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Executive Order Expands Tele-Medicine

Eases Burden on Rural Medical Providers

By Health Capital Consultants, LLC

***

Executive Order Expands Telemedicine and Eases Burden on Rural Providers

On August 3, 2020, President Donald Trump signed an executive order aimed at expanding access to care through two avenues: telemedicine and eased financial burdens on rural providers. The executive order builds on President Trump’s original expansion of coverage for telemedicine services in early March 2020, an order which was praised by the American Telehealth Association (ATA) and American Medical Association (AMA) for swiftly responding to the growing healthcare crisis. This Health Capital Topics article will discuss the executive rule and the subsequent agency actions on these fronts. (Read more…)

***

TH

2021 Physician Fee Schedule

2021 Physician Fee Schedule & Quality Payment Program Proposed Rules Released

[By Health Capital Consultants]

***

On August 3, 2020, the Centers for Medicare & Medicaid Services (CMS) released two proposed payment rules for calendar year (CY) 2021: the Medicare Physician Fee Schedule (MPFS) and the Quality Payment Program (QPP). CMS included in the MPFS proposed rule adjustments to physician payment rates and an expansion of telemedicine services.

The proposed QPP rule, meanwhile, takes into account adjustments made for the COVID-19 public health emergency (PHE) and seeks to reduce unnecessary regulatory burden on providers by eliminating some requirements. These rules, which have garnered mixed reactions from stakeholders, are both open for comment until October 5, 2020. (Read more…)

***

***

New Index Ranks Hospitals’ Community Benefit


N
ew Index Ranks Hospitals’ Community Benefit

By Health Capital Consultants, LLC

On July 7, 2020, the Lown Institute, a nonpartisan think tank, announced the initial release of its new ranking system for hospitals. Called the “Hospitals Index,” this ranking analyzes not just the quality of care and patient outcomes but also the hospital’s civic leadership and avoidance of overuse, ideas that harken back to the core mission and vision of the Lown Institute itself.

Founded in 1973, the Institute advocates for a healthcare system that “rejects low-value care, incentivizes healing over profits, promotes health equity, and honors the value of the clinician-patient relationship.” (Read more…)

***

***

“Medical Management and Health Economics Education for Financial Advisors”

CMP® CURRICULUM: https://lnkd.in/eDTRHex
CMP® WEB SITE: https://lnkd.in/guWSApq

Your thoughts and comments are appreciated.

BUSINESS, FINANCE, INVESTING AND INSURANCE TEXTS FOR DOCTORS:

1 – https://lnkd.in/ebWtzGg

2 – https://lnkd.in/ezkQMfR

3 – https://lnkd.in/ewJPTJs

THANK YOU

***

Atlanta’s Piedmont Hospital Pays $16 Million to Settle Kickback Allegations

Piedmont Pays $16 Million to Settle Kickback and Overbilling Allegations

By Health Capital Consultants, LLC

On June 25, 2020 Atlanta’s Piedmont Healthcare, Inc. agreed to pay $16 million to the federal government to resolve two False Claims Act (FCA) allegations of kickbacks and overbilling. The relator, a former Piedmont physician, alleged Stark Law and Anti-Kickback Statute (and subsequent FCA) violations of paying an amount that was above fair market value (FMV) and commercially unreasonable in Piedmont’s 2007 acquisition of Atlanta Cardiology Group (ACG).

Additionally, Piedmont’s payments settle allegations that the hospital admitted patients without medical necessity in order to bill Medicare and Medicaid for inpatient procedures that were recommended to be performed at the less expensive outpatient or observation settings.  (Read more…)

Assessment: Your thoughts are appreciated.

NOTE: I was on the courtesy medical staff of Piedmont Hospital in Atlanta for more than a decade = DEM.

“Medical Management and Health Economics Education for Financial Advisors”

CMP® CURRICULUM: https://lnkd.in/eDTRHex
CMP® WEB SITE: https://lnkd.in/guWSApq

BUSINESS, FINANCE, INVESTING AND INSURANCE TEXTS FOR DOCTORS:

1 – https://lnkd.in/ebWtzGg

2 – https://lnkd.in/ezkQMfR

3 – https://lnkd.in/ewJPTJs

THANK YOU

***

Alternative Medical Payment Models

“The Path to Successful Utilization of Alternative Payment Models”

By Health Capital Consultants, LLC

An article authored by Todd ZigrangJessica Bailey-Wheaton, and Khaled Klele was featured in the most recent issue of The Health Lawyer published by the American Bar Association. Read the article entitled, “The Path to Successful Utilization of Alternative Payment Models,” here: https://lnkd.in/e78kXmE

***

***

ESSAY: The Path to Successful Utilization of Alternative Payment Models

ASSESSMENT: Your thoughts and comments are appreciated.

