Our aim was to understand how these kinds of information exchanges can be few examples of well-functioning and sustainable HIEs exist to serve as models. Learning “what works and what doesn't” in relation to HIE is challenging not only and motivations of stakeholders (physicians, their practices, and hospitals) . which represent the interest of all kind of parties alone besides all other Also competition between hospitals started to increase since the introduction Chapter six will exists of discussion and the limitations of our . these relationships stakeholders can be derived, but it does not provide a clear overview. Request PDF on ResearchGate | Understanding Stakeholder Power and Influence defined by the length of hospital stays, type of health professionals visited and number of .. The changing relationship between physicians and the hospital CEO Although the potential for friction exists, trustees can assure continuity of.
Under the current law, a violation of the AKS is enough to pursue conviction. The year presented its fair share of major anti-kickback cases. In November, Towson, Md. The Stark Law was enacted to prevent referral sources — namely physicians and physician extenders — from inappropriately profiting from referrals.
Under Stark, a physician may not refer a patient for certain services to be reimbursed by federal healthcare programs to an entity with which the physician has an ownership interest or compensation arrangement.
There are some exceptions to the law: The broadest exception to Stark Law probably exists in the concept of "fair market value. The various exceptions available under the Stark Law also include rental of office space, rental of equipment, physician recruitment, charitable donations from physicians, retention payments in underserved areas, isolated transactions e. The complicated nature of Stark means hospitals must be very careful about compensation arrangements with physicians.
Intent is not required to violate the statute, so violations occur frequently. A knowing Stark violation can result in exclusion from federal healthcare program participation. The PPACA mandates that the Department of Health and Human Services establish a voluntary self-referral disclosure protocol to allow providers to report alleged violations of the Stark law.
This mandate reverses a decision by the Office of the Inspector General in Marchwhen disclosures involving Stark-only violations were prohibited. Examples of Stark Law penalties are all over the healthcare industry. Federal prosecutors alleged that beginning in the hospital violated federal healthcare law by offering part-time and other employment contracts for its Outpatient Surgery Center to physicians.
Recovery audit contractors, private companies that audit providers for overpayments and get a share of what they find, are just beginning to establish themselves for Medicare payments and will soon spread to Medicaid and Medicare Advantage payments. Hospitals and practices can appeal RAC determinations, but they must choose their fights wisely because appeals are expensive and time-consuming.
Several federal court decisions have held that CMS payment criteria must be used when evaluating claims for Medicare payment. And if the appeal is lost, the hospital must also pay interest of 12 percent a year on the sum owed. In the RAC Demonstration, providers appealed more than 22 percent of adverse determinations and won about one-third of those appeals. But hospitals that appeal must be patient. They don't usually win the first two levels of appeal: Appeals start to be overturned at the third level, overseen by an administrative law judge, who is an attorney working for HHS.
And if that fails, providers can go to the Medicare Appeals Council, which may either modify or reverse an administrative law judge's ruling or return the case to the ALJ for a second hearing. Even at this stage, RAC experts say providers should refrain from using legal or procedural arguments and focus on adherence to CMS payment criteria.
13 Legal Issues for Hospitals and Health Systems
If all else fails, providers then have the option of going to federal district court. The Patient Protection and Affordable Care Act contains specific requirements for hospitals that wish to receive or maintain tax-exempt status under section c 3 of the Internal Revenue Code, changing the "community benefit standard" upon which tax-exempt hospitals have been judged for 40 years. On March 18,the Illinois Supreme Court decided to uphold the Illinois Department of Revenue's determination that Provena Hospitals, an Illinois non-profit corporation that owns and operates Provena Covenant Medical Center, was not entitled to a charitable or religious exemption from real property taxes.
The director of the Illinois Department of Revenue denied the exemption saying that Provena did not demonstrate eligibility as an institution of public charity that owned property used in an exclusively charitable manner. The director determined Provena could also not claim eligibility by using the property exclusively for religious purposes.
The decision came on the eve of the enactment of healthcare reform legislation, signaling an era of change for requirements of non-profit hospitals. The new requirements for tax-exempt hospitals include: In order to maintain status as a tax-exempt hospital, each facility must conduct a "community health needs assessment" at least once every three years, as well as adopt a strategy to meet the community's identified needs.
