Tag Archives: health law attorney

CMS Extends Waivers under the ACO Shared Savings Program

Lance Leider headshotBy Lance O. Leider, J.D., The Health Law Firm

On November 2, 2011, the Centers for Medicare and Medicaid Services (CMS) promulgated the interim final rule on fraud and abuse waivers for Accountable Care Organizations (ACOs) participating in the Medicare Shared Savings Program. The interim rule can be found at 76 Fed. Reg. 67801. The waiver was granted pursuant to the agency’s authority under the Affordable Care Act, specifically, 42 U.S.C. § 1899(f).

You can read our prior blog postings on the ACO waiver programs here.

Normally, interim final rules are only permitted to remain in effect for a maximum of three years (see 69 Fed. Reg. 78422). CMS regulations require the agency to publish a final rule within three years of a proposed or interim final rule. As the interim final rule is set to expire on November 2, 2014, the agency took advantage of the procedure that allows it to extend the life of the rule for an additional year by publishing a notice explaining the reasons why the regular timeline was not met.

Explanation for the Extension.

CMS stated that it is in the process of preparing a final rule, and allowing the interim final rule to expire would create a great deal of legal uncertainty for ACOs currently participating in the Shared Savings Program. According to CMS, this uncertainty has the potential to disrupt ongoing ACO business, plans, and operations.

Ultimately, CMS has learned through the course of its operation of the Shared Savings Program that certain modifications to the program are necessary. Although these modifications are not yet defined completely, CMS nevertheless believed the prudent course of action was to maintain the status quo during the rule making process.

Check back with us for updates on the process and any further information as the final rule is developed.

Comments?

Have you considered joining an ACO? Why or why not? Please leave any thoughtful comments below.

Contact Health Law Attorneys Experienced With Healthcare Business Practices.

The Health Law Firm routinely represents physician groups and practices with issues involving establishing, licensing, selling, merging, and intergroup affiliation. If you are considering establishing an ACO or have been approached to become a participant in one, you can contact The Health Law Firm at (407) 331-6620 or (850) 439-1001 or you can visit our website at http://www.TheHealthLawFirm.com.

About the Author: Lance O. Leider is an attorney with The Health Law Firm, which has a national practice. Its main office is in the Orlando, Florida, area. http://www.TheHealthLawFirm.com The Health Law Firm, 1101 Douglas Avenue, Altamonte Springs, Florida 32714, Phone: (407) 331-6620.

The Health Law Firm” is a registered fictitious business name of George F. Indest III, P.A. – The Health Law Firm, a Florida professional service corporation, since 1999.

Copyright © 1996-2014 The Health Law Firm. All rights reserved.

Fake Surgeon in Florida Accused of Performing Liposuction Without a License

2 Indest-2009-1By George F. Indest III, J.D., M.P.A., LL.M., Board Certified by The Florida Bar in Health Law

A Kissimmee, Florida, man was arrested on December 18, 2013, on charges that he has been allegedly performing liposuction without a medical license in a Central Florida clinic. According to the Orlando Sentinel, the Metropolitan Bureau of Investigation (MBI) began investigating the phony surgeon about a year ago, after Florida Department of Health (DOH) received a complaint about the clinic in which the phony doctor worked. The clinic was called “Sculptural Orlando.”

Click here to read the article from the Orlando Sentinel.

Investigators Looking for More Victims.

According to the Orlando Sentinel, it is alleged the fake surgeon has been performing illegal liposuction surgeries for about a year and telling his patients he was a licensed medical doctor.

After further investigation, MBI agents discovered the clinic was licensed as a massage establishment and the fake surgeon did not hold a valid medical license in Florida. Several MBI agents visited the clinic undercover, posing as potential customers. The agents allege the fake surgeon performed evaluations on them and showed them before-and-after photos of his patients.

The DOH is still looking for victims or tips related to the fake surgeon and any unlicensed activity at the clinic.

Practicing Without a License Is a Crime.

