Category Archives: Affordable Care Act (ACO)

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Tying health spending to the economy: What does it mean for the future?

Politicians, researchers, and other stakeholders have long recognized the importance of a slowdown in health spending in the U.S. Optimistically, the nation’s health spending has experienced a record slow growth rate in recent years, and the Congressional Budget Office (CBO) recently revised Medicare spending estimates downwards, albeit slightly. A recent article published in the Journal … Continue Reading

The Future of DSH Payments?

According to the Centers for Medicare and Medicaid Services (CMS), the federal government disburses $11.5 billion annually in disproportionate-share hospital (DSH) payments to states.  DSH payments are intended to offset the cost of treating the uninsured (uncompensated care) and Medicaid shortfalls in public hospitals.  A recent study published in Health Affairs on the impact of … Continue Reading

Oscar, a new, venture-backed health insurance company, seeks to compete against industry giants

The Affordable Care Act is driving innovation at all levels of the healthcare system, creating opportunities for small start-ups to compete with industry giants. One such start-up is Oscar, a venture-backed health insurance company that launched on the New York State Health Plan Marketplace, and the State’s first new commercial health insurer in 15 years.[1]… Continue Reading

Obama Administration Further Delays Employer Mandate and Releases Final Regulations Regarding Implementation

The Treasury Department and Internal Revenue Service announced on Monday that the Obama Administration would further delay implementation of the “employer mandate” under the Affordable Care Act for certain employers until 2016.  The employer mandate requires businesses that employ more than 50 full-time employees to provide minimum levels of affordable health insurance to their employees, … Continue Reading

New Budget Deal Can Bring Extension of Medicare Sequestration Cuts

While many in Washington, D.C. are celebrating today the unusual display of bipartisan budgetary comity as the new budget deal is announced, there is a direct and immediate adverse effect for hospitals and physicians.  As predicted by Sheppard Mullin Healthcare Team leader Eric Klein in his recent talk to the National ACO Congress, Congress has … Continue Reading

Pioneer ACOs Exit the Program

On July 16, 2013, the Centers for Medicare and Medicaid Services (CMS) announced the first year results from its Pioneer Accountable Care Organization (ACO) program. The program, launched by the CMS Innovation Center, is part of the Affordable Care Act’s efforts to promote lower cost, high quality, coordinated care for Medicare beneficiaries. In 2012, there … Continue Reading

Obama Administration Delays ACA’s Employer-Coverage Mandate Until 2015

The Obama Administration announced on Tuesday that it is delaying implementing a key component of the Affordable Care Act for a year following complaints from the private sector about reporting requirements. The so-called “employer mandate”, which penalizes employers with more than 50 employees if they fail to provide a minimum standard of affordable health insurance, … Continue Reading

Final Rule Implementing ACA Wellness Program Requirements Increases Financial Incentives to Participate and Allows Financial Penalties

On June 3, 2013, the Departments of Health and Human Services (HHS), Labor (DOL), and the Treasury (collectively, the Departments) published joint final regulations in the Federal Register implementing the Affordable Care Act (ACA) requirements for wellness programs. More specifically, the final rule applies to group health plans that offer wellness programs with a financial … Continue Reading

Health Benefit Exchanges: False Claims Gold Mines?

The Affordable Care Act enables the establishment of Health Benefit Exchanges of several types, including (i) State-based, (ii) State-Federal partnerships and (iii) Federally Facilitated Exchanges.[1] The purpose of the Exchanges is to, among other things, “provide competitive marketplaces for individuals and small employers to directly compare available private health insurance on the basis of price, … Continue Reading

Time to Revamp Primary Care?

Will bundled payments lead to restructuring of our primary care healthcare delivery system? Healthleaders has a great article discussing the vision for healthcare delivery system reengineering proposed by Thomas H. Lee, MD, the network president of Partners Healthcare and Michael E. Porter, PhD, Bishop William University Professor at the Harvard Business School. The two advocate … Continue Reading

Supreme Court Upholds Individual Mandate in the Affordable Care Act, but Medicaid Expansion is in Question

By Eric Klein The Supreme Court ruled today 5-4 that the Affordable Care Act is constitutional and upheld the individual mandate, requiring most Americans to maintain "minimum essential" health insurance coverage. The decision was written by Judge Roberts for the majority. The Court held that the argument relying on the Constitutional commerce clause would not … Continue Reading

No Mandatory Antitrust Review for ACOs

The Department of Justice and Federal Trade Commission recently issued their final "Statement of Antitrust Enforcement Policy Regarding Accountable Care Organizations Participating in the Medicare Shared Savings Program" pursuant to the 2010 Patient Protection and Affordable Care Act. The final statement was issued in conjunction with the Department of Health and Human Services’ Centers for … Continue Reading

Accountable Care OrganizationsPayment Options for ACOs Pursuant to the Proposed Rule

By Eric Klein, Kenneth Yood, Aytan Dahukey and Lynsey Mitchel The Affordable Care Act (the “ACA”) establishes the general requirements for payments to participating Accountable Care Organizations (“ACOs”) pursuant to the Shared Savings Program, described in Section 3022 of the ACA.  The ACA provides that ACO participants will continue to receive payment under the original … Continue Reading

Levels of Antitrust Scrutiny for ACOs

By David R. Garcia & Helen Eckert The Department of Justice and Federal Trade Commission have recently proposed new guidelines delineating a three-tiered structure of antitrust scrutiny for accountable care organizations — the new healthcare delivery model mandated by the 2010 Patient Protection and Affordable Care Act — based on certain calculations of market shares … Continue Reading

Proposed Rule: Legal Structure and Governance of ACOS

By Eric Klein, Kenneth Yood, Aytan Dahukey and Lynsey Mitchel This blog entry will be the first of a series of entries discussing the long anticipated 400 plus-page Accountable Care Organization proposed regulations (the “Proposed Rule”) released on March 31, 2011, by the Centers for Medicare & Medicaid Services (“CMS”). The Proposed Rule is designed to … Continue Reading