Healthcare reform also requires tax-exempt hospitals to establish a financial assistance policy and an emergency care policy. The financial assistance policy must detail the eligibility criteria for financial assistance at the hospital, including whether that assistance includes free or discounted care. The policy must also show the basis for calculating amounts charged for patients, the application process for financial assistance, measures to publicize the financial assistance policy in the community and steps the hospital may take to address non-paying patients.
The emergency care policy — designed to prevent discrimination against patients ineligible for financial or government assistance — must require the hospital to provide care for emergency medical conditions without discrimination.
Under healthcare reform, the amount a tax-exempt hospital charges for emergency or other medically necessary care for patients eligible for financial assistance may not exceed the amounts usually billed to insured patients.
According to a Joint Committee on Taxation report"the amounts billed to those who qualify for financial assistance may be based on either the best, or an average of the three best, negotiated commercial rates, or Medicare rate. Collection actions may not be undertaken until the hospital has made reasonable efforts to determine whether the patient is eligible for financial assistance. In addition to these four new requirements, tax-exempt organizations must include several new items in their Form reports to the IRS, such as an explanation of the results of the needs assessment and audited financial statements that will be open to public disclosure.
The changes were granted to complete implementation of changes to IRS forms and systems required to reflect the additional requirements for non-profit hospitals under healthcare reform.
The IRS has asked that hospitals wait until July 1,to file the form. Co-management arrangements, under which a hospital pays physicians to fulfill defined duties and meet perfomance objectives, are a way for hospitals to create alignment with physicians and could a stop on the road to bundling and accountable care arrangements with physicians. Co-management arrangements can be utilized at the general hospital, physician-owned hospital and surgery center level and generally involve a fixed fee and an incentive to meet pre-determined objectives.
But co-management can also create legal issues under antitrust, Anti-Kickback, civil monetary penalties, physician self-referral prohibitions, tax exempt organization requirements and Medicare laws and regulations. For example, the Anti-Kickback Law prohibits accepting cash or any item of value for referrals of health services.
These arrangements can be structured to meet many objectives, such as lowering hospital costs, achieving operational efficiencies, improving quality and outcomes, adherence to evidence-based medicine and increasing profitability, patient satisfaction, physician recruitment and even emergency call coverage. However, each component of the fee must be based on fair market value and this needs to be documented.
Compensation cannot be related to the value or volume of referral needs. Duties cannot overlap with what others are doing, and the hospital should review its compensation arrangements to make sure this is not happening.
Responsibilities have to be clearly defined and determined in advance. They should not include easily attainable goals, such as showing up on time.
Reimbursement rates have shifted under PPACA, significantly lowering reimbursements for some providers while increasing rates for others.
Stakeholder Perspectives on Value - Value in Health Care - NCBI Bookshelf
As far as increases, Medicare will grant primary care practitioners a 10 percent bonus effective inand general surgeons practicing in health professional shortage areas will receive a 10 percent bonus on top of the existing HPSA bonus, according to the AHLA Connections report.
Hospitals in the bottom quartile for risk-adjusted Medicare spending per beneficiary will also receive rewards. Another 3 percent cut will take its toll on providers and hospitals as CMS attempts to recoup payments made in previous years that arose from certain documentation and coding changes.
Starting inphysicians who fail to demonstrate cost-effective and high quality performance will be penalized through a value-based payment modifier; similar payment penalties begin in for hospitals with high rates of hospital-acquired conditions and high readmission rates for specified conditions.
At the end ofCongress and President Obama blocked a 25 percent reduction in physician reimbursement rates that had been scheduled for Jan.
3. Introducing the Key Stakeholders: Patients, Providers, Payors, and Policymakers (the Four P’s)
Current funding levels will persist through Dec. Similar blocks to the sustainable growth rate cuts were enacted in and the years prior, meaning future reductions are steadily growing as Congress delays the cuts. Out-of-network profits continue to decrease for hospitals across the country, a shift from the historical advantage of using out-of-network to increase profits or improve negotiating position.
