David Winkle Bill Boling Meredith [email protected] [email protected] [email protected]
Regulatory Challenges and Opportunities for Regulatory Challenges and Opportunities for Georgia’s Rural Hospitals:Georgia’s Rural Hospitals:
Anti-Kickback Law & Safe Harbors Anti-Kickback Law & Safe Harbors Stark Law & ExceptionsStark Law & Exceptions
April 27, 2007April 27, 2007
© 2006 Powell Goldstein LLP. All Rights Reserved.
2
What’s the Big Deal?What’s the Big Deal?
Physician financial relationships with hospitals and other health care providers to which they refer patients are heavily regulated under federal and state law
If these relationships are improperly structured, documented or implemented, these laws can subject a hospital, its management and the physicians to civil, administrative and criminal penalties
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Federal Anti-Kickback StatuteFederal Anti-Kickback Statute
Prohibits a person or entity from knowingly and willfully offering, paying, soliciting or receiving any remuneration (including any kickback, bribe, or rebate) directly or indirectly, overtly or covertly, in cash or in kind, with the intent to induce referrals for federal health care program reimbursable items or services
Can implicate immediate family members
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Federal Anti-Kickback StatuteFederal Anti-Kickback Statute
The statute applies to physician – hospital financial relationships of all types, including common arrangements:
Service and supply contracts
Ancillary services
Imaging
Equipment
Leases (space, equipment)
Ambulatory surgery centers
5
Federal Anti-Kickback StatuteFederal Anti-Kickback Statute Criminal Penalties
$25,000
Five years’ imprisonment
Civil Money Penalties
$10,000 per item or service
3 times amount claimed for each item or service
Exclusion
Federal and State healthcare programs
False Claims Act Liability
Treble damages; penalties
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Federal Anti-Kickback StatuteFederal Anti-Kickback Statute
“Safe Harbors” protect conduct that otherwise
might be found to violate the statute
The conduct or arrangement must fully satisfy
all of the safe harbor’s conditions to claim safe
harbor protection from sanctions
Safe harbor conditions are detailed, narrow,
and difficult to satisfy consistent with common
business practices
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Federal Anti-Kickback StatuteFederal Anti-Kickback Statute
Safe Harbors commonly relied upon in hospital-physician arrangements:
Personal services/management contracts
Physician Recruitment
Employment
Space leases and equipment leases
Electronic Health Records (EHR) & E-Prescribing *NEW*
Certain investment interests: “small entity”
Investments in Ambulatory Surgery Centers
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Federal Anti-Kickback StatuteFederal Anti-Kickback Statute
Services/Management Agreement Safe Harbor
Written agreement signed by the parties; must be at least for a one-year term
Services are specified; terms are commercially reasonable
Aggregate compensation is set in advance, is FMV, and is not related to the volume or value of referrals or business otherwise generated between the parties
Percentage, “per-click” or “per service” fees are not protected, but not specifically prohibited
If services provided on part-time basis, agreement specifies the exact schedule, length and charge for such services; time logs must be maintained
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Federal Anti-Kickback StatuteFederal Anti-Kickback StatutePhysician Recruitment Safe Harbor
Safe harbor protection limited to recruitment into a health professional shortage area (HPSA) (Document community need if not a HPSA)
Written agreement; benefits not exceeding 3 years
At least 75 percent of revenues of new practice must be from new patients
No requirement to make referrals to or practice exclusively at hospital; physician to treat federal patients in non-discriminatory manner
Benefits may not vary with referrals or be provided to any other person or entity in a position to make or influence referrals to hospital
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Federal Anti-Kickback StatuteFederal Anti-Kickback Statute
Employment Exception/Safe Harbor
Anti-Kickback statutory exception and safe harbor
protect amounts paid by an employer to a bona fide
employee
“Employee” defined with reference to IRS guidelines
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Federal Anti-Kickback StatuteFederal Anti-Kickback Statute
Space and Equipment Lease Safe Harbor
Written lease signed by the parties; at least a one-year term
Aggregate rent set in advance, is FMV, and not determined in a manner that takes into account the volume or value of referrals or business otherwise generated by the parties
No adjustment for proximity to referral sources
Percentage, “per click” or “per use” rent not protected
Aggregate space/equipment leased must not exceed commercially reasonable business purpose of Lessee/Tenant
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Summary: General Anti-Summary: General Anti-Kickback Problem AreasKickback Problem Areas
Offering terms or returns based on referrals