BUSINESS, FINANCE, INVESTING AND INSURANCE TEXTS FOR DOCTORS:

1 – https://lnkd.in/ebWtzGg

2 – https://lnkd.in/ezkQMfR

3 – https://lnkd.in/ewJPTJs

THANK YOU

***

CMS Value Based Purchasing for Drugs

CMS Proposed Rule Supports Value-Based Purchasing for Drugs

Courtesy: www.CertifiedMedicalPlanner.org

On June 19, 2020 the Centers for Medicare & Medicaid Services (CMS) issued a proposed rule regarding Medicaid Drug Rebate Program (MDRP) regulations, with the aim of lowering drug prices, increasing patient access, and encouraging innovation in the insurance and pharmaceutical industries.

This proposal is consistent with the Trump Administration’s Blueprint to Lower Drug Prices (Blueprint) released in May 2018, in which the administration highlighted its goal to “avoid excessive pricing by relying more on value-based pricing by expanding outcome-based payments in Medicare and Medicaid” and to “speed access to and lower the cost of new drugs by clarifying policies for sharing information between insurers and drug makers.”

***

***

The proposed rule seeks to accomplish the Blueprint’s goals by reducing regulatory barriers that have previously prevented commercial plans and states from entering into value-based purchasing (VBP) arrangements with drug manufacturers.

Colleagues from Health Capital Consultants, LLC; explain.

ESSAY: DRUGS

Assessment: Your thoughts and comments are appreciated.

BUSINESS, FINANCE, INVESTING AND INSURANCE TEXTS FOR DOCTORS:

1 – https://lnkd.in/ebWtzGg

2 – https://lnkd.in/ezkQMfR

3 – https://lnkd.in/ewJPTJs

THANK YOU

***

Post-Coronavirus Physician Practice Acquisitions

Proceed with Caution

By Health Capital Consultants, LLC

As the coronavirus (COVID-19) global pandemic has wreaked havoc on the U.S. economy generally, and the healthcare industry specifically, the previously-active healthcare transactional environment has been largely stunted.

Despite (or perhaps because of) this economic turbulence, stakeholders expect that merger and acquisition (M&A) activity will soon resume with a vengeance. This potential opportunity, however, is not without pitfalls, due in part to the concern from stakeholders and regulators that well-capitalized entities may use this economic and public health crisis to prey on debilitated physician practices. (Read more…)

 

ASSESSMENT: Your thoughts and comments are appreciated.

BUSINESS, FINANCE, INVESTING AND INSURANCE TEXTS FOR DOCTORS:

1 – https://lnkd.in/ebWtzGg

2 – https://lnkd.in/ezkQMfR

3 – https://lnkd.in/ewJPTJs

THANK YOU

***

COVID-19 Forces Value-Based Reimbursement Model Revision

COVID-19 Forces Value-Based Reimbursement Model Revision

By Health Capital Consultants, LLC

***

On June 3, 2020, Seema Verma, the Administrator of the Centers for Medicare & Medicaid Services (CMS), announced in a Health Affairs article that CMS is providing significantly more flexibility for healthcare entities participating in CMS-sponsored value-based reimbursement (VBR) models for the duration of the COVID-19 pandemic.
***
CMS has made a number of changes related to these models to provide added flexibilities to participating entities and to respond to participant concerns that VBR models will incur losses this year due to both the general disruption in operations and the greater expense associated with treating COVID-19 patients. (Read more…) 
***
***

ASSESSMENT: Your thoughts and comments are appreciated.

BUSINESS, FINANCE, INVESTING AND INSURANCE TEXTS FOR DOCTORS:

1 – https://lnkd.in/ebWtzGg

2 – https://lnkd.in/ezkQMfR

3 – https://lnkd.in/ewJPTJs

THANK YOU

***

The Health Care “DISRUPTORS”

A NEW I.P.O

BY HEALTH CAPITAL CONSULTANTS, LLC

***

On January 30, 2020, 1Life Healthcare, Inc. (One Medical) went public, opening at $14 per share, and closing at $22.07 per share. The innovative San Francisco-based direct primary care organization more closely resembles a technology start-up than a traditional healthcare organization.

The membership model service provides “seamless access” to primary care services at “calming offices,” 24/7 virtual care, and 21st century technology (e.g., a mobile application that allows patients to schedule appointments and message their provider).

**

HEALTH CARE DISRUPTIVE INNOVATORS

***

A new report from our colleagues over at Health Capital Consultants, LLC:

LINK: https://www.healthcapital.com/hcc/newsletter/02_20/HTML/IPO/convert_ipo_hc_topics.php#_edn4

ASSESSMENT: Your thoughts are appreciated.

