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Triage Healthcare reform winners & losers

Monthly Archives: April 2011

US Supreme Court Rejects Early Hearing of PPACA Consitutionality

Posted in PPACA

On Monday, the United States Supreme Court rejected the request by Virginia that the Court accept immediate review of whether PPACA is constitutional, without waiting for the case to go through the usual intermediate appeals process.  Virginia had argued that the case will eventually be resolved by the US Supreme Court in any event, so the Court… Continue Reading

Physicians Practice Interview on ACO Payments: Risk, Reward, and Reviewing Your Healthcare Partners

Posted in Accountable Care Organizations, Payment Methodologies

We’re getting some good traction in the hospital and physician trade press regarding our analysis of the ACO regs. I provided an interview with Physicians Practice discussing the shared savings models of the proposed rules for accountable care organizations and balancing risk versus reward in establishing new health care partnerships.  The interview centered on how the… Continue Reading

ACOs: Will High Start up Costs and Downside Risk Limit Interest in This Health Care Reform Darling?

Posted in Accountable Care Organizations, Payment Methodologies

Providers considering applying to CMS to become an ACO should be aware that the proposed ACO rules are modeled in significant part after Medicare’s Physician Group Practice demonstration project.  Five years in the planning and launched in April 2005, the PGP Demonstration included 10 multi-specialty group practices in various regions of the country comprised of… Continue Reading

Majority vs. Plurality Rule for Beneficiary Assignment

Posted in Accountable Care Organizations, Governance/Management

The Affordable Care Act requires the assignment of Medicare beneficiaries based on which physician provides a beneficiary’s primary care services, and delegates the task of prescribing the assignment methodology to the Secretary of Health and Human Services. After considering a majority rule and a plurality rule, CMS believes that the latter should be the governing… Continue Reading

Discord at the Agencies Regarding Antitrust Reviews?

Posted in Accountable Care Organizations, Antitrust

As discussed previously here, here, and here, antitrust matters are a key consideration in the design of the Shared Savings Program and ACO development.  For example, antitrust review of prospective ACOs by the FTC and/or DOJ is a critical aspect of the ACO application process. Despite the release of the joint statement, there is evidence… Continue Reading

Proposed Definition of At-Risk ACO Beneficiaries Leaves Questions Unanswered

Posted in Accountable Care Organizations, Quality and Performance Measures

Among other reasons, CMS may terminate an ACO from participating in the Medicare Shared Savings Program if the ACO avoids “patients at risk” to reduce the likelihood of increasing costs to the ACO.  The Affordable Care Act, however, does not define which patients are at risk. In the recently release proposed ACO rule, CMS proposes… Continue Reading

Prospective or Retrospective Beneficiary Assignments to Calculate Eligibility for Shared Savings

Posted in Accountable Care Organizations, Payment Methodologies

CMS has considered two basic options for assigning beneficiaries to an ACO to calculate eligibility for shared savings.  The first option is that beneficiary assignment would occur at the beginning of the performance year on a prospective basis.  The second option is for beneficiary assignment to occur on a retrospective basis based on the actual… Continue Reading

The ACO Information Gold Rush: “Accountable Care Organizations” in the News

Posted in Accountable Care Organizations

by David Sheon, WHITECOAT Strategies What a week since CMS launched its regulations on ACOs. The complexity of the rules offered little help to journalists seeking to explain the implications to readers.  CMS tried its best to help by providing fact sheets for providers as well as for consumers.  And while most journalists writing on… Continue Reading

When it Comes to ACOs, Some Primary Care Physicians are More Equal Than Others

Posted in Accountable Care Organizations, Quality and Performance Measures

Although the Affordable Care Act allows hospitals employing physicians and other non-physician professionals such as advance practice nurses, physician assistants and nurse practitioners, to be eligible providers for an ACO, only primary care services provided by primary care physicians matter in determining the beneficiaries that would be assigned to an ACO. And only those ACOs… Continue Reading

Squire Sanders Participates in Successful Webinar on ACOs with Strategic Health Care and Plante Moran

Posted in Accountable Care Organizations, Antitrust, Regulatory Compliance

On Friday, April 8, Peter Pavarini and I co-presented a webinar overviewing the ACO regulations from a legal perspective. We were part of a three-firm “task force” that came together to analyze the rules and provide guidance to our clients and friends. In addition to Squire Sanders, Paul Lee and others from Strategic Health Care and… Continue Reading

Taking the Antitrust Policy Statement a Step Further…

Posted in Accountable Care Organizations, Antitrust, Regulatory Compliance

In commentary to the proposed regulations, CMS has committed to coordinate with other Federal agencies on various issues that relate to the Shared Savings Program. This includes coordination with the FTC and DOJ (the “Antitrust Agencies”) with respect to antitrust issues. This coordination is shown through CMS’s intention to incorporate the FTC/DOJ Proposed Statement on… Continue Reading