This is by no means the first report we’ve heard of phony health care professionals operating on patients or injecting people with toxic chemicals. For some reason, Florida seems to get more than its fair share of these.

Practicing medicine without a license is a crime. Additionally, so is helping someone practice medicine without a license. As a licensed healthcare practitioner, you may be asked to supervise others or participate in a clinic or practice as a “medical director,” supervisor, or monitor. Remember that your license may be at stake with any wrongdoing by those subordinates under your supervision. Before you join a practice or agree to supervise others, check first with the DOH that the other providers have legitimate, active licenses. You can verify a license for free on the DOH’s website.

Also, remember that a license to practice medicine in Venezuela, Cuba, Mexico or anywhere else, is just that: a license to practice in that country. It does not allow a person to practice medicine in the United States or Florida. A license from the State of Florida is required to practice in Florida, except for certain military and government-employed physicians. Always check a physician’s license.

Additionally, a medical clinic that is not owned 100% by a licensed physician, podiatrist, chiropractor, physical therapist or nurse practitioner (or a few other specified medical professions) must have a separate Health Care Clinic License (HCCL) that is issued by the Agency for Health Care Administration (AHCA).

We have been consulted by many professionals who have found themselves caught working in illegal clinics. For example, a medical clinic cannot be owned by a deceased physician’s spouse who is not a licensed health professional, unless it has a HCCL. A clinic cannot be owned 50% by a CPA and 50% by a doctor, unless it has a separate HCCL. A dental clinic cannot be owned 20% by a non-dentist and 80% by a dentist; this is illegal and even a HCCL will not make it legal.

Always check out the credentials of a clinic, and its owners before you accept a job there or before you seek treatment there.

More Stories on Fake Physicians and Other Phony and Fraudulent Professionals to Come.

On this blog we will include additional articles on fake doctors and health care professionals, similar to those we have published in the past.

To see a blog on a fake dentist in Miami, click here. You can also read the story of a fake plastic surgeon in New York by clicking here. To read the story of a fake doctor in Texas accused of injecting patients with silicone instead of Botox, click here.

Contact Health Law Attorneys Experienced with Investigations of Health Professionals and Providers.

The attorneys of The Health Law Firm provide legal representation to physicians, nurses, nurse practitioners, CRNAs, dentists, pharmacists, psychologists and other health providers in Department of Health (DOH) investigations, Drug Enforcement Administration (DEA) investigations, FBI investigations, Medicare investigations, Medicaid investigations and other types of investigations of health professionals and providers.

To contact The Health Law Firm, please call (407) 331-6620 or (850) 439-1001 and visit our website at http://www.TheHealthLawFirm.com.

Comments?

What do you think of all of these news stories of phony health care professionals? Please leave any thoughtful comments below.

Sources:

Pavuk, Amy. “Man Accused of Performing Illegal Liposcutions.” Orlando Sentinel. (December 19, 2013). From: http://www.orlandosentinel.com/news/local/breakingnews/os-liposuction-without-license-arrest-20131219,0,7677863.story

About the Author: George F. Indest III, J.D., M.P.A., LL.M., is Board Certified by The Florida Bar in Health Law. He is the President and Managing Partner of The Health Law Firm, which has a national practice. Its main office is in the Orlando, Florida, area. http://www.TheHealthLawFirm.com The Health Law Firm, 1101 Douglas Ave., Altamonte Springs, FL 32714, Phone: (407) 331-6620

 

 

“The Health Law Firm” is a registered fictitious business name of George F. Indest III, P.A. – The Health Law Firm, a Florida professional service corporation, since 1999.
Copyright © 1996-2012 The Health Law Firm. All rights reserved.

