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| Dear Friend,
Triple aim or triple shame?
That's the subject of this past Monday's blog post, which you can read at the following link,
You’ve probably heard of the healthcare “triple aim”, the notion that healthcare should be focused on (1) improving patient experience, (2) improving quality, and (3) lowering cost.
In what can only be surmised as a political game played out within the “hospital government complex”, the Biden administration recently announced its intention to pursue what can only be described as a “triple shame”: reversing CMS’s prior decisions to phase out the inpatient-only list by 2024 and to add hundreds of new procedures to the ASC covered procedure list.
On July 19, 2021, with the swipe of a bureaucratic pen, no doubt guided by hospital industry lobbyists, CMS proposed that the inpatient only list would not be phased out, and that 258 of the 266 procedures that it had placed on the ASC payment list in January 2021 would be removed.
Striking a victory for lower patient satisfaction, higher infection rates, and higher costs, let no one forget that the American Hospital Association threw its support behind Obamacare after the legislation was amended to make permanent the then temporary prohibitions on physician-owned hospitals, with their higher patient satisfaction scores, higher quality, and lower costs.
I can’t blame the hospital industry for trying. There’s big business in preventing competition. The American hospital Association reports that it has approximately 5,000 member hospitals, health care system, and other providers of care members, as well as 43,000 individual members.
Some say that it was laziness that led to Congress taking the easy way out, passing broadly worded bills and leaving it to administrative agencies, with their near unfettered power to make rules and regulations, to work out, and change, the details. But maybe it was just spreading the wealth among lobbyists. After all, lobbyists from the insurance and managed-care industries will now have their shot at wining and dining and cajoling their way out of what the hospital industry lobbyists have just done to the cost of care.
In the long run, this will only slow down, not defeat, the fact that ASCs are the preferred site of surgical services. In the meantime, though, patients and carriers and physician owners of ASCs will have to pay the price. |
| | | Business Life in the Time of Coronavirus Mini-Series
The coronavirus crisis caused a short term economic crisis for many medical groups. Our mini-series shows you the way out. Plus, many of the concepts discussed are applicable during both good times and bad.
[If you haven't already seen them, follow this link to watch our entire series.] |
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Watch Tuesday's video here, or just keep reading below for a revised, more polished transcript:
I want to talk with you today about spreading your risk.
A few weeks ago, I posted on the blog about an anesthesia group in Fresno, California that thought it had spread its risk. Unfortunately, the group had spread its risk within the same hospital system. The hospital system terminated their agreement. They then had no business (or not enough business) along with significant debt; they filed bankruptcy.
There’s a saying that if you fail to plan, you plan to fail. It sounds goofy but it’s really true.
Whether we're talking hospital-based groups or office-based groups, betting your whole business on a single relationship with a hospital or system is failing to plan for the event in which the hospital decides they want to have someone else fill the role. The group's entire practice is now gone.
We often hear that investing in ourselves is the best investment – I think that’s bullshit. To invest in yourself as an individual, that’s one thing. But to invest in your business when that business is so narrowly focused, or is focused on an illusion (to think of your risk as spread over multiple facilities, when all of the facilities have a common parent) is extremely risky.
This is especially true today, when more and more medical services are contracted. Much of that contracting is based on the maxim, "what have you done for me lately?", with the emphasis on lately.
Look at your relationships - referral relationships, hospital relationships, all of your business relationships - and think about what would happen if those relationships were terminated, if contracts were terminated.
Even if you think that your contracting partners will never become disenchanted with you, think about what would happen if those with whom you contract suffer a business failure and close down. Then what's your option?
Start spreading that risk now because, sooner or later, one of those things will happen.
(And if I'm wrong, think how delighted you'll be!) |
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Others see a crisis and freeze in fear. Learn how to see the opportunities and obtain the tools to increase your odds of obtaining them.
The price to attend is $479. The cost of not attending is astronomical. |
| | | Wednesday – UnitedHealth Pushing Business to ASCs and Outpatient Imaging – Medical Group Minute
Watch the video here, or just keep reading below for a slightly polished transcript:
In case you weren’t listening, on June 15th, UnitedHealth told you where they were going to push cases, and it wasn’t to hospitals.
That’s the day on which the parent company, UnitedHealth Group, announced that their goal is to ensure that more than 55% of outpatient surgeries and radiology services are delivered at a high-quality, cost-efficient site of care. If you haven’t already figured it out, “cost-efficient” is a euphemism for not at a hospital but at an ASC or freestanding imaging center. Feel free to read the full report which is filled with gobbledygook about sustainability and stakeholders and other woke BS designed to get people to lay off the $22.4 billion in profit they made in 2020.
