Roadblocks to Reform: The Influence of HIPAA and HITECH on the Affordable Care Act0

This article was first published at Michigan Business Professional Association on April 30, 2013.

When it comes to health care, our nation has reached a crossroads.  President Obama’s fledgling Affordable Care Act is a multifaceted, aggressive program designed to overhaul the delivery of health care by effectively restructuring its foundations from the inside out.  In doing so, it seeks to reduce the number of uninsured patients who have for so long been a burden to a struggling health care system that must provide medical care as a service while also turning a profit as a business.  But such a far-reaching plan has little chance of success if it is forced to evolve while fettered with the restrictions placed upon providers by certain grandfathered programs, most notably the Health Insurance Portability and Accountability Act (HIPAA) and the Health Information Technology for Economic and Clinical Health Act (HITECH).  As a result, we as a nation must now consider whether the ACA’s fundamental mission or patient privacy should rule the day. … Read more →

Administrative, Clinical, Community, Health Care Reform, Hospitals, News, Regulatory, Technology

Taxing Health Care Reform0

Benjamin Franklin said:  “In this world nothing can be said to be certain, except death and taxes.”

For almost 60 years, April 15 has meant “Tax Day,” or the day when individuals must submit their income tax returns to the Federal Government. The Sixteenth Amendment to the United States Constitution establishes Congressional “power to lay and collect taxes on incomes, from whatever source derived, without apportionment among the several States, and without regard to any census or enumeration.”

Three years since its passage, the Affordable Care Act (ACA) has become inextricably connected to the laws of federal taxation. The following overview explains some key points of intersection: … Read more →

Administrative, Clinical, Community, Health Care Law, Health Care Reform, Historical, Hospitals, Miscellaneous, News, Regulatory

Navigating The Rapids of Health Care Reform Without a Paddle0

 This article first appeared in Corporate Compliance Insights on March 28, 2013.

“The only fence against the world is a thorough knowledge of it.”  – John Locke, philosopher (1632-1704)

In its bid to restructure the nation’s health care system, the 2010 Patient Protection and Affordable Care Act (the “ACA”) has created both challenges and opportunities in the areas of corporate compliance, governance and risk communities. In three short years, myriad regulatory clarifications have swollen this 906-page statutory giant into a 70,000-page behemoth whose might has been enough to overcome the judicial and electoral challenges of 2012, eliminating any doubts as to whether reform is here to stay.

At its core, the ACA means different things to different people. Patients typically focus on the promise of new guarantees and protections for health insurance for the populace, as well as the penalties for those who remain without coverage. But the ACA has also captured the attention of health care providers as they shift from a formerly cost-based system toward one that gauges success or failure primarily on patient experience. Even the insurance industry must yield to the new law and wend its way through a changing landscape complete with medical loss ratio requirements, the end of lifetime limitations, challenges to any increase in premiums over a certain percentage, and the soon to be introduced Health Insurance Exchanges.

While the infusion of elements such as innovation, preventative care and overall wellness provide the Federal Government with a new and as yet untested backup plan to ensure the success of health care reform, plenty of room still exists within the ACA to combat health care fraud, abuse and waste. The False Claims Act stands at the forefront in the government’s battle to preserve the integrity of health care resources, although the law has evolved considerably since first signed into effect by President Lincoln in 1863.  By ensuring the legacy of the FCA for future generations, however, the ACA has also created several compliance risks for companies across the nation.  Here are the top five: … Read more →

Administrative, Clinical, Community, Health Care Reform, Historical, Hospitals, News, Regulatory

Two Strikes and Contraception is Out0

On February 1, 2013, the Federal Government issued proposed rules that may finally end the contraception controversy and its challenge to the Affordable Care Act’s commitment to preventative services, including addressing requirements relating to all FDA-approved contraceptive methods, sterilization procedures, and patient education and counseling for all women with reproductive ability.