Fake Doctor in Texas Accused of Injecting Patients with Silicone Instead of Botox

8 Indest-2008-5By George F. Indest III, J.D., M.P.A., LL.M., Board Certified by The Florida Bar in Health Law

A South Texas woman was charged on October 31, 2013, for allegedly injecting people with silicone, that she claimed was Botox. The phony health professional, described in some media reports as an “unlicensed plastic surgeon,” has been charged with practicing medicine without a license. According to Reuters, the unlicensed health professional could also be facing charges of manslaughter if investigators confirm that a woman’s death was related to treatments received from the imposter.

Click here to read the entire article from Reuters.

If convicted, the fake health care professional could spend up to ten (10) years in prison and have to pay up to $10,000 in fines.

Investigators Looking for More Victims.

Investigators say this phony health professional would travel to different spas and massage parlors along the Texas-Mexico border offering her services and leaving advertisements. She allegedly made injections in patients’ lips, buttocks and legs. The advertisements seized by authorities touted collagen treatments for $250.

According to Fox News, investigators learned of the underground practice when a victim allegedly received a series of injections in her legs in August 2013. The victim has allegedly been hospitalized since October 9, 2013. Authorities also say they are investigating the death of a woman who may have been a victim of the treatments. So far around 30 victims have been identified, but investigators say there could be more, according to Fox News.

To read the Fox News story, click here.

Underground Injections Happen All Over the Country.

This is by no means the first report we’ve heard of phony health care professionals injecting people with toxic chemicals.

In February 2013, a South Florida man was arrested for allegedly injecting people with silicone in a West Palm Beach motel room. According to police, this fake physician injected his patients with buttocks-enhancing silicone injections. He would then allegedly seal up the skin wounds with Krazy Glue. To read more on this, click here to read my previous blog.

As far as we know, there is no relationship between the Florida fake doctor and the Texas fake doctor. However, they could have attended the same medical school.

Practicing Without a License Is a Crime.

Practicing medicine without a license is a crime. Additionally, so is helping someone practice medicine without a license. As a practitioner, you may be asked to supervise or join a practice. Remember that your license may be at stake with any wrongdoing by your subordinates. Before you join a practice or agree to supervise others, check first with the Department of Health (DOH) that the other providers are legitimate. You can verify a license for free on the DOH’s website.

Also, remember that a license to practice medicine in Venezuela, Cuba, Mexico or anywhere else, is just that: a license to practice in that country. It does not allow a person to practice medicine in the United States. A specific license from the State of Florida is required to practice in Florida, except for certain military and federal physicians. Always check a physician’s license.

More Stories on Fake Physicians and Other Phony and Fraudulent Professionals to Come.

In the near future on this blog we will include additional articles on fake doctors and health care professionals.

To see a blog on a fake dentist in Miami, click here. You can also read the story of a fake plastic surgeon in New York by clicking here.

Contact Health Law Attorneys Experienced with Investigations of Health Professionals and Providers.

The attorneys of The Health Law Firm provide legal representation to physicians, nurses, nurse practitioners, CRNAs, dentists, pharmacists, psychologists and other health providers in Department of Health (DOH) investigations, Drug Enforcement Administration (DEA) investigations, FBI investigations, Medicare investigations, Medicaid investigations and other types of investigations of health professionals and providers.

To contact The Health Law Firm, please call (407) 331-6620 or (850) 439-1001 and visit our website at http://www.TheHealthLawFirm.com.

Comments?

What do you think of all of these news stories of phony health care professionals? Please leave any thoughtful comments below.

Sources:

Taylor, Jared. “Phony Plastic Surgeon Accused of Using Silicone for Botox.” Reuters. (October 31, 2013). From: http://www.reuters.com/article/2013/10/31/us-usa-crime-texas-idUSBRE99U1CT20131031

Associated Press. “South Texas Woman Charged for Allegedly Injecting Client; Authorities Seek More Victims.” Fox News. (October 31, 2013). From: http://www.foxnews.com/us/2013/10/31/south-texas-woman-charged-for-allegedly-injecting-clients-authorities-seek-more/

About the Author: George F. Indest III, J.D., M.P.A., LL.M., is Board Certified by The Florida Bar in Health Law. He is the President and Managing Partner of The Health Law Firm, which has a national practice. Its main office is in the Orlando, Florida, area. http://www.TheHealthLawFirm.com The Health Law Firm, 1101 Douglas Ave., Altamonte Springs, FL 32714, Phone: (407) 331-6620.