Loans to investors for capital
Investors have little or no risk
No legitimate business purpose; No “Value Added”
Departure from contract terms
Service fees not FMV
Payments Changed to Reflect Referrals
Increased Program Costs
Overutilization
Quality of Care Compromised
Rewards for limiting or withholding of care
Patient Choice Restricted
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Stark LawStark Law
Stark law prohibits a physician from making referrals for Medicare/Medicaid designated health services (“DHS”) to an entity with which the physician (or a member of the physician’s immediate family) has a financial relationship
Strict Liability: No intent or knowledge necessary
DHS includes inpatient and outpatient hospital services
Financial relationships covered by Stark law can be:
A direct or indirect ownership interest, or
A direct or indirect compensation arrangement
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Stark LawStark Law
Stark Law’s prohibition is absolute:
If the financial relationship exists and no exception
applies, the physician may not refer patients to the
entity (in the case of a hospital for inpatient or
outpatient hospital services or other designated
health services)
If the financial relationship exists, no exception is met,
and a referral is made, the hospital may not bill for
the services it provides as a result of that referral
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Stark LawStark Law
If the hospital bills for its services pursuant to an illegal referral, it must refund the entire amount of the payment
If the hospital fails to properly refund illegally billed amounts, the hospital is subject to:
A fine of $15,000 per item billed
Exclusion from the Medicare program
Stark law violation may give rise to liability under the False Claims Act
Treble damages, penalties (apply to each transaction)
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Stark LawStark Law
Exceptions related to compensation arrangements
Personal services agreements
Fair market value compensation
Indirect compensation
Physician recruitment
Employment
Space and equipment leases
EHR & E-Prescribing *NEW*
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Stark LawStark LawService contracts, space/equipment leases,
FMV compensation:
Exceptions have requirements similar to those under the Federal Anti-Kickback Safe Harbors:
Contracts in writing, signed, at least one year term
All services/space/items must be covered by the written contract
Commercially reasonable and necessary for legitimate business
Does not violate the Anti-Kickback Statute or other law
Compensation must be:
Fair market value
Set in advance
Unrelated to volume or value of referrals or other business generated between the parties
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Stark LawStark LawIndirect Compensation Arrangement
Exception
Any unbroken chain of financial relationships (whether ownership or compensation) may link hospital and physicians in an “indirect compensation” arrangement
Exception allowed if:
Compensation to physician is FMV for items/services actually provided
Compensation is unrelated to volume or value of referrals to or other business generated with the hospital
Set out in writing that specifies services covered by arrangement
Does not violate the Anti-Kickback Statute or any laws on billing and claims submission
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Stark LawStark LawRecruitment Exception
Protects payments to physician to induce physician to relocate practice to the area served by the hospital and become a member of the medical staff
Must be in writing, no condition that physician refer to hospital and payments cannot be based on volume or value of actual or anticipated referrals
Physician must be allowed to establish privileges at and refer to other entities (unless recruited for employment)
Physician must either (i) move practice at least 25 miles, or (ii) derive at least 75 percent of revenues from new patients (physicians in practice for less than one year not subject to these requirements)
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Stark LawStark LawRecruitment Exception
If recruitment payments are made to group which physician joins:
Written agreement must be signed by group
Payments flow straight through to physician except for actual costs incurred by group in recruiting physician
If income guarantee, overhead allocated to physician must be limited to incremental cost increase attributable to that physician
Practice may not impose additional practice restrictions on physician
Payments must not take into account referrals to hospital from group
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Stark LawStark LawEmployment Exception
Protects payments by hospital to physician with bona fide employment relationship for identifiable services
Employment compensation must be fair market value and not determined in a manner that takes into account referrals to the employer
Productivity bonuses are permitted based on services personally performed by physician. Use Relative Value Unit (RVU) method; that is, measure of productivity of provider, which reflects time to perform service, technical skill and mental effort of provider.
