Upload
harriet-wheeler
View
39
Download
0
Tags:
Embed Size (px)
DESCRIPTION
Institutional Issues. Charitable Hospitals. What was charitable immunity and why did we have it? What is the social bargain behind charitable status of hospitals? What is competitive advantage of being a charitable hospital? - PowerPoint PPT Presentation
Citation preview
Institutional Issues
Charitable Hospitals
What was charitable immunity and why did we have it?
What is the social bargain behind charitable status of hospitals? What is competitive advantage of being a
charitable hospital? What issues does this raise during a
conversion to a for-profit hospital?
Who Benefits in Charitable Organizations?
Who stands in the shoes of shareholders in overseeing the mission of charitable organizations?
What is surplus? What is the inurnment problem?
How do you decide if there is an inurnment problem? What are the constraints on joint ventures between
charitable and for-profit organizations?
Charitable Purpose
What is charitable purpose? Is a bigger better hospital a proper charitable
purpose? Is more surplus?
What are ways to measure community service? What should the IRS or state tax agencies look at
in determining charitable purpose?
EMTALA
How does EMTALA work? Who does it apply to? Is EMTALA a medical malpractice law? What is emergency care under EMTALA?
Why does this pose a problem for chronic disease management?
What are the government remedies for violations? What are the private remedies for violation? What incentives does EMTALA give hospitals in poor
neighborhoods?
Specialty Hospitals
What is the quality justification for specialty hospitals?
What is the cost justification? How does EMTALA affect their economics in LA? What is the impact on community hospitals? What problems does this cause for health care in
the community?
Theories of tort liability for health care institutions
Direct negligence Vicarious liability
Employee? Control theories
Ostensible agency Implied agency Apparent agency
ERISA
What is ERISA? Why was health insurance included in ERISA? What competitive advantages does an ERISA qualified
health plan have? Who regulates the plans - state or the feds? Affects on liability for medical necessity decisions? About coverage decisions, i.e., does the plan have to
pay for things like experimental care? How do you tell the difference between a coverage
decision and a medical necessity decision?
ERISA and Health Care Reform
How does ERISA affect state efforts to create statewide access to health care?
What was the Maryland Wal-Mart bill? Why did it run afoul of ERISA? What things can a state do that are not a problem
for ERISA? What state actions will run afoul of ERISA
Think about California and Massachusetts
Discrimination Law
How does the ADA affect health care providers? What other discrimination laws do health care
providers have to worry about? Explore the issues posed by an HIV or hepatitis B
infected health care provider Explore the issues posed by an HIV or hepatitis B
infected patient
Staff Privileges and Hospital–Physician Contracts
What is the effect of removing a physician from the hospital medical staff? National Practitioner Database issues? Practice issues?
What are the due process rights for physicians? Private hospitals? Public (government) hospitals?
What legal claims might a physician make for improper termination? How did Congress limit these claims? Why did Congress limit these claims?
Labor and Employment
What is employment at will? What is the NLRB?
What can unionized physicians do that independent contractor physicians cannot do?
Who can form a union? What is a bargaining unit? Why do hospitals hate unions?
Discuss the limitations of whistleblower laws
Fraud and Abuse
Are You Cheating the Government?
Conditions of Participation (COP)
The contract between the providers and CMS If you do not comply with the COP you can be
denied payment or excluded from the program If you knowingly violate the provisions of COP it
can be grounds for false claims and criminal prosecution
What does the government care about?
Cost Utilization (medical necessity) Quality
Cost
This is controlled directly The feds decide what they want to pay What are the constraints on pricing?
Utilization (Medical Necessity)
What are the issues we have seen on medical necessity? Is the treatment needed? Is it experimental? Is it effective? Is it covered by the policy
What are the political constraints on the government in setting utilization rules?
Quality
Does the government care about quality? What about when quality and cost collide? Should patients have a right to cheaper, lower
quality care? Does the federal government directly control
quality? States? JCAHO?