 

 

“The Health Law Firm” is a registered fictitious business name of George F. Indest III, P.A. – The Health Law Firm, a Florida professional service corporation, since 1999.
Copyright © 1996-2012 The Health Law Firm. All rights reserved.

MedPAC Wants to Hold Accountable Care Organizations More Accountable

Lance Leider headshotBy Lance O. Leider, J.D., The Health Law Firm

As the Centers for Medicare and Medicaid Services (CMS) prepares to designate the next class of accountable care organizations (ACOs), the agency sought the advice and input of the Medicare Payment Advisory Commission (MedPAC) on how to proceed.  MedPAC is an independent Congressional Agency established to advise the U.S. Congress on issues affecting Medicare.

Click here to read our previous blog on the background and purpose of ACOs.

MedPAC Suggests All Medicare Shared Savings Program ACOs Join the Two-Sided Risk Model.

In response to the request from the CMS, MedPAC reiterated its previous position that it would like to see all Medicare ACOs take on greater financial risk.  As it presently stands, some Medicare-contracted ACOs do not share in the risks associated with the ACOs patients’ healthcare costs exceeding certain target ranges.  Even though those ACOs do not bear any financial risk if the goals are not met, they nevertheless stand to benefit if they are.

MedPAC found that the one-sided risk model being used by most Medicare Shared Savings Program (MSSP) ACOs to be insufficient to reach the goals of the MSSP.

Specifically, MedPAC wants to see all MSSP ACOs in the two-sided risk model.  That model requires the ACO to reimburse Medicare for some of the costs which exceeded the target ranges. This pressure is important to note because only 13 of the 32 Pioneer ACOs generated enough savings to Medicare to qualify for MSSP savings payments.

Understand an ACO Agreement Before You Sign.

As we see more and more physicians being approached to join or form ACOs, it is crucial to understand exactly what type of arrangement you are getting into.

Many ACO contracts we see are simply for participation as a provider in the organization.  However, some of the contracts we see require that the physician make a financial investment in the ACO or otherwise require that the physician pay a “pro rata” share of any penalty assessed by CMS.

Current ACO participation and recruiting is something akin to the gold rush of the nineteenth century.  Everyone is rushing to stake a claim in fear of being left out.  Be careful about what kind of an agreement you sign and be sure that you understand the long-term consequences of tying your practice to an as-yet unproven model. To read our previous blog on the first year pioneer ACO results, click here.

If you are approached to join an ACO, or are considering signing a participation agreement/contract with one, make sure to read the contract carefully and consult with an experienced healthcare attorney.

Contact Health Law Attorneys Experienced With Healthcare Business Practices.

The Health Law Firm routinely represents physician groups and practices with issues involving establishing, licensing, selling, merging, and intergroup affiliation.  If you are considering establishing an ACO or have been approached to become a participant in one, you can contact The Health Law Firm at (407) 331-6620 or (850) 439-1001 or you can visit our website at www.TheHealthLawFirm.com.

Comments?

What do you think of MedPAC’s position on ACOs? Have you considered joining an ACO? Why or why not? Please leave any thoughtful comments below.

About the Author: Lance O. Leider is an attorney with The Health Law Firm, which has a national practice. Its main office is in the Orlando, Florida, area. www.TheHealthLawFirm.com  The Health Law Firm, 1101 Douglas Avenue, Altamonte Springs, Florida 32714, Phone:  (407) 331-6620.

“The Health Law Firm” is a registered fictitious business name of George F. Indest III, P.A. – The Health Law Firm, a Florida professional service corporation, since 1999.
Copyright © 1996-2012 The Health Law Firm. All rights reserved.