Cannot bonus on volume of ancillaries ordered
Agreement would be commercially reasonable even if no referrals were made to employer
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Summary: Stark Problem Summary: Stark Problem AreasAreas
Complex Business Arrangements: Failure to Bring Every Payment, Financial Relationship under an Exception
Agreement Not in Writing; Written Agreement Lapsed
Departure from Contract Terms
Compensation not FMV
Compensation not set in advance
Compensation Tied to Referrals, Business Generated between the Parties
No Bona Fide Business Purpose
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Georgia Self-Referral LawGeorgia Self-Referral Law
Applies referral prohibitions similar to Stark law to relationships between hospitals and other health care providers, including physicians
Unlike Stark law, applies only to ownership (equity) interests (not compensation [salary] interests)
Unlike Stark law, applies to all payors
Broad exception for referrals for services performed by referring physician or by member of referring physician’s group practice, and for referrals made to a hospital by a physician holding medical staff privileges
Requires notice of ownership interest to patients
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A Positive OutlookA Positive Outlook
Many opportunities
remain despite
stringent regulation
and enforcement
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Hospital-Physician Integration Hospital-Physician Integration Models Models
Can help rural hospitals stay in compliance under these statutes, especially those centered on:
Recruitment
Employment
Personal Services
Medical Directorships
Co-Management
Leasing Arrangements
Equipment, Space, Property
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EmploymentEmployment
Regulatory issues turn in part on how
physicians become employees of the hospital
Recruitment
Acquisition of existing physician practices
Community Need
Primary care vs. specialists
Coverage
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EmploymentEmployment
Recruitment
Recruit as hospital employee
Satisfy employment exception and safe harbor
Recruit to join existing physician practice
Satisfy recruitment exception and, if possible, safe harbor
Document community need for physicians in that specialty
No recruitment benefits to pay overhead of physician practice
No restrictions on establishing privileges or referring elsewhere
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EmploymentEmployment
Acquisition of existing practice/Stark law
Acquisition of practice/isolated transaction exception
(requires that subsequent financial arrangements satisfy
Stark exception)
Employment exception
Applies only to employment compensation
Places limits on productivity bonuses
If doctors maintain investment interests, must satisfy:
Personally-performed services exception
In-office ancillary services exception
Practice must satisfy the Stark definition of “group practice” to fall under
these exceptions
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EmploymentEmploymentAcquisition of existing practice/Anti-
Kickback Statute
Purchase of medical practices have been treated as kickbacks (safe harbor extremely limited)
Purchase must be FMV, legitimate business purpose, arms length
Pay for hard assets, value of ongoing business, covenants not to compete, exclusive dealing arrangements and patient lists/records; not goodwill
Do not require seller to refer to hospital
Ensure post-purchase compensation to seller is reasonable with no incentives for referrals
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Leasing ArrangementsLeasing Arrangements
Hospital may affiliate with physicians through various leasing arrangements
Medical office buildings and other real estate
Equipment
Service lines (imaging, outpatient surgery, cardiac lab, physical therapy)
Likely issues: Commercially reasonable business purpose; short-term leases; FMV; rental that varies with clinical income, referrals, or other business
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Leasing ArrangementsLeasing Arrangements
Space, Real Property Leases: Stark law
Space lease exceptions available
May be indirect compensation relationship
Space, Real Property Leases: Anti-kickback statute
Lease safe harbor
“Per use” rent payments do not qualify for safe harbor protection
Contractual joint venture?
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Leasing ArrangementsLeasing ArrangementsEquipment Leases: Stark law
Equipment lease exceptions available
May be indirect compensation relationships
Leased service lines must be structured to comply with in-office ancillary services exception and other reimbursement regulations for lessee to be eligible to bill for services
Can compensate on “per use” or “per click” basis
Equipment Leases: Anti-kickback statute
Lease safe harbor
“Per use” rent payments may not qualify for safe harbor protection
Contractual joint venture?
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Electronic Health Records Electronic Health Records & E-Prescribing& E-Prescribing
New Federal Exceptions
On August 8, 2006, both the Centers for Medicare &
Medicaid Services and the Office of the Inspector
General of the Department of Health and Human
Services published final rules providing for
exceptions from Stark and safe-harbors under the
Anti-Kickback law.
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New CMS Stark ExceptionsNew CMS Stark Exceptions
The new CMS final rule contains two
exceptions to Stark:
Hospitals may provide technology to
support EHRs; and
Hospitals may provide e-prescribing
technology
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EHR Stark ExceptionEHR Stark Exception
Hospitals furnishing designated health services may provide “software or information technology and training services” to a physician so long as the technology is used “predominantly to create, maintain, transmit or receive” EHRs.
The arrangement must also comply with the anti-kickback law.
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EHR Stark ExceptionEHR Stark Exception
Technology covered under the exception:
Software meeting certain conditions;
Interfaces and translation software;
Rights, licenses and intellectual property related to EHR software;
Connectivity services;
Clinical support and information services related to patient care;
Maintenance services;
Secure messaging; and
Training and support services.
