To Be or Not To Be Independent, That Is The Question. Lisa Chase Law Offices of Lisa Chase, P.C.

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1 To Be or Not To Be Independent, That Is The Question Lisa Chase Law Offices of Lisa Chase, P.C. (520)

2 Overview Private Practice Trends Benefits of Independence Threats and Challenges Strategies for Addressing Challenges and Maintaining Independence Conclusions

3 Private Practice Demographics Between 2001 and 2008, American Medical Association reported percentage of physicians in private practice remained essentially unchanged at 61.5%. As of 2008, AMA reported: 16.3% of practicing physicians were employed by a hospital 24.6% were in solo practice 21.4% were in a 2-4 physician small group Proportion of those employed by hospitals was almost twice as high among physicians under 40 (22.3%) as was for physicians 55 and over (11.9%) Proportion of solo physicians was much higher among physicians 55 and over than under 40 (36.2% vs 13.6%) Proportion of physicians working in 2-4 physician practices higher among physicians under 40 than 55 and over (25.6% vs 17.4%) (Source: American Medical Association s Physician Practice Information (PPI) Survey)

4 Recent Practice Trends 211,000 physicians employed by hospitals 34% increase since 2000 (Source: American Hospital Association s Hospital Statistics, 2012) Rate of truly independent physicians declining 2% per year since 2000 (Source: The Independent Physician: Going, Going..., S. Isaacs et al., New England Journal of Medicine, February 12, 2009) Rate of hospital employment of physicians projected to grow 5% annually from 2011 such that about 36% of physicians will remain independent by 2013 (Source: Adapting to a New Model of Physician Employment, A. Ziskand et Al., Accenture Outlook Journal, July 2011)

5 Physician Dissatisfaction Physician ratings of the practice of medicine is dismal 1 in 3 rated the practice of medicine as satisfying or very satisfying 2 out of 3 rated it less satisfying or unsatisfying 60% stated would not recommend medicine as a career to their children or other young people (Source: Merritt Hawkins, 2008 Physician Survey) U.S. faces a shortage of 90,000 physicians by 2020; increasing to 130,000 by % increase in Medicare enrollees; 32 million added to insurance roles by ACA (Source: Association of American Medical Colleges, 2012)

6 Benefits of Independence Autonomy over practice environment Flexibility Able to react to change in circumstances more quickly Able to more quickly purse business opportunities Control lifestyle Hours Call Vacation Control patient volume & medical decision-making Access to unrestricted capital

7 Threats and Challenges Increasing Practice Costs Physician Shortages and Recruitment Difficulties Declining Reimbursement Exclusivity of Managed Care Contracting Hospital Employment of Physicians Ancillary Services Competition Among Physicians Health Reform Initiatives/Regulatory Burdens Bundled payments Pay for Performance Meaningful Use HIPAA compliance

8 Physician Survey Results Survey of 204 specialty and primary care physicians cited the most pressing concerns driving consideration of hospital employment as: 87% - business expenses 61% - prevalence of managed care 53% - concerns about EHR requirements 53% - maintaining and managing staff 39% - number of patients required to break even (Source: Clinical Transformation: New Business Models for a New Era in Healthcare, Accenture, Oct. 31, 2012)

9 Strategies for Addressing Challenges & Maintaining Independence Internal Practice Management Strategies External Practice Opportunities

10 Actively Manage Current Practice Establish sound corporate structure Have up-to-date written bylaws and owner agreements Avoid agreement terms and conditions that invite disputes or litigation valuations/appraisals at time of departure withdrawal is a breach Be willing to re-examine in light of new circumstances Reconsider traditional buy in models Cultivate strong innovative physician leadership Engage physicians in active practice management Create effective governance Make succession plans Foster reputation for quality and service Develop positive clinical reputation among peers & service quality reputation among patients

11 Actively Manage Current Practice Regularly analyze and manage expenses Incentivize employees to achieve cost savings (gainsharing) to reward length of service Cross train employees Shed unprofitable locations and service lines Address physician and midlevel provider productivity & quality issues Evaluate compensation models Reward efficiency, quality Explore and invest in cost-saving technologies Use consultants, accountants and lawyers as costsaving resources

12 Manage Revenue Ensure internal billing software or outside billing company produces comprehensive billing data Collections ratio AR Aging Physician and midlevel productivity (wrvu, CPTs and encounters) Evaluate profitability of ancillary services Utilization as relates to cost to provide Track quality data PQRS payments Meaningful Use Code and bill correctly, not defensively Undercoding adds up to real dollars Medicare E&M profile is a bell curve Perform prospective documentation, coding and billing audits