The American Academy of Family Physicians Releases Third List for Choosing Wisely Campaign

IndestBy George F. Indest III, J.D., M.P.A., LL.M., Board Certified by The Florida Bar in Health Law

On September 24, 2013, the American Academy of Family Physicians (AAFP) released its third list of commonly prescribed tests and procedures that may not be necessary. This list is part of the American Board of Internal Medicine (ABIM) Foundation’s Choosing Wisely campaign.

The Choosing Wisely Campaign was initiated to give patients a catalog of procedures, tests and treatments that have been overused, misused or have been identified as ineffective. Since its launch in April 2012, more than fifty (50) medical specialty societies have created lists of procedures, tests and drug treatments that deserve to be questioned before a physician orders them or patients accept them.

The purpose is to help patients become more discriminating about what care they receive. Physicians and health care providers also need to use this information to review the latest research and use that information to help avoid any litigation.

I’ve previously written about the Choosing Wisely campaign. Click here for part one and here for part two.

AAFP’s Updated List of Commonly Prescribed Tests and Procedures That May Not be Necessary.

1. Do not prescribe antibiotics for otitis media in children aged 2-12 years with non-severe symptoms where the observation option is reasonable.

2. Do not perform voiding cystourethrogram routinely in first febrile urinary tract infection in children aged 2-24 months.

3. Do not routinely screen for prostate cancer using a prostate-specific antigen (PSA) test or digital rectal exam. Evidence suggests that PSA-based screening leads to an overdiagnosis of prostate tumors.

4. Do not screen adolescents for scoliosis. Potential harms include unnecessary follow-up visits resulting from false-positive test results.

5. Do not require a pelvic exam or other physical exam to prescribe oral contraceptive medications. Hormonal contraceptives are safe, effective, and well tolerated by most women.

Click here to read the AAFP’s previous recommendations.

Health Care Providers and Professionals’ Responsibility to Patients.

A doctor should have the knowledge, skill, training, and confidence to know when such tests and procedures are not warranted. Also, a health care professional or provider should not be swayed by increasing his/her personal bottom line. Specifically, physicians that work in a fee-for-service setting that rewards doctors for performing more procedures are at risk for ordering unnecessary tests or procedures. If a physician persists in ordering these tests solely for the means of increasing profits, he or she should be penalized. If not, the physician should be able to justify them.

Laws Protect Patients from Unnecessary Testing.

This situation may have the side effect of promoting additional litigation against doctors, healthcare clinics and hospitals that provide the unnecessary tests and procedures. Many states have laws that prohibit unnecessary tests and procedures and sanction those who provide them. For instance, Section 766.111, Florida Statutes, provides a private cause of action by a patient against a health provider who orders or furnishes such “unnecessary” diagnostic tests, but unlike other tort and medical malpractice statutes, it allows the prevailing party in such a case to recover attorney’s fees and costs. This law may by itself promote litigation in the face of the lists of tests produced by the specialty groups in the Choosing Wisely campaign.

Look for More Whistleblower/Qui Tam Cases.

As this list continues to grow, I believe that we will see more qui tam/whistleblower and false claims cases.

Qui tam cases have been brought under the federal False Claims Act for the recovery of Medicare payments from hospitals, physicians, nursing homes, diagnostic testing facilities, clinical laboratories, radiology facilities and many other types of healthcare providers. These cases allege that a false claim was submitted to the government. If the test or procedure was unnecessary, then it seems almost axiomatic that a claim for it is false. The plaintiff bringing such cases receives a percentage of the recovery, which often amounts to millions of dollars in successful cases.

Most states now have similar false claims act or qui tam laws providing similar causes of action and recoveries to individual plaintiffs in the case of state Medicaid payments as well.

Because medical necessity is a requirement for practically every Medicare and Medicaid service, as well as most services paid by private health insurers, the lists provided by the specialty may very well be exhibit one in future lawsuits.