HARDWARE IS NOT COVERED
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EHR Stark ExceptionEHR Stark Exception
In donating technology to physicians,
hospitals may not take referral volume or
value into consideration in choosing who
receives the technology.
Hospitals may, however, use criteria not
directly related to the value or volume of
referrals in choosing recipients.
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EHR Stark ExceptionEHR Stark Exception
In choosing recipients for EHR technology,
hospitals may consider:
Total number of prescriptions written;
Size of medical practice;
Physician’s overall use of technology; or
Other reasonable and verifiable criteria not related
to volume or value of referrals.
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EHR Stark Exception EHR Stark Exception
Additional conditions:
Donated items cannot be the “equivalent” of items the physician already has;
The arrangement must be detailed in a written agreement;
The physician must pay 15% of the donor’s costs;
Hospital may not disable or limit interoperability functions that the technology may have;
Hospital may not limit the kinds of patients for whom the technology is used;
Donation must include an e-prescribing function.
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E-prescribing Stark ExceptionE-prescribing Stark Exception
Under the final rule, hospitals may provide
e-prescribing items and services to:
Members of their medical staffs;
Practices and their physician members;
Medicare Part D Prescription Drug Plan sponsors;
Medicare Advantage organizations.
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E-prescribing Stark ExceptionE-prescribing Stark Exception
The e-prescribing exception contains limitations similar to
those discussed with the EHR exception:
Items must be used solely to receive and transmit electronic
prescription information;
Items must not be equivalent to items the recipient already has;
Donor may not limit or disable interoperability functions the
technology may have;
Donor may not consider volume or value of referrals in deciding who
receives the technology;
Arrangement must be in writing
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OIG Safe HarborsOIG Safe Harbors
On the same day that CMS published its
Stark exceptions for EHR technology and e-
prescribing, the OIG published safe harbors
for similar EHR and e-prescribing items.
The Anti-Kickback safe harbors closely
reflect the Stark exceptions previously
discussed
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EHR Anti-Kickback EHR Anti-Kickback Safe HarborSafe Harbor
EHR safe harbor allows hospitals to
provide “software or information
technology and training services” to:
Physicians
Individuals
Organizations
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EHR Anti-KickbackEHR Anti-KickbackSafe HarborSafe Harbor
Donation must be used “predominantly to
create, maintain, transmit or receive” EHRs.
The covered technology closely reflects that
under the Stark Exception.
Broad range of protected donors – those
who provide health services covered by a
federal health program.
45
E-prescribing Anti-KickbackE-prescribing Anti-KickbackSafe HarborSafe Harbor
Similar to e-prescribing exception under Stark.
Hospitals may give items and services relating to
e-prescribing to members of their medical staffs.
Other potential donors and recipients:
Group practices and their members;
Medicare Part D Prescription Drug Plan Sponsors
Medicare Advantage organizations.
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Certification RequiredCertification Required
Under both Stark and Anti-kickback, interoperability of EHR items must be certified by a recognized body
The Certification Commission for Healthcare Information Technology (CCHIT) is the first group to be designated a Recognized Certification Body (RCB) by HHS
HHS hopes CCHIT’s seal of approval will accelerate adoption of health IT products by removing uncertainty about the technical capabilities of the products, and thereby limiting the risk associated with investing in health IT for health care providers
CCHIT has certified 59 EHR products so far, consistent with published criteria
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Reasons for Move to National Reasons for Move to National Electronic Medical Record GridElectronic Medical Record Grid
According to Rand Corp study, EMR system creates an estimate annual administrative cost savings of $81 billion a year and $346 billion annual savings from a more efficient practice of medicine.
Sept. 2006 – National Academies of Medicine reported: “Medicare payment System encourages volume rather than efficiency and quality.”
According to the Advisory Board (study by Penn. Healthcare Council) in-hospital-acquired infections resulted in an average additional cost of all hospital-acquired infections of $60,678.
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• According to Reinertsen Group (the 100,000 Lives Campaign): Doctors’ treatment helps their patients only 55% of the time, with serious harm 1% of the time. Hospital’s care is defective 10% of time, resulting in over 200,000 annual deaths
• Tenet’s recent corporate integrity agreement requires quality initiatives based upon evidence-based medicine
• The federal government’s goals of rapid EMR adoption are: (1) improve quality and reducing errors by connecting patients’ healthcare information across all practices settings, (2) measure and report outcomes, and pay for outcomes to realign financial incentives of healthcare.