The proposed rules lower the bar for employers engaged in secular and religious purposes, as well as those religious employers who hire outside the fold. The latest version acquiesces to eligible organizations opposed to contraceptive coverage, finally offering absolution from the requirements of Section 2713 of the Public Health Service Act, Section 715(a)(1) of the Employee Retirement Income Security Act and Section 9815(a)(1) of the Internal Revenue Code.  In essence, the proposed rules let these employers practice what they preach. … Read more →

Administrative, Clinical, Community, Health Care Law, Health Care Reform, Historical, News, Regulatory

The Affordable Care Act: A Not-So-Little Train That Must0

This article was first published in the Los Angeles Daily Journal on February 25, 2013.

“Things do not change. We change.”  – Henry David Thoreau

Finally free from the uncertainty of looming elections or Supreme Court decisions questioning constitutionality, modern American health care can now be compared to a speeding train serving infinite destinations, with conductors and passengers alike learning the routes along the way. Public transportation is usually forgiving, as the tardy or confused passenger always has the opportunity to catch the next train, but such is not always true in matters of public health.  Whether fan or foe of the Affordable Care Act (the ACA), this epic codification of health care reform is something that America cannot afford to miss.

At the time the ACA was passed in March 2010, by a margin of seven of the collective 431 Congressional votes, few of those involved had any real working knowledge of the 10,909 sections contained within the Patient Protection and Affordable Care Act, which were quickly adjusted and finalized by congressional changes the following week in the form of the Health Care and Education Reconciliation Act. Weighing in at over 900 pages, hindsight makes it clear that the ACA was only the beginning of the federal government’s plan to restructure the nation’s health care system, a fact that has been compounded by an estimated 70,000 pages of further regulations in the three years since President Barack Obama signed the ACA into law. … Read more →

Administrative, Clinical, Community, Health Care Law, Health Care Reform, Historical, Hospitals, News, Regulatory

Return of the Hall Monitor0

Say Hello to the Chief Compliance Officer at a Pharmaceutical Company Near You

This article first appeared in Pharmaceutical Compliance Monitor on February 11, 2013.

As any teenager will tell you, nobody likes a snitch. When it comes to the antics of the adolescent, rarely is unwanted disclosure or unsolicited intervention met with appreciation.  And yet, in observing the conduct displayed recently throughout many fields in our nation’s business sector, similar sentiment rang true across corporate America, and the moral “high road” was rarely found to intersect with the path most traveled. The health care industry was no different, and any strict constructionist interpretation of the Hippocratic Oath usually limited “do no harm” to the delivery of patient care in its most literal sense, foregoing the machinations conspiring behind the scenes to keep a hospital’s doors open in the face of a souring economic climate.

Now Is the Time for Compliance

The ethical transformation in health care that gained momentum one score and seven years ago has its origins in a law signed on March 2, 1863, by the president famous for the words “four score and seven years ago” uttered that same year.  The False Claims Act (the “FCA”), also known as “Lincoln’s Law” and the “Informer’s Act,” has evolved considerably since its enactment to become the “primary litigative tool for combating fraud” (see S. Rep. 99-345, at 2 (1986)).  … Read more →

Administrative, Community, Health Care Law, Health Care Reform, Hospitals, News, Regulatory

Modern American Health Care (in 83 slides)1

This presentation provides an overview of the Affordable Care Act three years after its passage. It explains how the landmark legislation evolved, what provisions are in place today, and what can we expect in the years to come. The implications for patients, providers and payers are massive, and this presentation is designed to provide a comprehensive overview for anyone interested to learn about health care reform.

Administrative, Clinical, Health Care Law, Historical, Hospitals, News, Non Clinical, Regulatory

The Poor Get Poorer: The Fate of Distressed Hospitals Under the Affordable Care Act0

This article, written by Samuel R. Maizel and Craig Garner, first appeared at 2012 No. 12 Norton Bankr. L. Adviser 1 in December 2012. 

