status of these waivers, the board of directors of an ACO would be prudent to recognize that: (1) if the ACO does not qualify under one of the finalized waivers; and, (2) the ACO is not considering the commercial reasonableness and Fair Market Value of its accumulated assets, then the organization is at risk for serious penalties on both an individual and corporate level. In evaluating these risks, the board of directors of healthcare organizations, including ACOs, which oversees the organization's decisions and actions, has ultimate responsibility for regulatory compliance.
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 Regulatory Scrutiny for Physician Compensation Continues
Since the beginning of September 2015, the Department of Justice (DOJ) and the Office of Inspector General (OIG) have announced three major settlements with health systems relating to physician compensation issues. In United States ex rel. Barker v. Columbus Regional Healthcare System et al., the Columbus, Georgia-based organization Columbus Regional Healthcare System agreed to pay a minimum of $25 million to settle allegations of healthcare fraud & abuse through excessive physician compensation and upcoding of physician services. In U.S. ex rel. Reilly v. North Broward Hospital District, the Broward County, Florida-based government hospital, North Broward Hospital District, agreed to pay $69.5 million to settle allegations of tracking physician referral dollars to offset the losses of employing physicians in violation of the Stark Law. Finally, in U.S. ex rel. Payne et al. v. Adventist Health System et al., Adventist Health System agreed to pay $115 million to settle allegations of employing physicians at a loss, which would be covered by referrals for inpatient and ancillary services by the employed physicians, in violation of the Stark Law.
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Impact of the "Per-Click" Ruling on Valuing Diagnostic Outpatient Enterprises
In recent years, the trend toward an increased volume of qui tam actions in healthcare fraud and abuse cases has manifested with an unlikely source of potential qui tam relators - professional appraisers. Specifically, a commercial real estate appraiser from Tennessee has filed two qui tam suits under the federal False Claims Act (FCA) against his clients, alleging violations of the Stark Law and Anti-Kickback Statute.. This Health Capital Topics article will first discuss the facts and circumstances of the two lawsuits, the allegations contained therein, and the potential impacts of the suits on FCA litigation in the future. In addition, this article will discuss the possible ethical implications of appraisers filing qui tam lawsuits against their clients and the potential manner in which qui tam lawsuits may impact the relationship between an appraiser and their client.
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Patient Wait Times for Medical Care Often Excessive
Removing barriers to the timely provision of medical care, including excessive wait times for doctor visits, has been identified by the Institute of Medicine (IOM) as a key quality goal for healthcare systems. In its 2001 report, entitled "Crossing the Quality Chasm: A New Health System for the 21st Century," the IOM stated that the excess time patients spend waiting for care, which does not convey information or allow for healing, suggests that "care has not been designed with the welfare of the patient at the center." However, in many healthcare settings, patients today are often still forced to wait for long periods of time before receiving care. In the emergency room context, on average, patients are forced to wait anywhere from 17 to 54 minutes before being seen by a physician and receiving care. A patient's entire emergency room visit - from arriving at the emergency room to receiving care and being sent home - can average as long as 191 minutes in some states. Excessive wait times may cause adverse effects to patients, including injuring patients further.
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Great Variability in Geographic Access to Primary Care Facilities
Primary care physicians play an integral role within the U.S. healthcare delivery system, in part, because they promote communication with patients and encourage them to become a partner in healthcare by being more informed about their health needs. For this reason, an appropriate primary care physician population is crucial for the healthcare system to be effective and efficient. Too few primary care physicians would result in increased costs due to delayed care, worsened health conditions, and increased hospital and emergency room usage. However, having too many primary care physicians could potentially increase healthcare spending due to the possibility that individuals would receive unnecessary health services. Currently, the U.S. is experiencing uneven levels of access to primary care physicians, which could negatively impact health outcomes for persons lacking access to primary care services. This Health Capital Topics article will discuss how, in light of the Affordable Care Act provisions promoting utilization of primary care, great geographic variability exists in many parts of the U.S. regarding access to primary care physicians. This article will also detail how geographic variability impacts access to healthcare services and overall community health while providing certain practices health systems can incorporate to address geographic variability in primary care access.
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