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Federal ResponseFederal Response
• By Executive order, President has adopted a 10 year plan to create EMR infrastructure and created office of National Coordinator for Health Information Technology
• Four federal contracts have been entered into: (1) establish IT standards and harmonization; (2) establish compliance certification; (3) establish privacy and security standards; (4) design national health information network
• August 22, 2006 – Executive order directing federal agencies that administer federal healthcare programs to increase price and quality transparency by January 1, 2007
◦ Require providers of federally financed healthcare adopt quality – measurement tools and uniform standards for health IT
◦ Require adoption of EMR and interoperability
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National ePrescribing Patient National ePrescribing Patient Safety Initiative (NEPSI)Safety Initiative (NEPSI)
Formed by a coalition of some of the nation’s largest technology and healthcare companies
Will provide free e-prescribing software (“eRxNOW”) to EVERY physician in America
eRxNow generates secure electronic prescriptions that can be sent computer-to-computer or via fax to 55,000 retail pharmacies
Includes instant “harmful interactions” check & real-time notification of insurance formulary status from payors
One Atlantic Center
Fourteenth Floor
1201 West Peachtree Street, NW
Atlanta, GA 30309
Tel. 404.572.6600
Fax. 404.572.6999
901 New York Avenue, NW
Third Floor
Washington, DC 20001
Tel. 202.347.0066
Fax. 202.624.7222
2200 Ross Avenue
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Dallas, TX 75201
Tel. 214.721.8000
Fax. 214.721.8100
www.pogolaw.com
A t l a n t a▪ W a s h i n g t o n ▪ Dallas
© 2006 Powell Goldstein LLP. All Rights Reserved.
David [email protected]
Bill [email protected]
Meredith [email protected]
OUTPATIENT IMAGING
Proposed Lease Transaction For 3 + 2 Year Term
Total Equipment Cost $3,587,465
Equity $1,076,240
Percent Financed by Venture 70%
Amount Finance $2,511,226
Assumed LLC Borrowing Interest Rate 7.75%
Annual Debt Service (3 years only) $1,028,250
Lease Term (Years) 3 + 2
Annual Lease Payment (3 years) $1,198,190
(2 years) $444,996
Residual Value of Equipment (3 years) $896,866
(5 years) $358,746
Estimated annual IRR for Investors (3 years) 15%
(Cash on Cash Return) = IRR (5 years) 17%
64 Slice
Projected Lease Transaction for 3 + 2 Year Term
Terms with Financial Institution
Total Equipment Cost $1,910,000
Equity – 30% $ 573,000
Amount Finance – 70% $1,337,000
Assumed LLC Borrowing Interest Rate 6.21%
Annual Debt Service (3 years only) $ 487,097
Terms with Leasing Company
Lease Term (Years) 3 + 2
Annual Lease Payment (3 years) $637,928
(2 years) $248,318
Residual Value of Equipment (3 years) $477,500
(5 years) $191,000
Estimated annual IRR for Investors (3 years) 15% (5 years) 14%
THE OFFERINGTHE OFFERING
Total Investment Units 500
Maximum Units Available 495
Minimum Units Per Investor 5
Maximum Units Per Investor 10
Unit Price $1,146
Minimum Unit (5) Commitment: $5,730
Maximum Unit (10) Commitment: $11,460
C A R D I O V A S C U L A R M A N A G E M E N T S E R V I C E S A G R E E M E N T
M A N A G E M E N T S E R V I C E S
A d m i n i s t r a t i v e K n o w s , u n d e r s t a n d s , i n c o r p o r a t e s , a n d d e m o n s t r a t e s t h e S R H S p h i l o s o p h y , m i s s i o n , v i s i o n , a n d v a l u e s i n b e h a v i o r s , p r a c t i c e , a n d d e c i s i o n s . 1 . P r o v i d e l e a d e r s h i p a n d m o t i v a t e c a r d i a c p h y s i c i a n s t o s u p p o r t a c o m m o n v i s i o n a n d f u n c t i o n a s a n
i n t e g r a t e d t e a m . 2 . D e v e l o p a s t r a t e g i c p l a n f o r t h e H o s p i t a l c a r d i o v a s c u l a r p r o g r a m t h a t i n c l u d e s :
• V i s i o n o f t h e p r o g r a m s / s e r v i c e s t o b e o f f e r e d ; • E n h a n c e m e n t o f g e o g r a p h i c d i s t r i b u t i o n o f h e a l t h c a r e s e r v i c e s ; a n d • C l i n i c a l B u s i n e s s D e v e l o p m e n t p l a n .