We’ve recently written about a couple of whistleblower/qui tam cases stemming from unnecessary procedures. To read a blog on a group of Florida radiation oncology service providers accused of performing unnecessary and improperly supervised procedures, click here. To read a blog on Winter Park Urology’s settlement over allegations stemming from radiation therapy used to treat cancer patients, click here.

Contact Experienced Health Law Attorneys.

The Health Law Firm routinely represents pharmacists, pharmacies, physicians, nurses and other health providers in investigations, regulatory matters, licensing issues, litigation, inspections and audits involving the Drug Enforcement Administration (DEA), Federal Bureau of Investigation (FBI), Department of Health (DOH) and other law enforcement agencies. Its attorneys include those who are board certified by The Florida Bar in Health Law as well as licensed health professionals who are also attorneys.
To contact The Health Law Firm, please call (407) 331-6620 or (850) 439-1001 and visit our website at www.TheHealthLawFirm.com.

Comments?

As a health care professional or provider what do you think of the Choosing Wisely campaign? Please leave any thoughtful comments below.

Sources:

Hand, Larry. “AAFP Releases Third Choosing Wisely List.” Medscape. (September 25, 2013). From: http://www.medscape.com/viewarticle/811638

Carman, Diane. “Useless, Costly Medical Procedures Targeted by Choosing Wisely Campaign.” Health Policy Solutions. (October 15, 2013). From: http://www.healthpolicysolutions.org/2013/10/15/useless-costly-medical-procedures-targeted-by-choosing-wisely-campaign/

About the Author: George F. Indest III, J.D., M.P.A., LL.M., is Board Certified by The Florida Bar in Health Law. He is the President and Managing Partner of The Health Law Firm, which has a national practice. Its main office is in the Orlando, Florida, area. www.TheHealthLawFirm.com The Health Law Firm, 1101 Douglas Ave., Altamonte Springs, FL 32714, Phone: (407) 331-6620.

“The Health Law Firm” is a registered fictitious business name of George F. Indest III, P.A. – The Health Law Firm, a Florida professional service corporation, since 1999.
Copyright © 1996-2012 The Health Law Firm. All rights reserved.

Orlando Health’s Restructuring Efforts Might Mean Pay Cuts and Layoffs for Employees

8 Indest-2008-5By George F. Indest III, J.D., M.P.A., LL.M., Board Certified by The Florida Bar in Health Law

Many employees at Orlando Health might be getting hit hard in the wallet with pay cuts schedule for later this year. According to the Orlando Sentinel, the eight-hospital health system notified its night-shift workers that their differential pay would be trimmed by several dollars an hour. For some employees that could be a twenty percent (20%) reduction in salary. The differential pay cuts are scheduled to take effect on September 8, 2013.

Meanwhile the hospital allegedly raised prices in the cafeteria, reduced the tuition reimbursement benefit, cut some workers hours and made a number of layoffs, according to the Orlando Sentinel. According to Orlando Health officials, this is all part of a restructuring effort that began in November 2012. The cutbacks will affect all eight hospitals and all departments.

Anyone who has eaten in the cafeteria at Orlando Regional knows what a bargain the food was. Now this will be the subject of reminiscence as when us old codgers fondly think back on 5 cent Coca Colas and 10 cent loaves of bread.

To read the Orlando Sentinel article, click here.

Night-Shift Workers Feel Under Paid and Under Appreciated.

Some Orlando Hospital employees spoke to the Orlando Sentinel about the pay cuts. According to the Orlando Sentinel, night-shift workers receive incentive pay on top of their base salary for their willingness to work night shifts. One worker interviewed explained the incentive pay is given to them because no one wants to work the overnight shift. Workers also get differential pay for weekend and holiday hours.

On top of the pay cuts, workers are seeing their hours drop, as well as layoffs around the hospital. In the November 2012, restructuring announcement, Orlando Health said 300 to 400 employees’ jobs were on the chopping block, according to WFTV. Some people were previously let go, while more layoffs will be coming. Hospital officials would not say how many people have been laid off so far.

