Sustaining Revenue Under the
Affordable Care Act
Alabama Hospital Association
January 24, 2014
Dan M. Silverboard
Jennifer E. Tyler
Copyright © 2010. Balch & Bingham LLP. All rights reserved
1
Presentation Overview

Background: Payment Reform Under the ACA

Readmissions Reduction Program

Hospital Value-Based Purchasing Program

Hospital-Acquired Conditions Reduction
Program

Direct Employer Contracting

Opportunities in Telemedicine

Mergers and Acquisitions

Billing and Collections
Health Spending/Percent GDP
Source: CMS
Background: Key Facts

Alabama opt-in to the Medicaid expansion would have
covered approximately 240,000 previously uninsured
persons—or sixty percent (60%) of its uninsured
population.

DSH Reduction (UAB):

$307,827,500 in DSH payments in FY2011. This accounts for
nearly 10% of all Medicaid spending in Alabama.
Background: ACA Payment Reform

“Estimates suggest that as much as $700 billion
a year in health care costs do not improve
health outcomes.”
- Peter Orszag, Former Director of the Congressional Budget
Office
Background: ACA Payment Reform

Focus on quality of care when determining
provider reimbursement.

Implemented through Prospective Payment
System and private commercial contracts.

Affected providers:

Hospitals

Individual clinicians

Managed care organizations (MAOs)

Accountable care organizations (ACOs)
Affordable Care Act Provision with
Quality Focus
Value based purchasing
•
3001 - Hospital value-based purchasing
•
3006 - Value-based purchasing for SNF
•
3014 - Quality and efficiency measurement
•
10301 - Develop a plan to implement VBP for ambulatory surgical
centers
•
10326 - Pilot testing for pay-for-performance
Hospital readmissions
•
3025 - Hospital readmissions reduction program
•
3026 - Community-based care transitions program
Healthcare acquired conditions
•
2702 - Payment adjustment for health care-acquired conditions
•
3008 - Payment adjustment for conditions acquired in hospitals
Accountable care organizations
•
2706 - Pediatric accountable care organization demonstration
project
•
3022 - Medicare Shared Savings Program
Dual eligibles
•
2602 - Providing federal coverage and payment coordination for
dual eligible beneficiaries
Preventative services
•
4103 - Annual wellness visit providing a personalized plan
•
4104 - Removing barriers to preventive services
•
4105 - Evidence-based coverage of preventive services
7
Coordination of care
•
2703 - State option to provide health homes for enrollees with chronic
conditions
•
2704 - Demonstration project to evaluate integrated care around a
hospitalization
Long term care
•
2401 - Community first choice option
•
2402 - Removal of barriers to providing home and community based
services
•
2403 - Money follows the person rebalancing demo
•
2404 - Protection for recipients of home and community-based services
against spousal
•
impoverishment
•
10202 - Incentives for states to offer home community based serviced
Public reporting
•
10303 - Development of outcome measures
•
10327 - Improvements to the physician quality reporting system -- also see
Provision 3002
•
10331 - Public reporting of performance information
Quality reporting initiative
•
2701 - Adult health quality measures
•
3002 - Improvements to the physician quality reporting system.
•
3004 - Quality Reporting for Long Term Care Hospitals (LTCH), inpatient
rehabilitation
•
hospitals, and hospice programs
•
3005 - Quality reporting for PPS-exempt cancer hospitals
•
10322 - Quality reporting for psychiatric hospitals
Financial Impact of CMS Quality
Programs
Program
FY 2014
FY 2015
FY 2016
FY 2017
Hospital VBP Program
±1.25%
±1.50%
±1.75%
±2.00%
Readmissions
Reduction Program
HAC Program
-1.0%
-2.0%
-3.0%
-3.0%
-1.0%
-1.0%
-1.0%
Hospital IQR
Program
-2.0%
-2.0%
-2.0%
-2.0%
Max Penalty:
4.25%
6.5%
7.75%
8.0%
Readmissions Reduction Program
Background

Recommended by Medpac in 2007, 2008 Reports to
Congress.