3 . M o n i t o r t h e i m p l e m e n t a t i o n o f t h e s t r a t e g i c p l a n ; d e v e l o p a c t i o n p l a n s f o r a r e a s o f t a r g e t s h o r t f a l l .
4 . G u i d e t h e d e v e l o p m e n t o f a c o m m u n i c a t i o n s t r u c t u r e f o r o t h e r c a r d i o v a s c u l a r c l i n i c i a n s i n v o l v e d i n t h e c a r d i o v a s c u l a r p r o g r a m .
5 . W o r k w i t h t h e H o s p i t a l l e a d e r s h i p t o i d e n t i f y p h y s i c i a n p r a c t i c e n e e d w i t h i n t h e c a r d i o v a s c u l a r p r o g r a m .
6 . E v a l u a t e c u r r e n t c l i n i c a l o f f e r i n g s r e l a t e d t o c u r r e n t a n d p r o p o s e d c o m m u n i t y n e e d o p p o r t u n i t i e s a n d e v i d e n c e b a s e d m e d i c i n e .
7 . P a r t i c i p a t e a s n e e d e d i n r e g i o n a l d e v e l o p m e n t a c t i v i t i e s .
8 . M e e t w i t h r e f e r r a l p h y s i c i a n s p e r i o d i c a l l y t o s o l i c i t i n p u t f r o m r e f e r r a l p h y s i c i a n s a s t o t h e o p e r a t i o n s o f t h e c a r d i o v a s c u l a r p r o g r a m .
9 . M o n i t o r p a t i e n t s , r e f e r r a l p h y s i c i a n s a n d p a y e r s a t i s f a c t i o n r e s u l t s ; w o r k i n c o n j u n c t i o n w i t h t h e H o s p i t a l 's M a n a g i n g D i r e c t o r a n d o t h e r m e d i c a l l e a d e r s t o d e v e l o p a n d i m p l e m e n t c o r r e c t i v e a c t i o n p l a n s a n d p r o c e s s i m p r o v e m e n t .
1 0 . D e v e l o p a n n u a l p l a n f o r p r o g r a m i m p r o v e m e n t s f o r a p p r o v a l b y t h e H o s p i t a l l e a d e r s h i p . P h y s i c i a n a n d C o m m u n i t y R e l a t i o n s 1 . S t r e n g t h e n t h e m a r k e t p r e s e n c e t h r o u g h m a r k e t i n g o f t h e H o s p i t a l c a r d i o v a s c u l a r p r o g r a m t o
c o m m u n i t y , p a y e r m a r k e t a n d o t h e r p r o v i d e r s .
2 . E s t a b l i s h q u a r t e r l y m e e t i n g s w i t h r e f e r r i n g p h y s i c i a n s r e g a r d i n g a c c e s s a n d s a t i s f a c t i o n . R e p o r t r e s u l t s t o H o s p i t a l l e a d e r s h i p s e m i - a n n u a l l y .
3 . P a r t i c i p a t e i n t h e e d u c a t i o n o f l a y c o m m u n i t y r e g a r d i n g r i s k f a c t o r s a n d b e h a v i o r s f o r c a r d i o v a s c u l a r d i s e a s e .
4 . P a r t i c i p a t e i n d e v e l o p i n g a n d i m p l e m e n t i n g s t r a t e g i e s f o r e f f e c t i v e r e l a t i o n s h i p s b e t w e e n c a r d i a c p h y s i c i a n s a n d o t h e r c o m m u n i t y p h y s i c i a n s .
5 . A c t i v e l y p r o m o t e t h e H o s p i t a l c a r d i o v a s c u l a r p r o g r a m i n o u t r e a c h a r e a s i n c l u d i n g p a r t i c i p a t i n g i n e d u c a t i o n a l s e m i n a r s / l e c t u r e s , p e r s o n a l v i s i t a t i o n s t o a r e a p h y s i c i a n s a n d h o s p i t a l s , e t c .
6 . P a r t i c i p a t e i n t h e a n n u a l m a r k e t a s s e s s m e n t p r o c e s s t o i d e n t i f y o p p o r t u n i t i e s f o r i n c r e a s e d m a r k e t s h a r e .