13 Manage Revenue Evaluate payor mix Know your patient demographics AHCCCS Expansion Actively negotiate managed care agreements Limit recoupment timeframe Multi-year agreements should have escalator clause Rates by CPT codes give more protection Watch for incorporation of Medicare payment policies for commercial products Watch for provisions that survive the term of the agreement Preserve and pursue rights to bill patients ABNs Lien rights Collection of co-payments and deductibles at time of service Manage claims denials Time consuming, but can add up to significant dollars Appeal denials and recoupments Provider success rates on RAC appeals -1/3 for FY

14 Re-Evaluate Practice Model Re-evaluate practice model Micropractice One physician, no staff, lots of technology, little overhead and increased time with patients Concierge medicine Capped number of patients High fixed annual fee for 24/7 services No insurance Requires opt out of Medicare

15 Strategic Expansion and Diversification Expand scope of practice strategically Physicians vs midlevels recruitment Recruitment incentives; hospital assistance Cash lines of business Non-covered services, e.g. cosmetics, screening exams Research New technologies/procedures In-office ancillary services Stark and Anti-Kickback Statutes apply to some Medicare reimbursement rules Adjunctive services (ASCs, PODs) Stark and Anti-Kickback Statutes to consider Satellite offices/telemedicine/new markets Rural Settings: have lots of pluses Run the numbers...do your due diligence...not all ideas are true opportunities

16 Collaborations, Affiliations and Alignments IPAs Separate groups contract to provide services to IPAs members Care Coordination Agreements Professional Services Arrangements Reading agreements Cross coverage agreements Shared Ancillary Services Arrangements Block leases Stark and Anti-Kickback Statutes will apply

17 Collaborations, Affiliations and Alignments Hospital Arrangements Identify Joint Interests Medical Director Agreements Co-Management Agreements Administrative Committee Leadership Positions EHR Donation Agreements Call Coverage Agreements Service Line Development Agreements Quality Initiative Agreements Gainsharing Agreements ACOs 52% of people live in area serviced by at least 1 ACO; 28% live in area served by at least 2* 4 million Medicare patients are part of ACOs Physicians lead more ACOs than hospitals Participant vs other entity (*Source: American Medical News, amednews.com, March 6, 2013)

18 Collaborations, Affiliations and Alignments Joint Ventures Adjunctive Services (ASC, IDTFs, PODs, equipment) Contractual or ownership Hospital and non-hospital partners Stark and Anti-Kickback apply Protect medical staff privileges Hospital Medical Staff Bylaws are an enforceable contract An open medical staff benefits independent physicians

19 Consolidation and Merger With Other Physicians Consolidation and merger potential benefits Improved coordination and management of patient care through sharing of best practices and development of clinical guidelines Enhanced recruitment opportunities More capital to develop and spread cost of new technologies, infrastructure and management expertise Cost savings and greater efficiencies on administrative overhead Consolidation and merger potential challenges Different practice cultures, loyalties and values Competing financial interests Different compensation and lifestyle models Differences in governance and management styles

20 Consolidation and Merger Full merger with other physicians Multispecialty groups Need compensation model not based strictly on productivity Related sub-specialty service lines groups Cardiology, vascular surgeons and cardio-thoracic surgeons Orthopedics, physical therapy and pain management Supergroups Semi-autonomous single specialty groups under single tax id # Need to navigate Stark in-office ancillary rules for group practices with ancillary services Administrative services supergroups MSOs, GPOs, EHR, collections, denial management, data management, compliance Caution: Payor contracting without financial integration raises Anti-Trust issues

21 Legislative Reform Managed care reform Timely pay requirements Any willing provider laws AHCCCS reform Submit comments on proposed healthcare legislation Track state association s positions on state and federal legislation Lobby elected representatives about regulatory burdens HIPAA compliance

22 Litigation Against Payors Payor Ingenix Settlements Aetna agreed to pay $120m in December 2012 to settle litigation over how pays out of network providers AHCCCS and CMS have payor oversight responsibilities File complaints about Medicare Advantage plans and AHCCCS contractors

23 Conclusion Hospitals need independent physicians to succeed Cost of acquiring practices of enough physicians to fill hospital beds and provide services is going to get prohibitive Physician independence and entrepreneurship spurs innovation Need independent physicians to implement hospital quality initiatives Payors should be considering that hospital employment may actually increase cost of healthcare due to lack of competition Hospital employment not surefire panacea for physicians in long run 3-5 year deals Limited opportunity for compensation increases because of Stark and Anti- Kickback statute fair market value concerns Hospitals driven by different motivations Hospitals have finite capacity to grow Hospitals not immune from financial downturns and reimbursement cuts More than survival is possible, but need to adapt to changing business of medicine

24 Lisa Chase Law Offices of Lisa Chase, P.C. (520)

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