Fraud Issues
Was the care delivered at all? Durable medical equipment scams Billing for more care that was actually delivered
Was the care necessary? Was the care unbundled?
(Charging separately for care that should be one charge)
Where kickbacks paid?
Related Laws
General government contracting laws Mail and wire fraud RICO False Claims Act
Statutory penalties - $5-11,000 per claim Treble damages (whichever is higher)
Qui tam - private enforcement
Coding
CPT codes - AMA Some are time based Others are work-based
You get paid more for doing more It does not matter how long you take Levels 1-5
Is it better to see a lot of patients or do a lot to each you see?
Why use Codes?
Uniform billing for all claims Equalize billing across specialties Provide incentives for more comprehensive care Allows computerized payment Allows tracking of medical information derived
from claims forms
Upcoding
Anything that increases the payment for the encounter
Can be legal Optimizing coding
Can be illegal Work that was not do, or work that was not
properly documented Misstating the patient's medical condition
US v. Krizek, 111 F.3d 934 (D.C. Cir. 1997)
The judge thinks the doc is a good guy Criticizes the crazy reimbursement system Let the doc put on evidence of standard billing
practices to refute fraud charges Thinks the law is crazy because the feds can
assess $81,000,000 in penalties
What did Krizek do wrong?
Did he actually treat the patients? Was his treatment medically necessary? What were the issues in billing? Billed for 40-50 minute time code for everyone
Who did this What was the justification? Did the doc know?
Doc's Defense
He really did spend the time, he just did not spend it all on the patient
Lots of stuff you do in the office as part of the care
"Scienter" - What does the prosecutor have to show the Doc knew?
Intent to defraud? Knowing that the claim is wrong but submitting it
anyway? Why does the statute specifically say that there is
no need to prove intent to defraud? What is the doc's certification problem?
District Court Ruling
Found liability on the days when there were more than 12 codes for 50 minutes
Thought that the doc was liable, but an unfortunate system
Appeals Court
Makes it clear that reckless ignorance is wrong and grounds for liability under the Act
Is not sympathetic to the doc's claimed slipshod accounting
Is Bad Care Fraud?
What would make bad care fraudulent? What are you certifying when you bill for care?
Whistleblower Provisions
Only protection if you bring suit Not a good protection
Interesting issues
Bribes by device and drug companies PATH audits (medical schools) HCA
Qui Tam
Standing in the shoes of the government 15-20% Feds can march in May not apply to claims against states
Understanding Self-Referral Laws
Physicians as Fiduciaries
Model Penal Code Informed consent law General principles
Knowledge differential Power differential
Fiduciary Obligations
The physician acts as purchasing agent for the patient
Self-referral laws target incentives that encourage the physician to make certain decisions contrary to the patient's interests Order unnecessary care or tests Choose providers based on criteria other than
the best interests of the patient
Why Does the Federal Government Care?
They claim to care about quality FTC undermines this with talk about the right to
buy cheap, crummy care They care a lot about costs
Unnecessary care is wasted money and bad for the patient
It is assumed that if a kickback is necessary, the care is either worse or more expensive
Problems with the Federal Bias
The feds are only concerned with incentives to order more care or to steer care
They do not care if there are incentives to deny care Big issue with HMOS and other structured
plans Underlines the problem with consumer directed
care
The General Self-Referral Laws
There is broad statutory authority banning deals that create incentives to refer business
These deals have to be analyzed to map out the cash flow to determine what incentives the physicians see
The Lease Scam
Hospitals often own professional buildings Physicians in the professional are more likely to
admit patients to the hospital Proximity Shared services
Is the hospital providing incentives for physicians to be in their professional building?
How do you put a fair market value on proximity?
The Recruitment Scam
The hospital sees that there is a need for physicians with specific skills in the community
The hospital recruits a physician with a relocation package Moving expenses Salary support for a period of time
Does any of this obligate the physician to refer to that hospital?