7 . A s s i s t i n i n t e r f a c i n g w i t h p a y e r m a r k e t t o v a l i d a t e n e e d s a n d r e v i s e p r o g r a m a n d p a c k a g e s e r v i c e s b a s e d o n c o n s u m e r n e e d s .
8 . A s s i s t i n c o m p l e t i n g w r i t t e n a n d v e r b a l r e s p o n s e s t o m a n a g e d c a r e r e q u e s t f o r p r o p o s a l s ( R F P s ) .
C l i n i c a l O p e r a t i o n s M a n a g e m e n t 1 . P a r t i c i p a t e i n p r o g r a m o p e r a t i o n s t e a m s w i t h i n t h e c o - m a n a g e m e n t s t r u c t u r e t o e n g a g e
p h y s i c i a n s i n t h e d a i l y o p e r a t i o n a l m a n a g e m e n t .
2 . I n c o n j u n c t i o n w i t h t h e H o s p i t a l 's M a n a g i n g D i r e c t o r a n d p h y s i c i a n s w i t h i n t h e p r o g r a m : • E v a l u a t e o p e r a t i o n a l p r o c e s s e s f o r o p p o r t u n i t i e s i n s e r v i c e a n d e f f i c i e n c y
i m p r o v e m e n t i n c l u d i n g c o s t a n d q u a l i t y • A n n u a l l y d e v e l o p , i m p l e m e n t a n d m o n i t o r t h e a c t i o n p l a n s f o r p r o c e s s
i m p r o v e m e n t • D e v e l o p , i m p l e m e n t , a n d m o n i t o r c l i n i c a l s t a n d a r d s o f p r a c t i c e b a s e d o n e v i d e n c e
b a s e d m e d i c i n e • D e v e l o p , i m p l e m e n t a n d m o n i t o r s t a n d a r d s f o r r e s o u r c e u t i l i z a t i o n b y D R G
a n d / o r d i a g n o s i s • P a r t i c i p a t e i n c o s t b e n e f i t a n a l y s i s f o r p r o p o s e d c l i n i c a l p r o c e s s i m p r o v e m e n t
c h a n g e s • A s s i s t w i t h t h e p r e p a r a t i o n a n d m o n i t o r i n g o f t h e a n n u a l b u d g e t s • M a i n t a i n c o m p l i a n c e w i t h a l l a p p l i c a b l e J C A H O a n d D e p a r t m e n t o f H e a l t h
r e g u l a t i o n s 3 . M o n i t o r p h y s i c i a n c o m p l i a n c e w i t h e s t a b l i s h e d c l i n i c a l p r a c t i c e g u i d e l i n e s a n d d e v e l o p
q u a r t e r l y r e p o r t t o t h e c a r d i o v a s c u l a r p r o g r a m c o m m i t t e e s .
4 . A s s i s t i n t h e c o o r d i n a t i o n o f a n d a t t e n d t e a m " c a r e c o n f e r e n c e s " t o p r o v i d e c o n c u r r e n t r e v i e w o f p a t i e n t c a r e a n d d e v e l o p a n d i m p l e m e n t a c t i o n p l a n s f o r i d e n t i f i e d i s s u e s .
5 . C o o r d i n a t e q u a l i t y r e v i e w a c t i v i t i e s r e l a t i v e t o a r r a n g i n g f o r r e v i e w a n d a c t i o n a s a p p r o p r i a t e o n c o m p l i c a t i o n s e x p e r i e n c e d a n d / o r s i t u a t i o n i d e n t i f i e d i n c l u d i n g h o l d i n g C a r d i o l o g y D e p a r t m e n t q u a l i t y i m p r o v e m e n t m o n t h l y m e e t i n g s w i t h t h e H o s p i t a l l e a d e r s h i p , m e d i c a l s t a f f a n d c l i n i c a l m a n a g e r s / c o o r d i n a t o r s t o r e v i e w p a t i e n t c h a r t s .
6 . G u i d e t h e d e v e l o p m e n t a n d m o n i t o r i n g o f a p p r o p r i a t e p h y s i c i a n c r e d e n t i a l i n g c r i t e r i a f o r t h e c a r d i o v a s c u l a r p r o g r a m . C r i t e r i a t o i n c l u d e p r i m a r y e d u c a t i o n , b o a r d c e r t i f i c a t i o n o r e l i g i b i l i t y r e q u i r e m e n t s , c u r r e n t l i c e n s u r e , r e l e v a n t t r a i n i n g o r e x p e r i e n c e , c o n t i n u i n g e d u c a t i o n , c l i n i c a l o u t c o m e s t a n d a r d s ( c u r r e n t c o m p e t e n c e ) , v o l u m e c r i t e r i a w h e r e a p p r o p r i a t e , a n d p e e r r e c o m m e n d a t i o n s .
