Pay For Performance And Clinical Integration.Reimbursement rates paid by government and commercial payors to providers and professionals alike are being compacted. Health care providers and professionals are burdened with simultaneously delivering quality health care and adjusting to the increasing complex reimbursement system. Add the regulatory strictures of the Anti-trust, Stark Law Stark law Physician self-referral law, 42 USC 1395nn Medicare A law that prohibits a physician from making a referral to an entity with which she or her immediate family has a financial relationship if the referral is for the furnishing of designated health , Anti-Kickback and Civil Monetary Penalties Act into the dynamic and you have a perfect witch's brew that is hampering the delivery of quality health care in this country. Commonly the health care industry's response to the decreasing rates has been to take actions that have further complicated the situation. Attempts to organize competitors into managed care organizations such as physician/hospital organizations and IPAs (together "Networks") has drawn price-fixing enforcement actions from the Federal Trade Commission. These investigations are costly and usually result in the organization entering into a Consent Decree A settlement of a lawsuit or criminal case in which a person or company agrees to take specific actions without admitting fault or guilt for the situation that led to the lawsuit. A consent decree is a settlement that is contained in a court order. with the FTC FTC See Federal Trade Commission (FTC). that contains significant restrictions on the joint-pricing of the competing participants' services. Whether one agrees or disagrees with the legal interpretations of the FTC concerning anti-trust laws related to health care services it must be obeyed. Many Networks have attempted to price their participants' services through the messenger model as prescribed by the FTC. The messenger model is difficult to appropriately implement and many of the enforcement actions of the FTC have resulted from a Network's ineffective attempts to implement the model. It is important to understand that the health care industry has operated as a cottage industry cottage industry: see sweating system. in the U.S. Even though the percentage of the U.S. GNP GNP See: Gross National Product related to health care is enormous the health care industry has operated on essentially a piece work basis. The lack of collaboration between providers and professionals has made the industry easy pickings for the insurance industry. So long as the providers and professionals are fragmented they cannot effectively negotiate with the payors in a meaningful way. The rapidly developing Pay for Performance model may be an answer to the problems related to the messenger model. It is time for providers and professionals to consider developing Networks the use of P4P P4P Pay for Performance (Medicare) P4P Proactive Network Provider Participation for P2P to achieve the clinical integration. Clinical integration has been held out by the FTC as an acceptable method for competing providers to create a vehicle to joint-price its participants' services. (Please see the April __and __editions of Health Industry Online for a more complete discussion of P4P and the FTC issues related to clinical integration) The development of a P4P Network in neither simple nor inexpensive. The expenses related to the development of a clinically integrated Network A network that supports both data and voice and/or different networking protocols. See converged network and new public network. are a necessary by-product by·prod·uct or by-prod·uct n. 1. Something produced in the making of something else. 2. A secondary result; a side effect. by-product Noun 1. of the move of the industry from fragmentation that leaves it vulnerable to the payors. The financing of the development of clinical indicator clinical indicator Patient care An objective measure of the clinical management and outcome of Pt care programs by Networks can have regulatory implications if hospitals are the primary participant that provides financing. Careful structuring of the financing of the P4P Network must be accomplished or Stark law/anti-kickback issues can arise that can make FTC investigations look mild. So what to do? Avoiding as much unnecessary whining as possible about low reimbursement rates is a necessity. P4P is coming and those providers and physicians that involve themselves in the process now will have the best chances of succeeding in the P4P evidence-based medicine evidence-based medicine Decision-making 'The use of scientific data to confirm that proposed diagnostic or therapeutic procedures are appropriate in light of their high probability of producing the best and most favorable outcome'. See Meta-analysis. model. There is a natural inclination for busy health care professionals to avoid involvement in the development or understanding of reimbursement methodologies. There is no one better however to take the lead in creation of quality indicators required for P4P programs. The health care industry should avoid allowing the payors to control the development of the P4P in a vacuum. Where possible health care professionals should be on the front line of the development of P4P programs. That is not what most health care professionals want to hear, but P4P will change the way health care is delivered and reimbursed. The abdication abdication, in a political sense, renunciation of high public office, usually by a monarch. Some abdications have been purely voluntary and resulted in no loss of prestige. of the process to the payors will result in more of the same problems for health care providers and professionals in a payor controlled world. Creation of a P4P network is costly and time-consuming. P4P represents a dramatic change for most health care providers and professionals. Clinical integration does however answer the question-"how can we have some control over our destiny as it relates to pricing by commercial payors without violating anti-trust laws?" The answer to that question is available-albeit at a price. Hospitals and physicians must be willing to pay that price as an investment in controlling the future of health care delivery. Mr William Darling Sir William Young Darling (8 May 1885 – 4 February 1962) was the Unionist Member of Parliament in the British House of Commons for the Edinburgh South constituency from 1945 to 1957. Strasburger & Price, L.L.P. 600 Congress Avenue, Suite 1600 Austin TX 78701-3288 UNITED STATES United States, officially United States of America, republic (2005 est. pop. 295,734,000), 3,539,227 sq mi (9,166,598 sq km), North America. The United States is the world's third largest country in population and the fourth largest country in area. Click Here for related articles (c) Mondaq Ltd, 2006 - Tel. +44 (0)20 8544 8300 - http://www.mondaq.com |
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