PCMH

Congratulations to Emory Healthcare Network on PCMH Level 3 Recognition

In early 2015, EHN partnered with PCMH University to transform 10 primary care sites to Patient-Centered Medical Homes.  The program completed in April 2016 with nine sites submitting their applications to NCQA.  All 9 sites received PCMH Level 3 recognition.

Like other health systems around the country, EHN is adapting to the trend of health insurance, including Medicare and Medicaid, paying hospitals and doctors based on the value of the care they provide rather than the volume of services they render.  Enhancing primary care services is a pillar of EHN’s strategy.  Numerous studies around the country have demonstrated the potential of the PMCH to both improve quality and lower costs.

After a competitive bidding process, EHN chose to partner with the Georgia Academy of Family Physicians (www.gafp.org) and Discern Health (www.discernhealth.com) to support the transformation. EHN is enrolling 10 primary care practices in GAFP’s PCMH University.

Congratulations EHN PCMH University Class of 2015:

  • General Internal Medicine at St. Joseph’s –  Dipak Vashi, MD
  • General Internal Medicine at Emory Midtown – Fred Turton, MD
  • Emory Clinic at Decatur –  Nick Church, MD
  • Integrated mEmory Clinic – Janet Cellar, MD
  • Emory Specialty Associates at Sugarloaf – Drew Huber, MD
  • Emory Specialty Associates at Eagles Landing –  Kennard Hood, MD
  • Internal Medicine of Newton – James Stillerman, MD

Accountable Care Organizations: A Contracting Primer for Family Physicians

The Medicare Shared Savings Program (MSSP), established by the Patient Protection and Affordable Care Act of 2010, offers a new path in healthcare delivery and aims to improve the quality of care for Medicare Fee-For-Service (FFS) beneficiaries while reducing unnecessary costs. The MSSP seeks to accomplish these goals through facilitating coordination and cooperation among healthcare providers. Family physicians can voluntarily participate in the MSSP by creating or participating in an Accountable Care Organization (ACO). Many members of the Georgia Academy of Family Physicians have already joined ACOs and are now looking at either terminating their memberships or switching to different ACOs.

ACOs are groups of physicians and other healthcare providers who choose to work together with Medicare to provide medical services to FFS beneficiaries. If beneficiaries receive at least one primary care service from a physician within an ACO, beneficiaries will be assigned to an ACO. In addition, ACOs must have a minimum of 5,000 FFS beneficiaries assigned to ACO participants. Therefore, it is very difficult and can even be impossible for some small group practices to meet the requirements to participate in an ACO. An ACO’s assigned population also cannot fall below 5,000 FFS beneficiaries at any time during the performance year.

A significant distinction in how the MSSP treats primary care practices and specialized medical practices is in the number of ACOs a physician practice can join. A primary care physician is restricted and can only join one single ACO; CMS rules do not limit the number of ACOs that a specialist may join, however.

While the MSSP has established goals it hopes to meet through ACOs, Academy member physicians are experiencing uncertainty regarding how successfully these goals will be met. As a result of the restrictions placed on primary care physicians participating in ACOs, as well as the difficulty some ACOs have in meeting (or continuing to meet) the CMS rules, family physicians should keep the following principles in mind when contracting with ACOs:

1) The contract should allow the family physician to terminate without cause after a certain number of days. This will allow the physician to switch to a different ACO;

2) The term of the contract should be for no more than two years, as ACOs will likely encounter difficulties that may encourage the family physician to switch to a different ACO;

3) The contract should carefully follow the parameters of the ACO rules and not include extraneous terms to the ACO;

4) The contract should describe the compensation methodology in detail (if it does not, the family physician should request the distribution policy from the ACO);

5) The contract should not include a non-compete or any other restrictive covenant that would limit a family physician from joining another ACO; and

6) If this is the first contract that a family physician contemplates signing, he or she should have an attorney review the contract for all the other, non-ACO related provisions.