7 . D e v e l o p a n d m o n i t o r b e d m a n a g e m e n t s y s t e m s i n c l u d i n g a d m i s s i o n a n d d i s c h a r g e c r i t e r i a f o r u s e o f t e l e m e t r y b e d s .
8 . W o r k w i t h M e d i c a l R e c o r d s s t a f f t o e n s u r e a d e q u a t e p h y s i c i a n d o c u m e n t a t i o n f o r a c c u r a t e c o d i n g .
9 . S e r v e a s t h e r e s o u r c e i n t h e r e s o l u t i o n o f p e r f o r m a n c e a n d / o r p e r s o n a l i t y i s s u e s r e l a t e d t o t h e c l i n i c a l c a r e t e a m .
1 0 . A s s i s t w i t h c o n f l i c t r e s o l u t i o n o f i s s u e s r a i s e d r e g a r d i n g p r o g r a m o p e r a t i o n s a n d / o r m a n a g e m e n t .
1 1 . P a r t i c i p a t e i n t h e p r o c e s s t o e v a l u a t e n e w t e c h n o l o g y i n c l u d i n g i t s i m p a c t o n s a f e t y , e f f i c a c y a n d e f f i c i e n c y o f c a r e .
1 2 . W o r k w i t h p h y s i c i a n s t o e n s u r e p a r t i c i p a t i o n , t i m e l i n e s s o f t a s k s a n d c o m p l e t i o n o f a s s i g n e d t a s k s .
CARDIOVASCULAR MANAGEMENT SERVICES AGREEMENTPERFORMANCE GOALS AND STANDARDS
Co-Management Agreement Quality Bonus Indicators
NA1.41.361.32
Appropriate documentation of severity of illness; impacts external measures
Appropriate case mix for all patients within the service lineCase mix index for MDC 5
General
$15,500 $17,500$17,500 $19,000$18,500 $20,000Single: $19,500Dual: $21,000
Acquisition costs to national benchmarksAcquisition cost per defibrillator
Defibrillator implant cost per case
1.51.5National Cardiovascular Data Registry (ACC)Utilization of procedure areas
Average number of lab visits per admission
2.82.8National Cardiovascular Data Registry (ACC)Utilization of procedure areasLength of stay
Electrophysiology
98%% of patients with antibiotic administered 1 hour pre-operatively
Prophylactic antibiotic within 1 hour of surgical procedures
90%IHl Surgical Infection Rate Reduction Plan
% of patients with serum glucose less than or equal to 200 mg/dL intro-operatively and during the first 48 hours postoperatively
Percent of patients with perioperative glucose controlVascular
92%90%85%82%JCAHO Core MeasureMeasurement of LVF through ultrasound or other means during hospital stay
Left ventricular function assessment
95%90%85%80%JCAHO Core MeasureLVEF <40%, med prescribed at discharge of documentation med not indicatedACE/ARB at discharge
44.24.74.8Fiscal managementAMLOS 5.2 GMLOS 4.1ALOS for DRG 127
CHF
81.8% <90 minutes90%15%44%CMSDoor to PCI; door to thrombolyticsDoor to PCI time for STEMI
95%95%94%93%JCAHO Core Measuredischarge of documentation medBeta Blacker at discharge
99%98%97%97%JCAHO Core MeasureMed prescribed at discharge of documentation med not indicatedASA at discharge
95%92%75%58%JCAHO Core MeasureMed prescribed at discharge of documentation med not indicatedACE/ARB at discharge
AMI
$7,800$8,000$8,250$9,028Fiscal managementBudget cost per interventional caseBudget cost per case
NA <0.5% <1%0%Post PCI complications -preventable errors% of PCI with complication codesAdverse events
75% 124;25% 125
60% 124; 40% 125
55% 124; 45% 125
48% 124; 52% 125
Case mix for diagnostic caths measures accurate documentation of patient severity%of IP caths in each DRGDRG Ratio - 124/125Interventional
Cardiology
National Benchmark Stretch Target BaselineRationaleDefinitionIndicatorProgram