Public reporting of readmissions began in 2009 on Hospital
Compare.

Authority:
 Adopted as part of PPACA (section 3025) in 2010.
 Codified in SSA, §1886(q).
 Initial program policies in FY 2012 IPPS final rule.
 Regulations at 42 C.F.R. §412.152.

Effective October 1, 2012.

$8.2 billion in cost savings.
Readmissions Reduction Program




Why are Readmissions a Target?
Hospitals are the most expensive setting for health
care delivery, costing between $1,600 and $2,000 a
day per patient and consuming $850 billion of the
$2.7 trillion spent annually on health care in the U.S.
MedPac (2008): “Within 30 days of discharge, 17.6
percent of admissions are readmitted, accounting for
$15 billion in Medicare spending in 2005…12 percent
were avoidable.”
NEJM (2009): 1 in 5 Medicare patients are
readmitted; avoidable readmissions cost $17 billion
annually.
Readmissions Reduction Program

Program Measurements

Acute-care hospital readmissions within 30-days for
discharged Medicare FFS patients.

Effective for discharges on or after Oct. 1, 2012.

Applicable Conditions:

Acute myocardial infarction

Heart failure

Pneumonia

Chronic obstructive pulmonary disease (2015)

Elective hip/knee arthroplasty (2015)
Readmissions Reduction Program
Key Points

“Readmission” occurs when a Medicare patient is discharged
from an acute care hospital and then is admitted to the same
or another acute care hospital within 30 days.

Can be for any cause (i.e., it does not have to be for the same
cause as the initial admission).

Exclusions:

For FY 2014, unplanned readmissions following a planned
readmission so long as within 30 days of the initial admission.

Same-day hospital inpatient readmissions for the same
condition to the same hospital.

Excludes transfers to another IPPS hospital, discharges
against medical advice.
Readmissions Reduction Program


Penalty Assessment:
 “Excess readmission ratio” (ERR) is calculated based
on the hospital’s readmission performance as
compared to the national average for the condition.
 ERR is then risk-adjusted for clinically relevant factors
(limited patient demographics, comorbidity, patient
frailty).
 CMS utilizes administrative claims data.
Penalty Amount:
 FY 2013: Up to 1%
 FY 2014: Up to 2%
 FY 2015: Up to 3%
Readmissions Reduction Program

Reporting Requirements

Readmission data is reported on Hospital
Compare website.

Hospitals are able to review data prior to
publication and may make corrections,
though not to claims data.

Limited appeal rights.
Readmissions Reduction Program
Hospital Compare Data
Readmissions Reduction Program

FY 2013 Program Results:
 2,225 hospitals penalized.
 $227 million in penalties.
 77% of safety net hospitals were penalized.
 81% of Alabama hospitals penalized.
 CMS considering incorporating socioeconomic
factors into risk-adjustment (race, ethnicity,
income, lifestyle, patient access to primary
care).
Value-Based Purchasing Program
Authority:

Section 3001(a) of PPACA.

Codified in SSA, §1886(o).

Final Rule, 76 FR 26490 (May 6, 2011).

Regulations at 42 C.F.R., §412.160 et seq.

Additional guidance in IPPS rules (2012-2014).
Applicability:

All “subsection (d)” hospitals – all hospitals paid under
IPPS. Critical access hospitals and small hospitals are
excluded.
Value-Based Purchasing Program
Program Metrics:

How well hospital follows “best clinical practices” in certain
areas (“Clinical Process of Care Domain”).

How well hospital enhances patient experience (“Patient
Experience of Care Domain”).

Mortality outcomes for certain conditions (added for FY
2014) (“Outcome Domain”).

Areas are evaluated based on specific quality measures.
Exposed Funds:

1% of DRG payment upwards or downwards for FY 2013,
increased annually by ¼%.

