Davis Wright Tremaine LLP Basic Legal Issues in Implementing Healthcare Incentives and Pay for...
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Davis Wright Davis Wright Tremaine Tremaine LLP LLP Basic Legal Issues in Implementing Healthcare Incentives and Pay for Performance Programs Paul T. Smith, Esq. Davis Wright Tremaine LLP San Francisco, CA Thomas E. Jeffry, Jr., Esq. Davis Wright Tremaine LLP Los Angeles, CA National Pay for Performance Summit
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Transcript of Davis Wright Tremaine LLP Basic Legal Issues in Implementing Healthcare Incentives and Pay for...
Davis Wright Davis Wright Tremaine Tremaine LLPLLP
Basic Legal Issues in Implementing Healthcare Incentives and
Pay for Performance Programs
Paul T. Smith, Esq.
Davis Wright Tremaine LLP
San Francisco, CA
Thomas E. Jeffry, Jr., Esq.
Davis Wright Tremaine LLP
Los Angeles, CA
National Pay for Performance Summit
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OverviewOverview
Context for P4P Antitrust Physician Incentive Programs Collection and Exchange of Data
Context for P4P Antitrust Physician Incentive Programs Collection and Exchange of Data
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A Growing TrendA Growing Trend
Many variations; we focus on health plan payments to providers to reward quality
Examples:Integrated Healthcare Association
(California)Bridges to Excellence (Boston,
Cincinnati, Albany)Leapfrog GroupMedicare
Many variations; we focus on health plan payments to providers to reward quality
Examples:Integrated Healthcare Association
(California)Bridges to Excellence (Boston,
Cincinnati, Albany)Leapfrog GroupMedicare
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FeaturesFeatures
Quality measuresClinical measures
Screening, immunization and other prevention
Patient satisfactionAdoption of technology
PaymentIncremental PMPM payment (typically
< 5%)Often competitive
Scorecards
Quality measuresClinical measures
Screening, immunization and other prevention
Patient satisfactionAdoption of technology
PaymentIncremental PMPM payment (typically
< 5%)Often competitive
Scorecards
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AntitrustAntitrust
The price-fixing concernElements of payment
MeasuresWeightingPayment
The price-fixing concernElements of payment
MeasuresWeightingPayment
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AntitrustAntitrust
The case for collaborationThe MedSouth clinical integration opinion
The FTC/DOJ Report - Improving Health Care
The case for collaborationThe MedSouth clinical integration opinion
The FTC/DOJ Report - Improving Health Care
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AntitrustAntitrust
How far is too far?MeasuresWeightingPaymentRecommended or bindingPossible anti-competitive effects
How far is too far?MeasuresWeightingPaymentRecommended or bindingPossible anti-competitive effects
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Physician IncentivesPhysician Incentives
Anti-kickback Laws Gainsharing Limitation of Care Physician incentive plans
Anti-kickback Laws Gainsharing Limitation of Care Physician incentive plans
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Anti-kickback lawsAnti-kickback laws
Both federal and state Prohibits the offer/receipt of remuneration for referrals
Civil penalties and criminal exposure
Exception for managed care
Both federal and state Prohibits the offer/receipt of remuneration for referrals
Civil penalties and criminal exposure
Exception for managed care
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GainsharingGainsharing
Alignment of financial incentives to improve efficiencies, increase quality of care, lower costs
Alignment of financial incentives to improve efficiencies, increase quality of care, lower costs
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GainsharingGainsharing
Programs scrutinized by OIG Acceptable programs
identify specific cost-saving actions
must monitor quality to assure no adverse impact
no cherry-picking incentives no hidden incentives for individual referrals
Programs scrutinized by OIG Acceptable programs
identify specific cost-saving actions
must monitor quality to assure no adverse impact
no cherry-picking incentives no hidden incentives for individual referrals
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Limitation of CareLimitation of Care
Civil Monetary Penalties (CMPs)
Prohibits remuneration intended to limit services to Medicare/Medicaid beneficiaries
Civil Monetary Penalties (CMPs)
Prohibits remuneration intended to limit services to Medicare/Medicaid beneficiaries
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Physician Incentive PlansPhysician Incentive Plans
Compensation arrangement that may directly or indirectly have the effect of reducing or limiting services provided with respect to enrolled individuals
Compensation arrangement that may directly or indirectly have the effect of reducing or limiting services provided with respect to enrolled individuals
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Physician Incentive PlansPhysician Incentive Plans
Contracts with CMPs no inducement to reduce of limit services
stop-loss if physicians at substantial financial risk
quality assurance/satisfaction survey
Contracts with CMPs no inducement to reduce of limit services
stop-loss if physicians at substantial financial risk
quality assurance/satisfaction survey
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Privacy/ConfidentialityPrivacy/Confidentiality
Protection of individually identifiable health informationHIPAA allows disclosure to
contractor for data aggregationPermissible use of aggregate data
Reporting to provider and health plan
Disclosure to othersResearchPublic scorecards Collateral uses
Protection of individually identifiable health informationHIPAA allows disclosure to
contractor for data aggregationPermissible use of aggregate data
Reporting to provider and health plan
Disclosure to othersResearchPublic scorecards Collateral uses
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Data Collection & IntegrityData Collection & Integrity
HIPAA requires reasonable measures to secure electronic data encryption physical safeguards access controls audits and monitoring
HIPAA requires reasonable measures to secure electronic data encryption physical safeguards access controls audits and monitoring
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Data Collection & IntegrityData Collection & Integrity
Issues Who collects and verifies data?
How is accuracy of data assured?
Publication of data regarding a specific provider
Issues Who collects and verifies data?
How is accuracy of data assured?
Publication of data regarding a specific provider
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QuestionsQuestions
Paul SmithSan Francisco, CA
(415) 276-6500
Paul SmithSan Francisco, CA
(415) 276-6500
Tom JeffryLos Angeles, CA
(213) 633-6800
Tom JeffryLos Angeles, CA
(213) 633-6800
