We have heard a lot about reforming healthcare through clinical integration lately.
On October 5, 2010, the Federal Trade Commission “will co-host a workshop on several issues associated with Accountable Care Organizations (ACOs), organizations authorized by the new Affordable Care Act that seek to deliver high-quality and efficient health care services to consumers. Joining the FTC in hosting the event are the Centers for Medicare & Medicaid Services (CMS) and the Department of Health and Human Services’ Office of Inspector General.”
The Federal Trade Commission (FTC) and U.S. Department of Justice define clinical integration as the implementation of:
…an active and ongoing program to evaluate and modify practice patterns by the network’s physician participants and create a high degree of interdependence and cooperation among the physicians to control costs and ensure quality. This program may include: (1) establishing mechanisms to monitor and control utilization of health care services that are designed to control costs and assure quality of care; (2) selectively choosing network physicians who are likely to further these efficiency objectives; and (3) the significant investment of capital, both monetary and human, in the necessary infrastructure and capability to realize the claimed efficiencies.
According to the American Hospital Association, several legal barriers to the implementation of clinical integration currently exist. They include:
- Antitrust laws designed to protect competition in order to protect consumers.
- The Ethics in Patient Referrals Act (Stark Law) enacted to keep doctors from referring patients to hospital and other facilities in which the doctor has a financial interest.
- The Civil Monetary Penalty Law which prohibits hospitals from rewarding doctors for reducing or withholding services to Medicare or Medicaid recipients.
- The anti-kickback law which makes it a felony to knowingly and willfully receiving or paying anything of value to influence the referral of federal health program business, including Medicare and Medicaid.
- The Internal Revenue Code which prohibits a tax-exempt not-for-profit organization such as a hospital from providing payments to benefit any private individual, including physicians.
ACOs may provide a structure through which clinical integration can be achieved. What are your thoughts?
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