Provider Sponsored Health Plans

We are pleased to share an article written by Dennis Eder and Hank Osowski, titled “Provider Sponsored Health Plans,” available here.  It has been our privilege to work closely with Mr. Eder and Mr. Osowski, co-founders and managing directors of Strategic Health Group, to advise our shared provider-clients regarding the challenges and rewards of becoming key players in the payor world.  The article provides a wealth of practical and sophisticated advice for providers contemplating functioning in the dual capacity of both a provider and a payor.  To quote from the article:  “In an era of health reform and population health management, providers are being held accountable for both the cost and quality of the care they provide. In that new world hospitals are discovering in which serving as both provider and insurer often gives them the best chance to lower the cost of care, prevent unnecessary hospitalizations through patient tracking, unearth new market share potentials, and truly create a healthier community.”

Enforcement of the Two-Midnight Rule Delayed Again

Last week President Obama signed into law a measure to extend Medicare physician pay rates for one year and to extend the enforcement delay of the “Two-Midnight” rule through March 2015.  Medicare Recovery Audit Contractors (RACs) are prohibited from auditing inpatient hospital claims for compliance with the rule from October 1, 2013, through March 31, 2015.

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New Approaches – and Increasing Oversight – for Medicaid Managed Long Term Services and Support

Approximately one-third of Medicaid spending, $136 billion, is on long-term services and supports (LTSS).  While the majority of Medicaid LTSS takes place in institutional settings, such as nursing facilities and mental health facilities, there is an ongoing emphasis on the role of non-institutional facilities. A growing number of states, from 8 in 2004 to 16 in 2012 and an expected 26 through 2014, are adopting a managed care approach to expanding home-and community-based services. This transition is commonly referred to as a “rebalancing” of LTSS systems.

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Congress Delays Medicare Cuts until 2015

On March 31, the Senate voted to pass yet another “doc fix” bill, which had been approved by the House the week before.  This doc fix bill marks the 17th time that Congress has postponed the implementation of the Medicare Sustainable Growth Rate (SGR) payment formula since 2003.  It comes at the 11th hour, as the SGR, put in place by the Balanced Budget Act of 1997, would have meant a sharp 23.7% drop in Medicare payments just hours later on April 1.

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Mobile Medical App Regulations on the Move – Proposed Bills To Further Alter the Regulatory Landscape of Mobile Medical Applications

Apple’s apps store lists close to a 100,000 health apps.  Together with wearable technology, direct-to-consumer testing services, and greater consumer participation in the decision to purchase health insurance, the healthcare market in the United States is undergoing a significant transformation.  Whether and how to regulate this evolving market is subject to substantial discussion and debate.

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Interstate Medical Licensing Compact Could Pave a Smoother Path for Telemedicine Providers

One of the largest hurdles to the growth of telemedicine – streamlined physician licensure in multiple states – soon may be addressed.  The Federation of State Medical Boards (FSMB) will vote on adopting the federation’s Interstate Medical Licensure Compact at its annual meeting in April.  The FSMB is a national non-profit organization representing all medical boards within the United States.  The telemedicine policy is a newly proposed licensing option under which qualified physicians seeking to practice in multiple states would be eligible for expedited licensure in all states participating in the Compact.

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New York State budget negotiations contemplate private equity investment into hospitals…again

Should private equity play a bigger role in New York State healthcare facilities? This is the question facing New York State legislators for the second year in a row.

Historically, investor-owned corporations have been essentially prohibited from owning and operating healthcare facilities in the state. Governor Cuomo’s proposed 2014-2015 budget and associated legislation would authorize a two-year private equity pilot program.[1]

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Colorado pilots an integrated model for the Medicare and Medicaid dual-eligible population

Last week, the Centers for Medicare and Medicaid Services (CMS) announced that Colorado is joining its Financial Alignment Initiative to pilot a managed fee-for-service model for people enrolled in both Medicare and Medicaid (commonly known as dual-eligibles).[1]

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Preparing for the Affordable Care Act Employer Mandate

As of January 1, 2015, the Patient Protection and Affordable Care Act (ACA-otherwise known as Obamacare) begins to impose certain health coverage requirements on employers who have at least 50 employees. Even though its implications are almost one year away, it is not too soon for employers to prepare for the Employer Mandate. Employers would be wise to figure out if the mandate applies to them, understand the potential penalties that can be imposed on them and, taking into account all of the various considerations, decide if they want to pay or play.

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