Synopsis

Distressed hospitals in America operate on small or non-existent profit margins.3 For many of those hospitals, the federal Medicare program and the individual States’ Medicaid programs are the largest payors. While the Patient Protection and Affordable Care Act of 2010 (the “Affordable Care Act”) was designed in part to increase the number of insured nationwide, the result of which should be positive for hospitals, any cause for celebration must first address the cost containment provisions in the Affordable Care Act that create new concerns for financially distressed hospitals. Included among the multitude of provisions in the Affordable Care Act are an immediate 1% cut in Medicare revenue, phased in reductions in disproportionate share payments to hospitals, future, permanent penalties of up to 1% of Medicare payments for hospitals which perform poorly under the Hospital Value Based Purchasing Program, and additional penalties for hospitals with unacceptable rates of re-admission or too many hospital acquired conditions rates.4 Together these cuts create a daunting challenge for the many financially distressed hospitals in America that simply lack the resources to establish an infrastructure designed to treat Medicare patients in this era of change.

Background

Medicare is the federal program that provides health care coverage to individuals aged 65 or older. Medicaid offers similar access for medical services on a state level for qualifying individuals, many of whom are poor. Medicaid covers 69 million people.5 By 2020, under the Affordable Care Act the number of Medicaid beneficiaries is likely to increase to 93 million.6 Combined, Medicare and Medicaid pay for more than half of the annual hospital bills in America. … Read more →

Clinical, Community, Health Care Law, Health Care Reform, Historical, Hospitals, News, Regulatory, Technology

A Lesson from the Sneetches0

This Practitioner Application to the article “Post Acute Care and Vertical Integration After the Patient Protection and Affordable Care Act” (by Patrick D. Shay and Stephen S. Mick) appeared in the January/February Edition (Volume 58, No. 1) of the Journal of Healthcare Management.

In his classic tale “The Sneetches,” Theodor Seuss Geisel (Dr. Seuss, 1961) created a society divided by entitlement in which the lines of separation were removed, thrusting its members together. A satire about discrimination, “The Sneetches” offers children an early introduction to the arbitrary walls that those forces governing society can build and destroy at their whim.

Shay and Mick may be said to describe a similar scenario as they apply provisions of the 2010 Affordable Care Act (ACA ) to post-acute care and vertical integration under the Medicare Shared Savings Program (also known as accountable care organizations or ACOs) and to bundled payment systems. They note that these are the areas in which the influences of the ACA are most apparent. In the process, Shay and Mick remind us that perception is formed largely on the basis of factors lurking beneath the surface that care little for public opinion. For example, much like Dr. Seuss’s Sneetches, Hurricane Sandy, which struck the East Coast shoreline in October 2012, rendered the “haves” and “have nots” almost indistinguishable. Bellevue Hospital, the oldest hospital operating in the United States, was capable of offering roughly as much care during and immediately following the hurricane as it was in 1736, when the New York City Almshouse designated six bedrooms as Bellevue’s first “ward.” … Read more →

Administrative, Children's Health, Clinical, Community, Health Care Law, Health Care Reform, Historical, Hospitals, News, Regulatory

Health Care Reform: Walking the Fine Line Between Epic and Tragic0

This article was first published at California Healthcare News on January 8, 2013.

The recent changes to the core structure of modern American health care are nothing short of epic, rivaled in historic scale only by the introduction of Medicare in 1965. Although each decade over the past 50 years has in some way used government programs and incentives in an attempt to urge health care to undergo recalibration as a means to establish industry stability, by the end of the first decade of the 21st Century it had become evident that health care in the United States was fast becoming unsustainable as it existed. Enter health care reform.

Three years after the Federal Government passed the Affordable Care Act in an attempt to right the sinking ship, we the people are still waiting for the tide to turn. Having survived last summer’s monumental challenge before the United States Supreme Court and a presidential election in November, the Affordable Care Act has not only emerged as the law of the land, it has cemented its place as health care’s blueprint throughout America for decades to come. For California, however, the timing is unjust, as the perfect storm brought about by fiscal cliff/debt ceiling concerns heads straight for Sacramento from the east just as health care’s versions of Scylla and Charybdis approach forebodingly from both north and south. … Read more →

Administrative, Clinical, Community, Health Care Law, Health Care Reform, Historical, Hospitals, News, Regulatory, Technology

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