To read more from WFTV, click here.

Orlando Health’s Statement.

Orlando Health reported an $8.1 million loss last quarter. That’s on top of losing money for the last four out of five quarters, according to the Orlando Sentinel. Hospital officials said the change in differential pay puts Orlando Health in line with the pay of other hospitals in the Southeast. On August 13, 2013, Orlando Health sent out an official statement, click here to read the full statement.

Petition to Block Pay Cuts Gaining Momentum.

A petition filed on August 9, 2013, on Change.org, is requesting the Orlando Health CEO block the pay cuts to the night shift workers. The petition was started by a registered nurse at Winnie Palmer Hospital for Women and Babies and is quickly picking up steam. As of August 15, 2013, the petition had more than 2,700 signatures, although not all are local. To view the petition, click here.

Contact Health Law Attorneys Experienced in Representing Health Care Professionals and Providers.

The Health Law Firm routinely represents pharmacists, pharmacies, physicians, nurses and other health providers in investigations, regulatory matters, licensing issues, litigation, inspections and audits involving the DEA, Department of Health (DOH) and other law enforcement agencies. Its attorneys include those who are board certified by The Florida Bar in Health Law as well as licensed health professionals who are also attorneys.

To contact The Health Law Firm, please call (407) 331-6620 or (850) 439-1001 and visit our website at www.TheHealthLawFirm.com.

Comments?

What do you think of the cutbacks at Orlando Health? Are these steps necessary? If you are an Orlando Health employee, how will these changes affect you? Please leave any thoughtful comments below.

Sources:

Jameson, Marni. “Orlando Health Workers Concerned by Cutbacks in Hours and Pay.” Orlando Sentinel. (August 9, 2013). From: http://www.orlandosentinel.com/health/os-orlando-health-cutbacks-20130809,0,5234963.story?dssReturn

Hughes, Ryan. “Orlando Health Confirms Second Round of Layoffs.” WFTV. (August 2, 2013). From: http://www.wftv.com/news/news/local/orlando-health-confirms-second-round-layoffs/nZCjC/

Lewis, Kena. Orlando Health Statement. Orlando Business Journal. (August 13, 2013). From: http://www.bizjournals.com/orlando/blog/2013/08/orlando-health-pay-cuts-to-save-18m.html?page=all

About the Author: George F. Indest III, J.D., M.P.A., LL.M., is Board Certified by The Florida Bar in Health Law.  He is the President and Managing Partner of The Health Law Firm, which has a national practice.  Its main office is in the Orlando, Florida, area.  www.TheHealthLawFirm.com  The Health Law Firm, 1101 Douglas Ave., Altamonte Springs, FL 32714, Phone:  (407) 331-6620.

“The Health Law Firm” is a registered fictitious business name of George F. Indest III, P.A. – The Health Law Firm, a Florida professional service corporation, since 1999.
Copyright © 1996-2012 The Health Law Firm. All rights reserved.

First Year Pioneer ACO Results: Medicare Money Saved But Some Physicians Leave Program

Lance Leider headshotBy Lance O. Leider, J.D., The Health Law Firm

On July 16, 2013, the Centers for Medicare and Medicaid Services (CMS) issued a press release summarizing the performance results for the first year of the Pioneer Accountable Care Organization (ACO) Model. Made possible by the Patient Protection and Affordable Care Act (PPACA), the Pioneer ACO Model encourages providers and care givers to deliver more coordinated care ans services for Medicare beneficiaries. ACOs, including the Pioneer ACO Model and the Medicare Shared Savings Program, are one way CMS is providing options to providers looking to better coordinate care for patients and use health care dollars more wisely, according to CMS.

Click here to read the entire press release from CMS.

Pioneer Model ACOs Increase Quality.

The press release states that all thirty-two (32) participants in the program successfully increased the quality of care received by their beneficiaries.  Consequently, each participant received incentive payments for achieving these results.

