legal issues in medical home development presented by: gerry hinkley davis wright tremaine llp...
TRANSCRIPT
LEGAL ISSUES IN MEDICAL HOME DEVELOPMENT
Presented by:
Gerry Hinkley Davis Wright Tremaine LLP
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Session goals
Understand the translation of Medical Home goals into a legally enforceable structure
Address some contracting issues – provider to provider; payor to provider
Consider antitrust risk Weigh privacy and security concerns Look at implications for the standard of care in
negligence actions
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Transforming the model into a system
The Model’s general goals Personal physician Physician directed medical practice Whole person orientation Quality and safety Enhanced access Supportive payment
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Components of a system Home provider – a professional or group of professionals Elements of care and care coordination -- detailed
description of the program: patient and provider selection and participation care paths and protocols reporting and improvement grievance resolution
Determination of costs to provide this level of care Documentation
Employment, home provider contracts Program plan and protocols Payor contracts Referral provider contracts HIT procurement and maintenance
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Payor contracts Payor business and financial support is key In exchange for support, home providers commit
to Quality measures: third party (NCQA), payor-specific Programmatic measures
Staffing Care protocols Reporting outcomes and patient/provider satisfaction
Payor participation takes the form of payment and care management
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Payor contracts – specific terms
Payment PMPM Patient attribution methodology
Evaluation Utilization expectations Quality measures Patient and provider satisfaction
Termination Dispute resolution Consequences for provider status
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Antitrust compliance
Sherman Act – prohibiting unreasonable restraints on trade Is setting a range of reimbursement horizontal price-
fixing? Is it a permissible restraint ancillary to a legitimate joint
arrangement Do procompetitive benefits outweight potential bad
consequences? Eliminates “free riders” Benefits consumers Reduces costs Improves quality
Implications of “State Action” to avoid antitrust violation
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Privacy and security More sharing of information than in typical model Most communications between providers should
be for “treatment” or “payment” and not require HIPAA authorization
HIPAA compliant authorization required to transmit out of the system – e.g. PHRs
State law may require specific consents Consider appropriateness of enhanced or
coordinated privacy policies for “trust”
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Standard of care The professional must render care with the
same degree of care as a reasonable member of that profession in similar circumstances would render in the community
Some courts have considered “resource restraints” to lower the standard
Will “resource expansion” push the standard to higher levels?
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Is this concierge medicine? Prohibition on additional charges to patients for
covered services (Medicare and perhaps HMO contracts) – can’t charge an “access fee” for Medicare covered services (and maybe for commercial services)
Do payors have a right to offset payments received from secondary paryors (COB)
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Thank You for Participating
Gerry HinkleyPartner
Davis Wright Tremaine LLP [email protected]
415.276.6530www.dwt.com
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The purpose of this presentation is to inform and comment upon transactions in the health care industry. It is not intended, nor should it be used, as a substitute for specific legal advice as legal counsel may only be given in response to inquiries regarding particular situations.
(c) Davis Wright Tremaine LLP 2009