Monthly Archives: November 2012

Will Your Business Pay a Penalty for Failing to Provide Healthcare Coverage?

The Affordable Care Act does not require businesses to provide health benefits to their workers, but larger employers face penalties starting in 2014 if they don't make affordable coverage available. This simple flowchart illustrates how those employer responsibilities work.

The Henry J. Kaiser Family Foundation provides this simple chart to figure out if you will pay a penalty for not providing healthcare coverage, or not providing the right healthcare coverage, for your employees. Generally, if you have fewer than 50 employees, you are generally exempt.

Selling Your Practice

Physicians often ask about how to prepare their practice to
make it attractive for potential purchasers.  Given the current
environment in California, where hospitals are utilizing foundations to
“purchase” practices and other payers are looking for primary care
physicians.  This article from American Medical News gives excellent
pointers for building your practice.

Physician Guidelines for Employment in Large Institutions

In this press release, the American Medical Association (AMA) adopts guidelines for
physicians considering employment with large institutions. AMA Guidelines are available here.

In addition to
the ethical issues described, California has strict legal requirements for
physicians considering a job and leaving their private practices such as:

Informing clients of the move

2.  How to
handle medical records

3. How to
handle accounts receivable

4  What
insurance to carry

5.  Control
in your new job over hours, appropriate care, medical records and billing.

Any physician
considering such an employment contract should get legal advice to discover
legal land mines and potential violations of law.

Submitted by Matthew L. Kinley

Primary Care Physicians Needed

When reviewing
the various new regulations concerning the Accountable Care Act and
particularly Accountable Care Organizations, it is clear that the Primary Care
Physician will be at the center of doctoring over the next several years. 
While there already is a shortage of good primary doctors, the shortage is
about to get worse. 

Here’s an article from Medscape Today:

Will Require 3% More Primary Care Physicians by 2025

Robert Lowes

12, 2012

 The Affordable
Care Act (ACA), experts predict, will only deepen a
of primary care physicians brought on by a growing — and
aging — population.

But to what
extent? A new study
in the Annals of Family Medicine offers a hard number. It will take an
extra 8000 primary care physicians in 2025 just to treat patients who obtain
insurance coverage under the law, according to lead author Stephen Petterson,
PhD, and coauthors.

In all, they
write, the nation will need 52,000 more primary care physicians in 2025 than it
has now, a figure resembling estimates in other recent studies. Before Congress
enacted the ACA in 2010, the Association of American Medical Colleges had forecast a
of 46,000 primary care physicians by 2025.

In the Annals
of Family Medicine
study, sheer population growth accounts for 33,000 of
the 52,000 extra physicians needed in 2025, according to Dr. Petterson, the
research director of the Robert Graham Center for Policy Studies in Family
Medicine and Primary Care, affiliated with the American Academy of Family
Physicians, and colleagues. Another 10,000 physicians of the total reflect the
higher level of services used by baby boomers on the rolls of Medicare.

The ACA will
extend insurance to roughly 30 million more Americans through 2019. The 8000
primary care physicians required by this expansion represent a 3% increase of
the current workforce.

As a baseline for
their projection, Dr. Petterson and co authors used the 246,090 primary care
physicians who were engaged in direct patient care in 2010 as reported by the
American Medical Association. They whittled down that number to almost 209,000
after excluding physicians who were retired, working as hospitalists, or
working in emergency departments and urgent-care centers.

To calculate how many
primary care physicians will be needed in 2025, the authors estimated the
number of primary care office visits that would occur that year and divided it
by the current number of annual visits per physician, which is 2237. According
to this math, the United States ought to have almost 261,000 primary care
physicians 13 years from now, a 25% increase over 2010.

Coauthor Andrew
Bazemore, MD, MPH, director of the Robert Graham Center, called the workforce
growth required by just the ACA "a surprisingly small proportion" of
the total.

Fielding an
additional 52,000 primary care physicians in 2025 is a daunting task, Dr.
Bazemore said, given long-term preferences of most medical students for other
specialties. However, in the last 2 to 3 years "we've seen an uptick in
the number of medical student seniors choosing family medicine," he said.
That trend, along with proposals to increase the number of residency training
slots and earmark more of them for primary care, justifies "a little more
optimism," he added.

At the same time,
the healthcare system needs to not only grow the primary care workforce, but
also do a better job allocating clinicians to underserved areas.

"You need to
find a way to get the doctors to where they're needed," Dr. Bazemore said.

The authors have
disclosed no relevant financial relationships.

Ann Fam Med. 2012;10:503-509.

Negotiating Contracts with ACO’s

There are several types of Accountable Care Organizations that a physician may be asked to sign a contract with, including the Medicare Shared Saving Program ACO, Pioneer ACO, and private insurance providers.

All ACO’s have certain attributes in common, including risk participation and assessment, patient participation, integrated care, evidence based care, utilization of non physician professionals (physician assistants, nursing assistants, etc.) data analysis and use of technology for improving communications and care.