Laugh about it or cry about it, the bottom line is the same: they are cutting costs by moving all cases that can be moved out of the hospital out of the hospital. Where does that leave you?
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| | | | | Listen to the podcast here, or just keep reading for the transcript.
Sorry college basketball fans, this post has nothing to do with basketball, unless former Continuum Healthcare, LLC executives, and now felons, Bobby Rouse, Steven Houseworth, Jeffery Parsons, and David Edison will be playing pickup games on the prison yard.
Rouse, Houseworth, Parsons, and Edison are the final four to be sentenced out of a total of 14 individuals charged and convicted in 2019 for their roles in a massive kickback scheme resulting in what prosecutors alleged resulted in $189 million in fraudulent billing to the Medicare program.
On April 22, 2021, Rouse, age 81, was sentenced to 10 years in prison, Edson, age 72, to 4 years in prison, Parsons, age 62, to 30 months in prison, and Houseworth, age 47, to 30 months in prison.
Continuum owned Westbury Community Hospital in Houston as well as community mental health centers, each of which operated a partial hospitalization program, also known as a “PHP”, an intensive, short-term treatment program for individuals with mental illness.
In addition to Rouse, Houseworth, Parsons, and Edson, the remaining 9 individuals charged and convicted in the scheme were either owners of personal care homes or “marketers” for Continuum’s mental health programs.
At the center of the allegations against the 14 was that the hospital executives, marketers and personal care home owners conspired, including concerning the payment and receipt of kickbacks, for the referral of patients from the personal care homes to the Continuum facilities. Additionally, the vast majority of the referred patients did not even qualify for the PHP program.
Although it’s unclear what triggered the investigation, the charges against the 14 resulted from a joint investigation on the part of the OIG, the Texas Attorney General’s Medicaid Fraud Control Unit, and the IRS.
In my experience, most kickback schemes are not as brazen as this. They involve fewer numbers of people and, sometimes, behavior that is more easily rationalized by the participants as “sort of legal”.
My usual admonition applies: Be extremely careful before becoming involved in any arrangement involving payment of any sort, whether in dollars or in kind, in connection with the referral of patients. Get advice from someone qualified to give it, someone who’s not simply earning a fee to tell you what you want to hear. As they say, talk’s cheap. Your freedom is dear.
You might come to the conclusion that the former hospital execs, Rouse, Houseworth, Parsons, and Edson, were crazy thinking they could get away with a scheme involving 14 individuals including fraud magnet “marketers”, especially when the program they ran was supposed to be treatment for individuals with mental illness.
Luckily, each of the four former Continuum executive team members will now qualify for free healthcare, including free mental health services, courtesy of the Federal Bureau of Prisons, your tax dollars at work.
If you think kickback schemes pay off in the end, well, you’re nuts, too.
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| | | Calibrate Your Compass
Read our exclusive RedPaper to guide you through this evolving situation.
The coronavirus crisis caused a short-term economic crisis for many medical groups. Our RedPaper shows you the way out. Plus, many of the concepts discussed are applicable during both good times and bad.
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| | | | We all hear, and most of us say, that the pace of change in healthcare is quickening. That means that the pace of required decision-making is increasing, too. Unless, that is, you want to take the “default” route. That’s the one is which you let someone else make the decisions that impact you; you’re just along for the ride. Of course, playing a bit part in scripting your own future isn’t the smart route to stardom. But despite your own best intentions, perhaps it’s your medical group’s governance structure that’s holding you back.
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| In fact, it’s very likely that the problem is systemic. The Medical Group Governance Matrix introduces a simple four-quadrant diagnostic tool to help you find out. It then shows you how to use that tool to build your better, more profitable future. Get your free copy Free.
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| | | | Whenever you're ready, here are 4 ways I can help you and your business:
1. Download a copy of The Success Prescription. My book, The Success Prescription provides you with a framework for thinking about your success. Download a copy of The Success Prescription here.
2. Be a guest on “Wisdom. Applied. Podcast.” Although most of my podcasts involve me addressing an important point for your success, I’m always looking for guests who’d like to be interviewed about their personal and professional achievements and the lessons learned. Email me if you’re interested in participating.
3. Book me to speak to your group or organization. I’ve spoken at dozens of medical group, healthcare organization, university-sponsored, and private events on many topics such as The Impending Death of Hospitals, the strategic use of OIG Advisory Opinions, medical group governance, and succeeding at negotiations. For more information about a custom presentation for you, drop us a line.
4. If You’re Not Yet a Client, Engage Me to Represent You. If you’re interested in increasing your profit and managing your risk of loss, email me to connect directly. |
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