Some examples of the quality improvements were lower readmission rates and better blood pressure and cholesterol control among diabetic patients.  Some examples of the quality control measures that were implemented were:

-    dispatch of hospital trained nurses to beneficiaries’ homes for management of prescriptions, blood-sugar readings, healthy eating education and delivery and set up of durable medical equipment (DME); and

-    care coordination by trained healthcare professionals at no cost.

Pioneer Model ACOs Increase Savings.

Of the thirty-two (32) Pioneer ACOs, thirteen (13) of them produced shared savings with CMS.  This means that they exceeded the cost reduction benchmarks and were eligible to receive a percentage of those savings from CMS as compensation additional to the fee-for-service payments.  In total CMS estimates that approximately $87.6 million in Medicare expenditures was saved.

However, two (2) of the Pioneer ACO participants had shared losses.  This means that their per beneficiary fee-for-service expenditures exceeded the stated goal and they were required to share in the losses suffered by CMS.  These losses were approximately $4 million.

Some Pioneer Model ACOs Withdrawal From Program.

Of the Pioneer ACOs that did not produce shared savings, seven (7) of them have decided to leave the Pioneer program and enroll in the standard Medicare Shared Savings Program.  This program offers lower risks and lower rewards and does not have the option of moving to a capitated payment model after the first two (2) successful years.

The two (2) Pioneer ACOs that experienced shared losses with CMS have signaled their intent to withdraw from the ACO model entirely.

The First-Year Pioneer ACO Lesson: Win Some, Lose Some.

While not a total success, the Pioneer ACO program did manage to produce net savings to Medicare and improve the quality of care provided to its beneficiaries.  Many news outlets who oppose PPACA are citing this as a failure of the program and yet more bad news for President Obama’s healthcare overhaul.  However, many other sources share CMS’s somewhat rosier view of the program.  These sources state that while the program may not have been as big a success as hoped, it was only the first year in operation and is nowhere near a failure.

According to an article in American Medical News, the American Medical Association (AMA) supports ACO programs that have allowed physicians practicing in groups of various sizes to participate in new care models. The AMA states that the first-year pioneer results are encouraging, and have the potential to improve quality and decease costs. To read the entire article from American Medical News, click here.

Data should be released on the standard Shared Savings Program ACOs in the near future.

Contact Health Law Attorneys Experienced With Healthcare Business Practices.

The Health Law Firm routinely represents physician groups and practices with issues involving establishing, licensing, selling, merging, and intergroup affiliation.  If you are considering establishing an ACO or have been approached to become a participant in one, you can contact The Health Law Firm at (407) 331-6620 or (850) 439-1001 or you can visit our website at www.TheHealthLawFirm.com.

Comments?

What do you think of the performance results summery for the first year Pioneer ACO Model? What do you think about the number of groups dropping out? Please leave any thoughtful comments below.

Sources:

Centers for Medicare and Medicaid Services. “Pioneer Accountable Care Organizations Succeed in Improving Care, Lowering Costs.” CMS.gov. (July 16, 2013). From: http://cms.gov/Newsroom/MediaReleaseDatabase/Press-Releases/2013-Press-Releases-Items/2013-07-16.html

Fiegl, Charles. “Medicare pioneer ACOs save money but lose physicians.” American Medical News. (July 29, 2013). From: http://www.amednews.com/article/20130729/government/130729933/1/?utm_source=nwltr&utm_medium=heds-htm&utm_campaign=20130729

About the Author: Lance O. Leider is an attorney with The Health Law Firm, which has a national practice. Its main office is in the Orlando, Florida, area. www.TheHealthLawFirm.com  The Health Law Firm, 1101 Douglas Avenue, Altamonte Springs, Florida 32714, Phone:  (407) 331-6620.

“The Health Law Firm” is a registered fictitious business name of George F. Indest III, P.A. – The Health Law Firm, a Florida professional service corporation, since 1999.
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