1.25% for FY 2014 DRG payments/1.5% for FY 2015.

Caps out at 2% in 2017.
Value-Based Purchasing Program


Program Funding:

All hospitals participating will have their base operating
DRG payment for each patient discharge reduced

The money will be used to fund the incentive payments.

CMS estimates $1.1 billion available in FY 2014.
Data Collection:

Patient Experience Domain: HCAHPs survey data is used.

Clinical Process of Care Domain: Chart abstracts are used.

Outcome Domain: Medicare claims data.

Surveys and abstracts are collected through the Hospital
Inpatient Quality Reporting Program.
Value-Based Purchasing Program

Hospital Inpatient Quality Reporting Program (HIQRP)

Requires acute care hospitals to submit data regarding
specific quality measures for common health conditions
among Medicare patients which typically result in
hospitalization.

Hospitals that successfully report are paid a higher
annual update to their payment rates by CMS.

Eligible hospitals that do not participate receive an
annual market basket update with a 2% reduction.

95% of hospitals participate.
Value-Based Purchasing Program

Scoring Methodology:

Achievement Score

Improvement Score

Total Performance Score:
Higher of Achievement
Score or Improvement Score for each measure. CMS
then aggregates the scores for each measure to
achieve one score for the category. After the scores are
weighted, they are added together to get the total
performance score, which is then converted into a
payment adjustment percentage (PAP).

VBP Bonus = PAP x hospital’s base DRG operating
payment.
Value-Based Purchasing Program
Value-Based Purchasing Program
Clinical Process of Care Measure
Performance Standard
(Achievement Threshold)
Benchmark
Prophylactic Antibiotics Discontinued Within 24 Hours
After Surgery End Time
0.9663
0.9996
Cardiac Surgery Patients with Controlled 6AM
Postoperative Serum Glucose
0.9634
1.0000
Postoperative Urinary Catheter Removal on
Postoperative Day 1 or 2
0.9286
0.9989
Surgery Patients with Recommended Venous
Thromboembolism Prophylaxis Ordered
0.9462
1.0000
Surgery Patients Who Received Appropriate Venous
Thromboembolism Prophylaxis Within 24 Hours Prior
to Surgery to 24 Hours After Surgery
0.9492
0.9983
Surgery Patients on a Beta Blocker Prior to Arrival That
Received a Beta Blocker During the Perioperative
Period
0.9565
1.0000
Value-Based Purchasing Program
HCAHPS Patient Experience Measure
Performance
Standard
(Achievement
Threshold)
Benchmark
Floor
Communication With Nurses
75.79%
84.99%
42.84%
Communication With Doctors
79.57%
88.45%
55.49%
Responsiveness of Hospital Staff
62.21%
78.08%
32.15%
Pain Management
68.99%
77.92%
40.79%
Communication About Medicines
59.85%
71.54%
36.01%
Hospital Cleanliness and Quietness
63.54%
78.10%
38.52%
Discharge Information
82.72%
89.24%
54.73%
Overall Hospital Rating
67.33%
82.55%
30.91%
Value-Based Purchasing Program
Mortality Outcome Measure
Performance Standard
(Achievement Threshold)
Benchmark
AMI 30-Day Mortality Rate
0.8477
0.8673
HF 30-Day Mortality Rate
0.8861
0.9042
PN 30-Day Mortality Rate
0.8818
0.9021
Value-Based Purchasing Program


Appeals:

Yes. Within 30 days from time CMS payment report is
posted, the hospital must submit a “Corrections Request.”

The hospital may submit an appeal within 30-days on the
CR if denied.

The appeals process is facilitated through QualityNet.
Reporting: Results for each individual performance measure
as well as a hospital's total performance are reported on
Hospital Compare.
Value-Based Purchasing Program
Early Program Results

FY 2013: 1,557 hospitals received bonuses, 1,427 had reductions.