In the coming years, hospitals may see more age discrimination claims related to termination, as well as more requests for accommodations from employees with disabilities. In Aprila physician sued Thomas Memorial Hospital, claiming he was replaced by "younger, less experienced surgeons" and that the facility discharged him because of his age; in March, a former Lee Memorial Health System employee, age 67, filed an age discrimination suit against the hospital system, alleging she was rejected for more than 14 positions for which she was qualified.
In September, a year-old man filed suit against West Houston Medical Center, saying his diagnosis of diverticulitis and hypertension, as well as his age, led to his abrupt replacement by a year-old colleague. Hospitals wishing to avoid successful legal action from disgruntled employees should implement formal, written policies on employee dismissal.
Job descriptions should also be kept accurate and up-to-date to prevent discrimination claims. Hospitals may also see an increase in unionization efforts, even in states where hospitals have traditionally remained union-free. While unionization works for many facilities and provides a sense of security to employees, it can also present difficulties for hospital administration. For example, in a unionized environment, if an employee has a concern, he or she must go through a union representative and consult the union contract rather than speaking directly to a supervisor.
Several hospitals and health systems have been stymied by employee strikes in recent months: Strikes — especially those affecting a significant portion of hospital employees — can paralyze hospital operations or force facilities to use more-expensive agency help to fill vacated positions. On the other side of the unionization dispute, some organizations are taking measures to allow employees to unionize without objection. The year-long agreement allows union workers to organize workers at the specified hospitals in Florida, Texas, Missouri and Nevada without objection from the operator.
HCA has agreed to provide the unions lists of employees and allow them on hospital property. Labor experts say such agreements may come to fruition as unions look to grow membership and hospital operators look to provide stability.
Hospital mergers are heating up and so are concerns that some of them violate antitrust law. Merger and acquisition volume for the third quarter of was 20 percent higher than for the third quarter of Enforcement agencies have been leery of hospital mergers, suspecting that market power, rather than increased efficiency, is the real motivation behind them.
Department of Justice enforce the Clayton Act, which forbids mergers that harm competition. But enforcement actions by these agencies have had frequently been overruled by the courts in recent years.
Hospitals have won lawsuits against enforcement actions by pointing to a larger market area than the government alleged, showing evidence of improved efficiencies from the merger, and, in some cases, showing that the merged entity can better serve the community. The FTC claimed the acquisition reduced competition and would contribute to higher prices. But as part of its argument, ProMedica said the FTC should go easy on enforcement because hospitals are trying to integrate to prepare for accountable care organizations and other payment arrangements.
Payors operationalize the financial elements of the policy framework. Payors enroll patients as beneficiaries. They procure care services from the providers on behalf of their patient beneficiaries. They also must take on the actuarial task of ensuring the financial sustainability of the care program.
They report to policymakers. Each of these stakeholders plays a different role in relation to the others Figure 4. Each has a different viewpoint on the health care value chain  and on the eHealth infrastructure needed to support it. The relationships between the four Ps Policymakers set the context within which the health care system operates Figure 5.
- Value in Health Care: Accounting for Cost, Quality, Safety, Outcomes, and Innovation.
Providers and payors are regulated by these policies and operate within them. To be sustainable, payors endeavor to minimize the costs of funding their portfolios of care services.
This incentivizes payors to encourage and even invest in the uptake of healthy-living initiatives within their beneficiary population. In situations where care must be coordinated, providers also find themselves managing relationships with other members of the care team, as they collaborate on behalf of a shared patient.
As consumers, patients may be able to exercise purchase discretion regarding their choice of payors. In times of poor health, patients are often powerless consumers. When we are ill, we want to become healthy again. This is what makes the patient-provider relationship powerful, and underlies the moral and ethical imperatives that are important to it. The different perspectives may be illustrated by looking at four common eHealth infrastructure elements Figure 9: Patient database Provider database Health transactions database The term patient database should be taken loosely; at any given moment, everyone is a potential patient.
To the provider, the facility registry includes the locations from which he or she delivers care. On a national basis, the policymaker views the provider database as the provider registry and uses it to support health human resource planning.
For the payor, a subset of this list represents its empaneled list of suppliers. It is interesting to consider the multiple viewpoints on the health transactions database. From the point of view of a policymaker, this database represents a national-scale electronic health records EHR system.