What if it is the only hospital in the community?
The Lab Scam
There is a huge amount of money in medical lab tests Hence my skepticism about the real causes of
defensive medicine Is the lab providing incentives to the physician?
Direct kickbacks Subsidized services, like renting space in the
physician's office Gifts - trips to the fishing camp
The Hospital Investment Scam
Hospital wants to increase the flow of surgical patients
Hospital sets up surgical suite as a separate corporation and sells surgeons shares
Earnings are based on the capital contribution What is the impact of a admitting patients on the
physician's return on investment?
The Practice Purchase Scam
Hospital buys the physician's practice Hires the physicians to deliver care in the new
hospital practice Is this really a sale or just a kickback scheme? How was the business valued? What are the terms for payment?
Is any of the payment contingent on referrals?
The Stark Law Approach
Start has a list of 11 defined services Any deals that influence the ordering of these
services are banned There are a series of safe harbors for transactions
that are not thought to be abusive
Philosophy of Stark
Simplify the law by clearly outlining the forbidden areas
Create safe harbors that can be used as models
Problems with Stark
Too much money in the forbidden areas Doc and hospitals go the extra yard to game the
system Spotty to non-existent enforcement
No clear boundaries Puts complying entities at a completive
disadvantage
Exceptions to Stark
Physician controlled ancillary services If the doc runs the lab and it is part of the
practice, it is not covered by Stark What is the incentive? Is it even worse than for an outside lab?
Analyzing Stark Transactions
Is it a covered service? Does it met the ancillary service exception? Is there any financial linkage between the provider
and the referring doc?
The Integrated Provider Exception
Integrated providers provide both medical and hospital and other services
It is OK to tell employees where to refer patients You cannot pay employees a bonus for referrals,
but they can share in the profits (gain share) Does this exception make any sense? Does it just provide a way for hospitals to avoid
self-referral laws by buying physician's practices?
Antitrust
Fundamental Assumptions
Competition is good Big is not bad Monopoly practices are bad People should be allowed to buy whatever quality
they want The market will provide whatever is necessary
Market Organization
Vertical markets Horizontal markets What is the market for services?
Rural markets with limited providers Urban markets
Are there specialized services?
Monopoly Power - What one Competitor Does
What does monopoly power allow? Unilateral anticompetitive actions
Tying Retail price maintenance agreements
Before the court right now
Joint Action
Any time competitors make agreements that affect competition there is an antitrust question
Professional standards can be anti-competitive vehicles
Why are docs such a problem? Are labor unions an alternative?
Penalties
Federal prosecution Criminal fines Prison time
Civil enforcement by the FTC Fines Treble Damages
Private enforcement Treble damages and attorney's fees
Per Se v. Rule of Reason Violations
Per se violations only require proof of the violation, not the market power of the competitors or the effectiveness of the action
Rule of reason violations require detailed market analysis
The defendant is well on the way to winning if the court decides it is rule of reason
The Professional Standards Defense
Is it a defense that the restraints improve patient care? Why does the FTC not care about quality? What are other controls on quality?
Can you do group action through a professional organization? Is JCAHO an illegal conspiracy?
Per Se Violations Through Joint Action
Group boycott Wilk - Chiropractor Indiana Federation of Dentists
Market division agreements Price fixing
The Advertising Cases
Lawyer advertising First case was advertising lower prices Then any truthful advertising
Physicians Followed the lawyer cases
Physician Staff Privileges Cases
How can staff privileges become an antitrust issue?
Is peer review among competitors always an antitrust issue?
How could the staff avoid this claim? What did the feds do to protect peer review?
Federal Health Care Quality Improvement Act
How do Antitrust Issues Change with Health Care Consolidation?
What can large group practices do that individual docs cannot do?
How about hospitals buying physician practices? How does this affect competition?