FY 2014: 1,231 hospitals received bonuses, with reductions to
1,451 hospitals.

Bigger teaching hospitals did the worst, with smaller, community
hospitals faring better.

Fifty-seven% of for-profit hospitals received bonuses, while only
21% of government-owned hospitals gained money.

“For nearly two-thirds of the hospitals, the changes are less than a
quarter of a percent…[s]till, for hospitals with lots of Medicare
patients, hundreds of thousands of dollars are at stake.” (Kaiser
Health News)
HAC Reduction Program
Beginning in FY 2015, the Hospital-Acquired Condition
(HAC) Reduction Program, mandated by the Affordable
Care Act, requires CMS to reduce hospital payments by 1
percent for hospitals that rank among the lowestperforming 25 percent with regard to HACs.
HAC Reduction Program

Authority:

2005 Deficit Reduction Act

In 2009, CDC found preventable HACs added $6 billion in
health care costs.

Section 3008 of PPACA.

Codified in SSA, § 1886(p)

Regulations at 42 C.F.R., § 412.170 et seq.

FY 2014 IPPS Rule.
HAC Reduction Program
Penalties/Reporting

HAC/POA Policy: For discharges on or after October 1,
2008, hospitals do not receive additional payment where a
designated HAC is not present on admission. Payment is
made as though no secondary diagnosis were present.

HRP: Beginning in FY 2015 hospitals in the lowest 25% for
HACs will receive a 1 percent penalty on reimbursement.
Penalty adjustment will occur after base DRG payment
adjustments have been calculated and made for the VBP
and readmission reduction programs.

Data: IQR Program.

Reporting: Hospital Compare.
HAC Reduction Program

Designated HACs (Present on Admission Policy):

Foreign Object Retained after Surgery

Air Embolism

Blood Incompatibility

Stage III and IV Pressure Ulcers

Falls and Trauma

Vascular Catheter-Associated infection

Catheter-Associated Urinary Tract Infection

Manifestations of Poor Glycemic Control

Deep Vein Thrombosis and Pulmonary Embolism Following Certain Orthopedic
Procedures

SSI Following Bariatric Surgery for Obesity:

SSI Following Cardiac Implantable Electronic Device (CIED)

SSI Following Certain Orthopedic Procedures

SSI, Mediastinitis, following Coronary Artery Bypass Graft (CABG)

Latrogenic Pneumothorax with Venous Catheterization
HAC Reduction Program: Calculation



Domain 1 (8 AHRQ Measures - 35%):

Pressure ulcer rate;

Iatrogenic pneumothorax rate;

Central venous catheter-related blood stream infection rate;

Postoperative hip fracture rate;

Postoperative pulmonary embolism /deep vein thrombosis rate;

Postoperative sepsis rate;

Wound dehiscence rate; and

Accidental puncture and laceration rate.
Domain 2 (2 CDC Measures - 65%):

Central Line-Associated Blood Stream Infection

Catheter-Associated Urinary Tract Infection.
Total HAC Score: D1 + D2 (Risk Adjusted - age, gender, and comorbidities).
Encouraging Enrollment in Exchanges
Encouraging Enrollment in Exchanges

Enrolling patients in exchanges is high priority

Various methods:

Navigators: Ascension Health/Providence Health and
AIDS Alabama, Tombigbee Healthcare Authority

Local meetings, local health fairs

Insurance phone hotlines

Mining patient records to determine potential eligibility
Finding Coverage for Patients


Medicaid enrollment: Presumptive enrollment

At least one state requires presumptive enrollment
(Illinois).

Under provisions of the ACA qualified hospitals are
allowed to make presumptive eligibility determinations for
individuals who show potential eligibility for Alabama
Medicaid under the primary ACA groups (children,
pregnant women and parent/caretaker relatives).
Alabama Medicaid recently issued new guidance
on presumptive enrollment
Finding Coverage for Patients

Alabama Medicaid Presumptive Enrollment

Individuals required to submit a simplified hospital PE
application to receive presumptive eligibility benefits.