As ACOs enter their “second generations”, many Academy members will become comfortable with contemplating membership in an ACO. Whether the family physician is looking at terminating or changing ACOs, or joining an ACO for the first time, the Academy member should carefully review the participation contract to ensure that it follows the ACO rules and allows for mobility if the ACO arrangement is not productive.

Richard Sanders, Esq. is a partner in The Sanders Law Firm, P.C. in Atlanta. He can be reached at (404) 806-5575 or rsanders@southernhealthlawyers.com.

Stark Law Changes Effective in 2016

By Richard D. Sanders, Esq.

Introductions

On October 30, 2015, the Centers for Medicare and Medicaid Services (“CMS”) revealed the 2016 Medicare Physician Fee Schedule (the “Final Rule”), which included significant changes to the Physician Self-Referral Law (the “Stark Law”). The Stark Law generally prohibits physician referrals for designated health services payable by Medicare or Medicaid to an entity with which such physician (or an immediate family member) has a financial relationship, unless an exception applies.

The purpose of this Final Rule is to accommodate healthcare delivery and payment system reform, reduce burdens, facilitate compliance, and issue new exceptions to the Stark Law. These new regulations became effective on January 1, 2016, with the exception of the definition of “ownership or investment interest” as it relates to the level of physician ownership in physician-owned hospitals, which will become effective on January 1, 2017.

New Stark Exceptions

Assistance to Compensate a Non-physician Practitioner

In an attempt to address changes to the healthcare delivery and payment systems, alarming primary care workforce shortage projections, and the increasing demand for primary care services (particularly in rural and underserved areas), the Final Rule includes a new exception that permits remuneration from a hospital, federally qualified health center (“FQHC”), or rural health clinic (“RHC”) to a physician in order to assist the physician in employing a non-physician provider in the geographic area served by the hospital, FQHC or RHC. The specific limitations and requirements of this new exception can be found under 42 C.F.R. § 411.357(x).

Timeshare Arrangements

The Final Rule also includes an exception to the Stark Law for “timeshare” arrangements in which a hospital or local physician practice may arrange with a specialist from another community to provide services in a space owned by a hospital or practice on a limited or as-needed basis. CMS acknowledged the utility of timeshare arrangements whereby an individual could use another person or entity’s premises, equipment, personnel, items, supplies or physician services under a license rather than under a traditional lease. Further details regarding this arrangement can be located at 42 C.F.R. § 411.357(y).

Modifications to Existing Stark Law Exceptions, Policies, Definitions and Other Changes

Writing Requirement

CMS clarified in its Final Rule that the existing writing requirement in many Stark Law exceptions does not require an arrangement to be in a single “formal” written contract. Rather, the writing requirement can be satisfied by showing a collection of documents evidencing the course of conduct between the parties. To further clarify this policy, CMS replaced the terms “agreement,” “lease,” “written contract,” and “contract,” with the terms “arrangement” and “writing.” Moreover, when parties use a collection of documents to satisfy the writing requirement, a signature is required on a contemporaneous writing(s) sufficient to document the arrangement.

Term Requirement

Certain Stark Law exceptions (i.e., rental of office space, rental of equipment, and personal services arrangements) require a term of at least one year. CMS clarified that a formal written contract or other document with an explicit term provision is not required to satisfy the “term” element. Instead, the term requirement can be satisfied so long as the arrangement clearly establishes that a business relationship will last for at least one year. On the other hand, an arrangement that actually lasts for one year will satisfy this requirement. CMS further provides that “Parties must have contemporaneous writings establishing that the arrangement lasted for at least one year, or be able to demonstrate that the arrangement was terminated during the first year and that the parties did not enter into a new arrangement for the same space, equipment, or services during the first year.”

