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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.

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:

ACA
Will Require 3% More Primary Care Physicians by 2025

Robert Lowes

Nov
12, 2012

 The Affordable
Care Act (ACA), experts predict, will only deepen a
shortage 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
shortfall 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.

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

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 Next Monday evening.

• 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

Date:
Monday, November 12, 2012

Time:
6:00 PM – Dinner
6:30 – 8:30 PM –

Presentation
Location:

OCMA Conference Center
17322 Murphy Ave.

Irvine, CA 92614

Price:
Free

RSVP:
http://acos.eventbrite.com

Questions:
Donna McPride
dmcpride @ocma.org
(949) 398-8100 ext. 107

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

The
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

The Department of Health and Human Services and Internal
Revenue Service have issued a recent regulation defining what “full-time” is
for employers wondering if they are required under the Affordable Care Act to
provide insurance.  In just one more indication how complicated the
regulations are under the Act as this takes 18-pages to describe.
Interestingly, “full-time” is an average of 30-hours a week (not the widely
accepted 40-hours per week).

This is a key rule because companies with more than 50
full-time employees must provide health insurance under the law. Defining the
term to include 30-hour per week employees will include several more small
businesses that will need to comply with this Act.

Submitted by Matthew L. Kinley

The US Centers for Medicare and Medicaid Services (CMS) has advertised and encouraged physicians across the country to take advantage of incentive payments in order to upgrade their offices for meaningful use of electronic health records (EHR) technology.

Government and private payers are seeking to have such EHR technology more standardized and many healthcare experts expect that EHR systems will be required to participate in government and private payer systems.   Reports from physicians about the incentive program have not been complimentary, with many physicians complaining that funding has been slow in coming.

Now, may providers who took advantage of the incentive payments are being audited.  Many have received letters from a CMS contractor asking that they submit extra documentation within 2 weeks to support their claims that they met federal meaningful-use criteria. CMS will recoup bonuses from those who turn out not to have deserved the payments.  While the regulations have always provided that such audits were possible, the audits are still surprising many physicians. See this CMS link for audit regulation information.

The audit letter from Figliozzi & Company asks for 4 types of information that back up what providers reported to CMS to obtain their bonuses.

• A copy of a document from the US Department of Health and Human Services that certifies the provider’s EHR technology as eligible for the incentive program.
• Documentation of reported emergency department admissions, a key number in calculating whether the provider met certain meaningful-use requirements.
• Supporting documentation for a provider’s claims to have satisfied mandatory meaningful-use objectives and measures, such as electronic prescribing.
• Supporting documentation for a provider’s claims to have satisfied voluntary meaningful-use objectives and measures.

Submitted by Matthew L. Kinley

By Kelly Greene

Twenty-nine states have “filial support” laws on the books that could be used to go after patient’s families for unpaid long-term-care bills.

We described one case in Pennsylvania, the main state where health-care providers have started using such a law, in last weekend’s Family Value column, “Are You on the Hook for Mom’s Nursing-Home Bill?”

This has become a hot topic for financial planners and others advising Americans, young and old, on healthcare costs for aging parents.

Many estate planners are selling all kinds of asset protection strategies (i.e. forming business entities, creating irrevocable trusts and off-shore trusts, re-titling property in joint-tenancies, etc.).

But since these filial responsibility laws were rarely enforced in the past, attorneys do not really know how well these strategies will hold up in court, in terms of protecting children's assets from their parents' creditors. As a result, attorneys aren't giving too much information, at least not on their web pages/blogs, about exactly what kinds of asset protection strategies they use and/or that work.

They merely alert their readers to the re-emergence of filial responsibility law enforcement, and then invite people to consult them about asset protection strategies, medi-cal planning, and long-term insurance possibilities.

Be careful if you are delving into estate planning and asset protection for this reason as it is truly uncharted territory as to what works and what does not.

Submitted by Jennifer N. Sawday

California Medical Association General Counsel and Vice President Francisco J. Silva, Esq., and Matthew L. Kinley, Esq. of Tredway, Lumsdaine & Doyle, LLP, spoke to the Orange County Medical Association on June 7, 2012, about the impact of medical foundations and accountable care organizations. 

The wide ranging topics included the legal basis for medical foundations and accountable care organizations, the benefits and burdens of physician employment by such entities, and the contracts and agreements that typically are utilized for such arrangements.

Matt reported that, "Physicians and medical providers who are considering working for an integrated health care model should carefully consider their options before signing on the dotted line.  A lawyer with healthcare experience should be retained to help the medical professional through the legal maze presented by such a step." 

Some the specific areas that a physician should be concerned with:

Does the culture of the new entity fulfill the needs of the physician group? 

How do valuations play a part in the transaction? 

What due diligence will take place? 

What potential contracts may need to be signed? 

What to look for in an employment contract, an asset purchase agreement, or a professional services agreement? 

How are physician salaries determined? 

The two hour seminar was attended by approximately 50 physicians.