GOVERNOR PENCE AND ATTORNEY GENERAL ZELLER ASK TO CANCEL 100,000 HOOSIER’S PRIVATE HEALTH INSURANCE POLICIES

Two persons employed by and paid for by Indiana voters have asked the United States Supreme Court, in a friend of the court brief, to deny federal subsidies under ACA to individuals purchasing health insurance through the federal insurance marketplace.

Approximately 118,000 Hoosiers now receive some form of subsidy for purchasing healthcare policies through the federally run exchange.  As you may recall, Governor Pence refused to create an Indiana health marketplace or exchange.

PERMANENT SGR FIX ILLUSIVE

Every few months we report on efforts to obtain a permanent solution or fix for the Sustainable Growth Rate formula (SGR) that determines Medicare physician reimbursement amounts.  This has gone on for years with short-term patches despite the best efforts of the American Medical Association and others.

The current patch expires March 31, and given that the Congress had difficulty passing a funding program for homeland security, the outlook for an SGR fix is terminal.  Unless and until hospitals, clinics and individual providers get the attention of their own congressmen and senators, this problem is not likely to be resolved.

NEW TAKE ON ILLEGAL KICKBACK PAYMENTS

In late February, Aetna sued North Cyprus Medical Center and Dr. Robert Behar claiming that North Cyprus and Dr. Behar created a fraudulent billing scheme which damaged Aetna to the tune of $120M.  Aetna alleges that North Cyprus paid kickback sums to physicians in exchange for patient referrals disguised as ownership interests in North Cyprus, and that it charged grossly excessive fees, had improper billing techniques and other matters.  Aetna claims that an overpayment amount of $120M is based on overpayment since January 1, 2009.

Aetna is bringing the suit under the Racketeering Influenced and Corrupt Organizations Act, and under Texas state law.

North Cyprus claims that Aetna is retaliating against North Cyprus because North Cyprus has been active in filing suits against insurers such as Aetna to include it in various networks, and refused to succumb to improper pressure from Aetna to lower rates.

DOCTOR SHORTAGES

The CEO of the Association of American Medical Colleges claims that given recent demographic trends and changes in delivery and payment methodologies, the US will face a shortage of 46,000 to 90,000 physicians through 2025.  Of these, the shortages are projected for primary care doctors at between 12,000 and 31,000.   Ignoring for the moment the rather wide spread between 12,000 and 31,000, even using the low end numbers, the shortage of physicians projected must result in non-physician gatekeepers for various healthcare delivery systems.  This raises a fundamental question about how we want to organize the giving of healthcare.

Do we want doctors to be the primary gatekeepers, the ones that make the decision on whether we need additional care, or do we want non-physicians acting as those gatekeepers and decision makers?  If we do have non-physicians, what will those caregivers be, advanced practical nurses (APRN) physician assistants or others?

EMR HOSTAGES

Disputes, arguments and accusations continue to flare in the EHR world.  End users claim that the government’s incredible ineptness in paying out $30B of our tax dollars without requiring EHR vendors to use a standard that would let the various systems actually exchange data, and the continuing arguments by every EHR vendor that it is someone else’s fault that they refuse to find common grounds with their competitors has resulted in great frustrations.

In fact, some are now suggesting that the government, having missed its opportunity to fix this problem, simply get out of the way and let the market pick the winning system or systems.  If the market demands interoperability, it is likely that the vendors will capitulate on this issue.

PRICE TRANSPARENCY COMES TO INDIANA

A new database, Care INsight, attempts to reveal average charges and quality information.  I have reviewed the Care INsight site.  Does it provide price and quality transparency?  No, not even close.

Fortunately, those involved in Care INsight, including the Indiana Hospital Association, recognize that Care INsight is only a first step towards transparency in price and quality data.

This newsletter is edited by Paul Wallace of Jones ∙ Wallace, LLC, a member of the American Bar Association Healthcare Law Section and the American Health Lawyers Association who has been representing physicians and healthcare practices for over 25 years.  Mr. Wallace assists physicians in health practices in contract items, federal legal compliance, creation of practice entities, estate and wealth planning and similar issues.  Please feel free to call if you have any questions on this newsletter or legal matters at (812) 402-1600 or pwallace@joneswallace.com.