Signature Requirement & Temporary Noncompliance

The Final Rule allows an entity ninety (90) days to obtain required signatures, regardless of whether the noncompliance was purposeful or inadvertent. In order to utilize this temporary noncompliance period, the arrangement must satisfy all other requirements of the applicable exception. However, an entity can only use this temporary noncompliance period to satisfy the signature requirement once every three (3) years for the same referring physician.

Holdover Arrangements

Previously, expired arrangements under the Rental of Office Space Exception, Rental of Equipment Exception and Personal Services Exception were permitted for up to six (6) months if the arrangement satisfies the requirements of an exception upon its expiration, and the arrangement continues to comply with the same terms and conditions after the stated expiration. Under the Final Rule, indefinite holdovers are permitted provided the arrangement: (1) satisfies all of the elements of the applicable exception at the time of the stated expiration; (2) continues under the same terms and conditions as the original agreement; and (3) continues to comport with all of the elements of the applicable exception during the course of the holdover.

Definition of Remuneration

The Final Rule revised the definition of “remuneration” under the Stark Law to make it clear that the provision of items, devices, or supplies that are used solely to collect, transport, process, or store specimens for the entity providing the items, devices, or supplies, or to order or communicate the results of tests or procedures for such entity does not constitute remuneration.

Geographic Area Served by FQHCs and RHCs

According to the Physician Recruitment Exception, remuneration may be provided by a hospital to a physician in order to induce the physician to relocate his or her medical practice to the geographic area served by the hospital and become part of the hospital’s medical staff. This exception was also expanded to include FQHCs and RHCs. The term “geographic area served by the hospital” is partially defined as “the lowest number of contiguous postal zip codes from which the hospital draws at least 75 percent of its inpatients.” However, this definition did not provide guidance as to the geographic areas in which a FQHC or RHC can recruit a physician. As a result, the Final Rule added a new definition to clarify this discrepancy by defining the geographic area served by a FQHC or RHC as “the lowest number of contiguous or noncontiguous zip codes from which the FQHC or RHC draws at least 90 percent of its patients, as determined on an encounter basis.”

Conclusion

In all, CMS made some very significant changes to the Stark Law (including the addition of two new exceptions) which should offer healthcare providers greater clarity and flexibility under certain arrangements.

Richard D. Sanders is an attorney in Atlanta who specializes in corporate and regulatory matters for physicians. He can be reached at rsanders@southernhealthlawyers.com or (404) 806-5575.

Congratulations PCMH University Team White!

PCMH University Team White concluded a 15 month journey this December. Four practices, sponsored by Universal American, have worked together since October 2014 to transform their practice to medical homes within an Accountable Care Organization. We would like to congratulate all practices for completing the PCMH University program. As of December, one practice has completed and submitted their PCMH application to NCQA.  The three remaining practices have submission target dates set for early January 2016.

Congratulations on your success!

PCMH University – TEAM WHITE:

  • Candler Internal Medicine – Rani Reddy, MD – Statesboro, GA
  • Evans Medical Group – Christopher Apostol, DO – Evans, GA
  • Southern Family Medical Center – Sean Lynch, DO – Augusta, GA
  • Steve Wilson, MD – Warner Robins, GA

Join us for the First Annual PCMH Best Practices Workshop

This November, GAFP will host the first annual Patient-Centered Medical Home Best Practices Workshop in conjunction with the Annual Scientific Assembly.  This collaborative event will bring together NCQA-recognized Medical Homes from Georgia, Tennessee, Alabama, and South Carolina to share tools and tips for sustaining transformation. PCMH University Graduates will present tools they have developed to maintain their medical home and enhance patient care.  Participants will also hear from local and national experts about changes on the horizon and how it will impact the medical home.  This CME workshop will be held on Thursday, November 5th at the Westin Buckhead in Atlanta, GA.

Registration is open to PCMH University Graduates and NCQA-recognized Patient-Centered Medical Homes.  To register, please visit the conference registration page: https://www.eply.com/2015GAFPAnnualScientificAssembly