Holland & Hart Healthcare Law Blog

FTC WORKING WITH CMS ON ACO ISSUES BUT SAYS ACO CLINICAL INTEGRATION SHOULD PASS ANTITRUST SCRUTINY

 

 It was raining here in Washington Wednesday, but the FTC is sunny about the compatibility of FTC guidance on clinical integration of health care providers and the thrust and aim of ACO healthcare delivery systems.  Marcus H. Meier, Assistant Director for theHealth Care Division, Bureau of Competition, Federal Trade Commission, said at the National Forum On Clinical Integration in Washington, D.C., that it  was likely that any organization that met the spirit and substance of a federally accepted Accountable Care Organization would also likely meet the qualifications for  clinically  integrated care organizations that would pass muster for group price negotiations.

 

THE “MASSIVE REDISTRIBUTION OF WEALTH” AND 31 OTHER INTERESTING STATISTICS AFFECTING THE HEALTHCARE REFORM.

 The United States has undergone a massive redistribution of wealth in the last 30  years. In 1980 the top 1 percent of taxpayers reported 8.5 % of the nations reported income to the Internal Revenue Service. In 2008, the top 1 percent of taxpayers reported receiving 20% of the nation’s income. This and the following 31 other statistics provide an interesting foundation to review the PPACA and its alternatives.

THE PROMISE AND PERIL OF EVIDENCE BASED CLINICAL STANDARDS.

 

A key component of the governments efforts to bend the cost curve for health care is the use of technology and new health delivery structures to introduce “evidence based” clinical standards for the treatment of patients.  Technology will be useful in determining the most clinical effective modalities of treatment and in monitoring the implementation of the guidelines across the spectrum of health car providers. It is an idea that on the surface makes a great deal of sense.  Providers should be held accountable to implement those methods of treatment that have shown themselves to be the most effective and cost efficient in the treatment of chronic disease disease syndromes.

 

THE EVOLUTION OF INTEGRATED HEALTH CARE DELIVERY SYSTEMS AND THE SINGULARITY

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    If one had to design a health care system that would seem doomed to failure one might start with one in which the providers of care were fragmented, independent and driven through the reimbursement system to provide ever more services that generate higher income on a fee for service basis. The system would provide care to patients who were isolated from the economic costs of the services by third party payments, through employer funded insurance coverage.  Third party payers would make their money through reducing premium payouts, by simply delaying or not paying out what they contracted to provide or extorting deep provider discounts in exchange for directed volume. The approach to care of individual patients would be ad hoc, without significant oversight. Severely ill patients would be passed back and forth by all providers like the black queen of spades in a deck of cards. Bad debts would be written off as “charity care.” Insurance premiums would rise faster than the world’s oceans in global warming. Sound familiar?

    

HOSPITAL/PHYSICIAN INTEGRATION: CAN THEY GET IT RIGHT THIS TIME?

    Healthcare is one of the trendiest industries in the nation. It is always in a state of flux. During the advent of the deep push into managed care in the 90s there was a feeding frenzy of hospitals trying to gobble up physician primary care practices to control the “gatekeepers” and provide hospital leverage with insurance companies. Hospitals paid huge sums to acquire physician practices before competitors beat them to it.

    

PROVIDER INTEGRATION AND THE ADVENT OF ACCOUNTABLE CARE ORGANIZATIONS (“ACOs”)

    Can financial incentives and physician practice structures be enlisted o enhance the quality and reduce the cost of healthcare?  Health Care Reform supporters believe they can and the new Patient Protection and Affordable Care Act ("PPACA")  signed into law by the President recently,  provides incentives for the development of ACOs for Medicare patients. ACOs have been described as HMO’s on steroids, but many wonder whether they will meet the same fate as the managed care systems of the past that focused on blind leveraged cost reductions and favorable beneficiary selection to achieve profits.

    

GERMAN HEALTH CARE COST CONTROLS: A GLOBAL COMPETITIVE ADVANTAGE.

There is an interesting article in the February, 2010 issue of the McKinsey Quarterly, the on-line journal of McKinsey & Company.  The article entitled “How Germany is reining in health care costs: An Interview with Franz Knieps” provides an interesting comparison to our own struggle to control rising health care costs.  Mr.Knieps is the director general for public health care, health insurance and long term care in the German Federal Ministry of Health. 

Wisconsin Supreme Court Orders HMO to

In Summers v. Touchpoint Healthplan, Inc., Case Number 2005-AP 2643 (Wisc. May 28, 2008), the Wisconsin Supreme Court ordered Touchpoint to provide coverage for an "experimental" high dose radiation and stem cell recovery procedure for a child suffering from a rare brain tumor. Surgeons removed the tumor and the child’s doctors recommended the high dose radiation treatment with stem cell recovery as the best of the follow-up options to assure full recovery. The problem was that the procedure was "experimental" as defined in the policy and was excluded from coverage under the policy. Included in the plan’s definition of "experimental" was any procedure that was the "subject of any ongoing Phase I or Phase II clinical trial."

Wisconsin Supreme Court Orders HMO to

In Summers v. Touchpoint Healthplan, Inc., Case Number 2005-AP 2643 (Wisc. May 28, 2008), the Wisconsin Supreme Court ordered Touchpoint to provide coverage for an "experimental" high dose radiation and stem cell recovery procedure for a child suffering from a rare brain tumor. Surgeons removed the tumor and the child’s doctors recommended the high dose radiation treatment with stem cell recovery as the best of the follow-up options to assure full recovery. The problem was that the procedure was "experimental" as defined in the policy and was excluded from coverage under the policy. Included in the plan’s definition of "experimental" was any procedure that was the "subject of any ongoing Phase I or Phase II clinical trial."

OIG BLESSES DENTAL PPO PAYMENT TO MARKETING FIRM FOR SIGNING UP FEDERAL EMPLOYEES HEALTH PLAN

Did it ever occur to you that a Preferred Provider Organization might run afoul of the federal anti-kickback statute by paying for the services of a marketing firm on the basis of PMPM (per member per month)?  On October 13, 2006 the OIG posted advisory opinion No. 06 17.  The dental network (the “Network”) contracted with a marketing firm for services.  The marketing firm introduced a third party administrator (“TPA”) to the network.  The marketing TPA made the network available to one of its clients, a Federal employee health benefits plan.  Most of the beneficiaries in the Federal employee health benefit plan do not qualify for federal healthcare benefits programs, although some do.