The hospital PE application must be submitted
electronically.

The hospital PE determination based on income,
household size, citizenship and state residency.

The qualified hospital will accept self-attestation of
information and will not perform any verification checks of
information provided.
Finding Coverage for Patients


Alabama Medicaid Presumptive Enrollment (cont.)

Presumptive eligibility granted for up to 60 days.

After completing the hospital PE application, the individual
will be referred to complete a full Medicaid application.

The individual will be able to complete the Medicaid
application online, via paper, over the phone, and in
person at their local Medicaid office.
Eligibility worker
• Another option for getting individuals signed up for
Medicaid is for hospitals to hire an eligibility worker that
could actually enroll patients in Medicaid using the
Medicaid system.
Finding Coverage for Patients


Certified Application Counselors

Individuals who work at hospitals or other provider
organizations who can assist individuals in applying for
coverage through the health care marketplace.

http://www.enrollamerica.org/toolkits/pe/home.html.
National enrollment site:

Enroll America has useful tools for enrollment, outreach

For example: How to create an Outreach Work Plan

www.enrollamerica.org
Encouraging Enrollment in Exchanges

Caution against premium assistance

October 30, 2013 – DHHS guidance: Qualified
Health Plans (QHPs) are not “federal health care
programs” for purposes of the Anti-Kickback
Statute (AKS)

Appeared to sanction 3rd party premium subsidies for
patients purchasing insurance through exchanges
Finding Coverage for Patients

November 4, 2013 DHHS FAQ:
“It has been suggested that hospitals, other healthcare
providers, and other commercial entities may be
considering supporting premium payments and cost-sharing
obligations with respect to qualified health plans purchased
by patients in the Marketplaces. HHS has significant
concerns with this practice because it could skew the
insurance risk pool and create an unlevel field in the
Marketplaces. HHS discourages this practice and
encourages issuers to reject such third party
payments. HHS intends to monitor this practice and to
take appropriate action, if necessary.”
Addressing Bad Debt
Addressing Bad Debt


Hospitals must address bad debt

Payment of copays and deductibles will continue to be a
problem for patients in exchanges

High deductible plans lead to large patient responsibility

High deductible plans lead to patients seeking to pay
cash only (not report to insurance)

Many patients will remain uninsured
Hospitals must find ways to turn accounts
receivable into cash
Addressing Bad Debt

Caution: ACA implemented new rules regarding
collections actions, effective Jan. 1, 2014

New IRC Section 501(r)(6) requires a hospital
organization to make reasonable efforts to
determine whether an individual is eligible for
financial assistance before engaging in
extraordinary collection actions (“ECAs”) against
the individual.
Addressing Bad Debt

ECAs include:

Reporting to credit agencies

Placing a lien on individual’s property

Attaching or seizing individual’s bank account

Commencing a civil action against an individual

Garnishing individual’s wages

Sales of patient’s debt to third party collection company

IRS is authorized to strip tax-exempt status for
“willful and flagrant” violations

AHA & HFMA issued “best practices” for hospitals
Encouraging Enrollment in Exchanges

ACA requires hospitals to revise financial
assistance policies to capture more patients (IRC
§ 501(r)(4)).

FAP should establish:

Eligibility for financial assistance (free & discounted care)

Basis for calculating amounts charged to patients

Method for applying financial assistance

Billing and collections policy (if not separate)

Measures to widely publicize the FAP within the
community
Direct Contracting with Employers
Direct Contracting with Employers


Traditional model

Employers contract with payors (HMO, MCO, PPO) to
access providers

Providers contract with payors (HMO, MCO, PPO) to
access patients
Problems

Inflexible

Costly

Administratively difficult to manage
Direct Contracting with Employers

Employers becoming receptive to innovative
options

Employers are facing:

Increasing pressure to trim healthcare costs

Drive to keep employees healthy

Employee benefit plans in flux

Drop coverage and push employees to exchanges?