Two views on Beneficiary Data Implications for Patients and ACOs: Part 2 – ACOs Use of Medicare Beneficiary Identifiable Claims Data to Track Population Health and Expenditures

Posted in Accountable Care Organizations

by Allen Dobson and Joan DaVanzo Section 3022 of the Affordable Care Act (ACA) provides for the development of the Medicare shared savings program for accountable care organizations (ACOs). The ACO program is intended to improve care for individuals and health for populations, as well as slow the rate of cost growth. The proposed rule… Continue Reading

Two Views on Beneficiary Data Implications for Patients and ACOs: Part 1 – Balancing Patient Privacy With the Objectives of the Program

Posted in Accountable Care Organizations

Under the proposed ACO rules, CMS will assign Medicare beneficiaries to ACOs based on where the patient receives the “plurality” of their primary care services during the year before the relevant ACO performance measurement period.  If medical cost savings can be achieved during the performance period for the ACO’s assigned beneficiaries as compared against the CMS projected benchmark… Continue Reading

Why AMDR and ACOs?

Posted in Accountable Care Organizations

By Daniel J. Vukelich, AMDR The acronyms and new terminology alone can be overwhelming: ACO: Accountable Care Organization; SSP: Shared Savings Program; VBP: Value-Based Purchasing; HIT: Health Information Technology; and of course, AMDR: Association of Medical Device Reprocessors. Medical Device Reprocessors? What do medical device reprocessors have to do with ACOs or even healthcare reform for… Continue Reading

Something Old, Something New, Something Borrowed….

Posted in Accountable Care Organizations, Governance/Management

For many of us still digesting last week’s ACO manifesto, the first question we must answer is what kind of organization should seek to qualify as an ACO? “In order to implement the statutory requirements that ACOs have a shared governance mechanism and a formal legal structure for receiving and distributing shared payments, we (CMS)… Continue Reading

For First-Wave ACOs, Buyer Beware

Posted in Accountable Care Organizations

ACOs who apply for this first wave of the Medicare Shared Savings Program will be shouldering significant risk, especially given the unknowns left after the Proposed Rules were released. Few organizations will be in a position by January 2012 to even apply for participation in the shared savings program, in all probability.  Those ACOs that… Continue Reading

ACO Regulation Review and Application Preparation Webinar

Posted in Accountable Care Organizations, Events

Join Squire Sanders and Strategic Health Care this Friday, April 8 at 11 a.m. EDT for a national webinar, “ACO Regulation Review and Application Preparation.” Squire Sanders partners Peter A. Pavarini and John M. Kirsner will discuss legal considerations relevant to the proposed Accountable Care Organization (ACO) regulations issued by the Centers for Medicare & Medicaid Services… Continue Reading

When it Comes to the Waiver Regulations, Comment Early!

Posted in Accountable Care Organizations, Regulatory Compliance

I agree with my colleagues that CMS appears to be looking to the industry to guide them on waiver development, as well as other details of the Medicare Shared Savings Program. CMS intends to grant waivers that would apply uniformly to all ACOs, ACO participants and ACO providers/suppliers participating in the Medicare Shared Savings Program…. Continue Reading

Introducing Risk Through a Shared Savings Program: The Two-Sided Model – A Carrot and Stick Approach

Posted in Accountable Care Organizations, Payment Methodologies

The Accountable Care Act permits the Secretary of HHS to implement partial capitation models or any other payment model the Secretary determines will improve quality and efficiency. The Proposed Rule states that the Secretary will test partial capitation models in the Innovation Center. Pursuant to the “other payment model” authority, however, the Proposed Rule would… Continue Reading

Proposed ACO Waiver Regulations: Not Far Enough? An OIG Challenge During My Presentation at Friday’s AHLA Medicare and Medicaid Institute

Posted in Accountable Care Organizations, Regulatory Compliance

Does anyone else feel that the proposed waiver regulations don’t go far enough? Do you think they allow providers to engage in flexible arrangements that deliver value to the government? The key is how the government has limited the waiver proposals mostly only to the shared savings distributions. That seems too narrow, although I think… Continue Reading

Antitrust Considerations from the Recently Released ACO Proposed Regulations

Posted in Accountable Care Organizations, Antitrust

The Federal Trade Commission and Department of Justice (the “Agencies”) recently released Proposed Statement of Antitrust Enforcement Policy Regarding ACOs, which contains several points of interest: Rule of Reason Treatment. The Agencies will provide rule of reason treatment to an ACO if, in the commercial market, the ACO uses the same governance and leadership structure and… Continue Reading

ACO 101 – Unicorns No More

Posted in Accountable Care Organizations

By Daniel J. Vukelich, President, Association of Medical Device Reprocessors I’ve been thinking about Robert Pear’s analogy, as he wrote in today’s New York Times that: Until now, accountable care organizations were like unicorns, creatures that flourished in the imagination but proved persistently elusive in the natural world. The rules define the new entity as a… Continue Reading