Download PDF - Medical Tourism Magazine

satisfaction, clinical treatment, and investment in information
technology.
Some substantial payments are being made. In addition, on August
24 Blue Cross of California, a subsidiary of WellPoint, announced
that is was rewarding 126 physician groups a total of $69 million in
bonuses for performance in 2006. About a week earlier, Blue Shield
of California announced that it distributed $31 million in bonus
money.
What do Physician Groups Fear about P4P?
� Getting used in a “shell game” manipulated by the payors
� To date there is no long term commitment to P4P by payors
� Measures are not geographically or socio-economically fair
or reliable
� P4P compliance is too burdensome and expensive
� Public reporting can increase liability
� Cost controls will masquerade as quality and initiatives
Physicians have embraced some P4P models over the last several
years such as the one Beckman developed for physician stages of
change P4P (see illustration below).
REGULATORY & LEGAL ISSUES
The issue of increased liability for P4P participation raises several
legal and regulatory issues – yet to be resolved. These include
Physician Anti-Self-Referral Law (the “Stark” law), Anti-Kickback
Statute, Civil Monetary Penalties Act, Antitrust, Defamation,
Malpractice and Privacy.
52 DECEMBER 2007
MEDICAL TOURISM
Physician Self-Referrals
The Stark Law prohibits a physician from referring Medicare and
Medicaid patients for designated health service to entities with which the
physician (or an immediate family member) has a financial relationship. A
P4P arrangement may be exempted from the Stark prohibitions by meeting
one of the following exceptions: personal services exception, fair market
value compensation exception, electronic items and services exception. In
the hospital/physician model, a hospital may become involved in a P4P or
gainsharing program by contributing funds as part of the program. If this
is the case, a financial relationship with the participating physicians will
be created, and the financial relationship must satisfy each element of a
Stark exception.
Anti-Kickback Statute
The Anti-Kickback statute prohibits the solicitation of, offering of, or
payment of any type of remuneration (directly or indirectly, in cash or in
kind) in exchange for referrals or the arranging for the furnishing of health
care that is paid for by federal health care programs. A P4P arrangement
may be immune from Anti-Kickback liability if it meets one of the following
Safe Harbors: investment interest, personal services and management
contracts, electronic items and services.
Civil Monetary Penalties Act
This Act prohibits a hospital from making a payment directly or indirectly
to a physician as an inducement to reduce or limit services to Medicare or
Medicaid beneficiaries under the physician’s care. This is the major issue
for gainsharing programs.
Antitrust
To avoid a price fixing charge, an arrangement should indicate financial and
clinical integration.