Optimize current coverage?
Direct Contracting with Employers

Examples of Direct Contracts between Employer
and Providers

Lowe’s

225,000 employees and dependents
enrolled in Lowes self-funded plan can
travel to Cleveland Clinic for heart
procedures.

Lowe’s covers all medical deductibles,
coinsurance payments, travel costs and
lodging for patient and companion.
Direct Contracting with Employers

Examples of Direct Contracts between Employer
and Providers


Perdue Farms

Contracts directly with physicians and hospitals

Healthcare costs for the company are less than half
of the national average
Wal-Mart

1.1 million employees and their dependents covered
by Wal-Mart’s plan can travel to Cleveland Clinic for
cardiac surgery with employer covering deductibles
and travel
Direct Contracting with Employers

Benefits of Direct Contracting

Lower costs—No “middleman” cut (network access fees)

More flexibility—Providers can negotiate better deals for
important procedures/services

Hospitals can obtain access to patients with reliable
source of payment

Less “nit-picking” of medical judgment

Less administrative hassle

Reduced physician burnout, since focus is less on volume
and more on quality of care
Direct Contracting with Employers

What makes a hospital attractive to employers?

Outcomes

Transparency

Aligned incentives (e.g., employed physicians)

Geography and access


What will save employees time?

For high risk procedures—employers may be willing
to send employees out-of-state

For OB or occupational medicine—employers
looking for local providers
Infrastructure (e.g., experience, staff)
Direct Contracting with Employers

Considerations before approaching direct
contracting


Start small and capitalize on current services

Occupational health department—can serve as
natural extension

Community based services (e.g., education, health
screenings, flu shots)
Review current managed care contracts

Which are most disadvantageous

Review contract terms—some may prohibit direct
contracting
Direct Contracting with Employers

Considerations before approaching direct
contracting (cont.)


Who are employer decision-makers?

Corporate benefit department may be located out-ofstate

May not have experience or knowledge of directcontracting concept

Employer contracts with payors may not permit
direct contracting
Set realistic goals
Opportunities in Telemedicine
Opportunities in Telemedicine

What is Telehealth/Telemedicine?


Transfer of clinical information through interactive
audiovisual media
Set to experience explosive growth

Predictions of 18.5% annual growth in telehealth
worldwide through 2018
Opportunities in Telemedicine

Benefits

Monitoring of chronic disease in less expensive settings

Approximately 125 million Americans living with 1 or
more chronic diseases and number expected to
grow to 157 million by 2020 (CDC).

Employer benefits—ensuring health of employees without
having employees take off work

Patients receive medical interventions in a more timely
manner

Specialists expand their reach
Opportunities in Telemedicine

Regulatory landscape

Medicare Coverage of Telemedicine

Traditionally, Medicare was seen as a roadblock to
expansion of telemedicine services

Only paid for limited number of Part B services furnished
by a physician or practitioner to an eligible beneficiary via
a telecommunications system

Beneficiaries must be presented from originating site in a
rural HPSA or in a county outside of a MSA
Opportunities in Telemedicine

Medicare Coverage of Telemedicine

Former regulations required hospital’s governing
body to appoint all practitioners to medical staff

In 2011, CMS issued final rule in (CoPs) for
credentialing of physicians/practitioners for
telemedicine to:

(1) Make current Federal requirements more flexible for
rural and/or small hospitals and CAHs and

(2) Encourage innovative approaches to patient-service
delivery
Opportunities in Telemedicine

Medicare Coverage of Telemedicine

New requirements: hospital’s governing body
must ensure through a written agreement with the
distant-site hospital that certain criteria are met,

Distant-site hospital is Medicare participating hospital;

The physician or practitioner is privileged;

The physician or practitioner holds a license issued or
recognized by the state where patient is located;

Hospital must have internal review of distant-site
physician’s or practitioner’s
Opportunities in Telemedicine

Alabama regulation of telehealth

Alabama Medicaid covers telemedicine for
physicians licensed in Alabama to patients in
Alabama


No mandatory coverage by commercial payors, but many
already cover telehealth
New telehealth regulations issued by Alabama
Board of Medical Examiners

Effective January 16, 2014
Opportunities in Telemedicine

Alabama regulation of telehealth

540-X-15-.09 Telehealth medical services provided
at an established medical site.