As a physician entering into any contract, but particularly a contract for an ACO, you should make sure you understand the contract. In most cases, if it’s not in the contract, it doesn’t exist. If you are promised some benefit from an ACO plan, like help with achieving meaningful use (technology), make sure it’s spelled out in the contract.

Here are some other things you should review In the contract:

1. Risk Participation: Shared Savings is a concept that has not been completely defined. Providers should understand how the billing works, and how the shared savings works. Some plans have penalties for physicians who do not meet benchmarks. This is an important part of the contract. Your payment should be clearly spelled out.

2. Exclusivity: Most plans require primary care physicians (including internists, general practitioners, family doctors, and geriatric doctors)to be exclusive with the ACO. Specialist can usually contract with several. Again, this should be clearly designated.

3. Corrective Action: What corrective action will take place if a physician does not meet benchmarks?

4. Benefits Provided: ACO’s need to provide infrastructure to help achieve cost savings. These include integrated care, behavior counseling, nurse phone availability, and improved technology. These benefits should be spelled out in the contract.

5. Regulatory Issues: Physicians have certain obligations under law to notify their patients about their medical plans and particularly for information sharing. A major goal of ACO’s is to review data for performance, but patients can opt out of sharing data. There should be a clear plan for complying with regulatory issues.

6. Payer Viability: If the payer fails, a clear exit strategy should be part of the contract.

All contracts have hidden agendas and concerns. Will there be an arbitration clause? Is there an attorney’s fee provision should there be litigation? Who exactly is contracting. ACO’s have particular issues that need special care so the contract should be carefully analyzed to make sure that all terms are carefully understood.

Submitted by Matthew L. Kinley

Limitations on Healthcare Advertisement

Healthcare providers, more than any other industry are
limited in how they may advertise. State and Federal laws, such as the
anti-kickback statutes and consumer protection laws restrict commission based
advertising, coupons or discounts, and the use of certain testimonials and
guarantees regarding the healthcare providers products or services.

The Anti-Kickback Statutes generally prohibit any payment
to any person who receives renumeration in exchange for a referral of a patient
to a healthcare provider. Penalties under this statute can be both financial and
criminal. In a typical commission
arrangement, a person is paid for providing customers.  For a doctor, it would include a person being
paid for referral of a patient. There are limited exceptions.  The exceptions require a set fee over a
period of time, unrelated to the number of patients referred.  Healthcare providers who wish to start a
program of advertising utilizing referrals should seek legal advice to assure
that the program doesn’t violate this law.

A recent
phenomenon  is utilization of website
discounts for medical services.  Groupon,
and other “daily deal” sites typically offer patients discounts on
cosmetic care, this can create fee splitting issues that implicate accusations
of providing unnecessary procedures because of the perceived obligation to
comply with a coupon. These issues will be dealt with by the state and federal
government in years to come.  Pay per
call or Pay per click arrangements may also implicate issues related to
anti-kickback issues.

Patient endorsements in advertisements can also be
problematical. First, they can be
reviewed for any dishonesty.
Statements must include all good and bad elements of treatment.  For cosmetic surgery, reference to an
“easy, outpatient procedure” that does not refer to anesthesia, may be
considered fraudulent.  Even the
implication that a procedure on one person will be the same for all patients is
also likely to be disallowed. Such ads can not look like news reports.

More and more healthcare providers are recognizing the
need to increase the number of patients actively seen by their practices.  Advertising may provide a method to increase
the medical business, but care must be exercised to make sure such
advertisement pass legal muster.

Submitted by Matthew L. Kinley


Join Us For An Evening Conversation about ACOs

Join Us Next Monday evening.

Topics to be discussed:
  • Background of the ACO
  • Description of structure: including Alignment, Care Coordination Programs
  • The benefits of belonging to an ACO including improvements to your practice and retaining patients for your practice
  • Partnership with OCMA
  • Physician involvement in ACO decisions
  • Resources provided by the ACO
  • Exclusivity
  • Contract term

Monday, November 12, 2012

6:00 PM – Dinner
6:30 – 8:30 PM –


OCMA Conference Center
17322 Murphy Ave.

Irvine, CA 92614



Donna McPride
(949) 398-8100 ext. 107

Healthcare Faces Difficulties All Over The World

The title of this post says it all: read
this article to see what I mean.

United States is not the only country that faces a shortage of medical care and
a lack of resources to pay for it.  According the The Economist,
most countries face aging populations.

At the same time, there are
chronic shortages of doctors.

The solution that seems to be currently in
vogue in both the United States and the rest of the world is to make the
physician less relevant to the healthcare.

The future of healthcare
utilizes more technology to make sure that patients stay healthy, including
remote monitors which notify centers if a patient’s blood sugar or blood
pressure are not normal. Technology will also help healthcare administrators to
judge success and quality, making adjustments to those practices that are too
expensive.  Healthcare intends to utilize more para-professionals in
healthcare, including nurses in place of doctors.  The doctors role will
be reduced to the most intensely medical activities, particularly surgery, which is interesting.

Submitted by Matthew L. Kinley