Telehealth can be provided at an established medical site
(e.g., hospital) may be used for all patient visits, including
initial evaluations to establish a proper provider-patient
relationship between distant site provider and a patient.

A distant site provider may delegate tasks and activities to
a patient site presenter during a patient encounter.
Opportunities in Telemedicine

Alabama regulation of telehealth

540-X-15-.10 Distant site provider who provides
telehealth at a site other than an established
medical site for a patients’ previously diagnosed
condition must either:


See the patient one time face to face visit before
telehealth OR

See the patient without face to face visit provided the
patient has received in person evaluation by another
provider who has referred the patient for additional care
Restrictions on Rx of scheduled drugs
Opportunities in Telemedicine

Alabama regulation of telehealth

540-X-15-.06 Protocols.


A provider who uses telehealth medical services in his or
her medical practice shall adopt protocols to prevent fraud
and abuse through the use of telehealth services.
540-X-15-.08 Notice to Patients

A provider who uses telehealth medical services must,
prior to providing services, give patients notice (except in
certain circumstances) including the risks and benefits of
telehealth, who to receive follow-up care, signed and
dated notice.
Opportunities in Telemedicine

Telemedicine/Telehealth Liability Considerations

Overall payor skepticism

Patients safety


Protocols in place for physicians and other
practitioners (nurses, PAs)

Follow-up

Prescribing practices (e.g., controlled substances)
Privacy & Security safeguards
Mergers, Acquisitions & Consolidation
Hospital Mergers, Acquisitions & Consolidation

Hospital industry consolidation


CHS/HMA

$7.6 billion dollar deal

CHS will obtain stronger presence in Florida,
Mississippi and Oklahoma
Tenet and Vanguard

Dallas-based Tenet acquired Nashville-based
Vanguard. $4.3 billion dollar deal.

Tenet gains market share in areas it previously had
no footprint: Chicago, Detroit, San Antonio, etc.
Mergers, Acquisitions & Consolidation


Acquisition of physician practice groups

Gain increased access points

Greater critical mass

Stronger presence in geographic areas or regions
Non-ownership collaborative agreements

Realize benefits of merging without giving up governance
Mergers, Acquisitions & Consolidation


Hospital Authorities

Public hospitals in states that have yet to expand
Medicaid face significant cut-backs

Hospital authority-owned hospitals are not likely to go
away—despite bleak outlook
Benefits of Hospital Authority Status

Immunity from antitrust liability (Ala. § 22-21-312)

Sovereign Immunity (Ala. § 22-21-312 and case law)

Property tax exemption (Ala. § 22-21-333)

Support from local governments and community
Summary

Summary of Methods for 2014 and Beyond for
Sustaining Revenue

Focus on quality and outcomes

Focus on enrolling patients in insurance if possible, and
managing bad debt

Consider new options for partnerships—with employers,
with practice groups, hospitals or local governments

Consider new and innovative uses of technology,
including telehealth
QUESTIONS?
THANK YOU!
Dan Silverboard, Esq.
Jennifer Tyler, Esq.
30 Ivan Allen Jr. Boulevard,
N.W. Suite 700
30 Ivan Allen Jr. Boulevard,
N.W. Suite 700
Atlanta, GA 30308-3036
t: (404) 962-3586
Atlanta, GA 30308-3036
t: (404) 962-3558
f: (888) 897-8549
f: (866) 270-1277
dsilverboard@balch.com
www.balch.com
jtyler@balch.com
www.balch.com