***

Product DetailsProduct Details

***

Centers for Medicare & Medicaid Services (CMS) finalized the calendar year (CY) 2019 Medicare Physician Fee Schedule (MPFS), the Hospital Outpatient Prospective Payment System (OPPS), and the Ambulatory Surgical Center (ASC) Payment System

CMS Finalizes 2019 Physician & Outpatient Fee Schedules

By TODD A. ZIGRANG

***
In the course of twenty-four hours, the Centers for Medicare & Medicaid Services (CMS) finalized the calendar year (CY) 2019 Medicare Physician Fee Schedule (MPFS), the Hospital Outpatient Prospective Payment System (OPPS), and the Ambulatory Surgical Center (ASC) Payment System. The finalized rules generally remained unchanged from their proposed versions, with a couple of exceptions. Each finalized rule is reviewed briefly in this special edition of the Health Capital Topics e-journal. (Read more…) 

https://www.healthcapital.com/hcc/newsletter/11.2.18_Alert/HTML/CMS/convert_hc_topics_alert_mpfs_opps_11.2.18.php

***

Conclusion

Your thoughts and comments on this ME-P are appreciated. Feel free to review our top-left column, and top-right sidebar materials, links, URLs and related websites, too. Then, subscribe to the ME-P. It is fast, free and secure.

Speaker: If you need a moderator or speaker for an upcoming event, Dr. David E. Marcinko; MBA – Publisher-in-Chief of the Medical Executive-Post – is available for seminar or speaking engagements.

Book Marcinko: https://medicalexecutivepost.com/dr-david-marcinkos-bookings/

Subscribe: MEDICAL EXECUTIVE POST for curated news, essays, opinions and analysis from the public health, economics, finance, marketing, IT, business and policy management ecosystem.

DOCTORS:

“Insurance & Risk Management Strategies for Doctors” https://tinyurl.com/ydx9kd93

“Fiduciary Financial Planning for Physicians” https://tinyurl.com/y7f5pnox

“Business of Medical Practice 2.0” https://tinyurl.com/yb3x6wr8

HOSPITALS:

“Financial Management Strategies for Hospitals” https://tinyurl.com/yagu567d

“Operational Strategies for Clinics and Hospitals” https://tinyurl.com/y9avbrq5

***

Product DetailsProduct Details

Micro-Hospitals [The Technological Environment]

Micro-Hospitals: The Technological Environment

[By Health Capital Consultants, LLC]

Technology has a broad meaning when applied to healthcare. It can range from the tangible tools and software that providers use during the provision of clinical services and the management of patient records to the procedures that constitute the standardized course of care.

The fifth and final installment of this series will explore how various healthcare technologies have supported the expansion of micro-hospitals, and how it may contribute to the sustained success of this novel provider.

***

***

https://www.healthcapital.com/hcc/newsletter/09_18/HTML/MICRO/convert_microhospitals_tech_hc_topics_cataloged_9.13.18_hba.php

Conclusion

Your thoughts and comments on this ME-P are appreciated. Feel free to review our top-left column, and top-right sidebar materials, links, URLs and related websites, too. Then, subscribe to the ME-P. It is fast, free and secure.

Speaker: If you need a moderator or speaker for an upcoming event, Dr. David E. Marcinko; MBA – Publisher-in-Chief of the Medical Executive-Post – is available for seminar or speaking engagements.

Book Marcinko: https://medicalexecutivepost.com/dr-david-marcinkos-bookings/

Subscribe: MEDICAL EXECUTIVE POST for curated news, essays, opinions and analysis from the public health, economics, finance, marketing, IT, business and policy management ecosystem.

DOCTORS:

“Insurance & Risk Management Strategies for Doctors” https://tinyurl.com/ydx9kd93

“Fiduciary Financial Planning for Physicians” https://tinyurl.com/y7f5pnox

“Business of Medical Practice 2.0” https://tinyurl.com/yb3x6wr8

HOSPITALS:

“Financial Management Strategies for Hospitals” https://tinyurl.com/yagu567d

“Operational Strategies for Clinics and Hospitals” https://tinyurl.com/y9avbrq5

Product DetailsProduct Details

***

CMS to Review Stark Law Relevance Once Again

CMS to Review Stark Law Relevance Once Again

***

By Health Capital Consultants LLC

***

On June 25, 2018, the Centers for Medicare & Medicaid Services (CMS) issued a Request for Information (RFI) related to the regulatory burden of the physician self-referral law (known as the Stark Law), on both providers and the overall healthcare industry.
***
***
The aim of this request is to determine whether revision(s) of healthcare fraud and abuse laws is needed in order to remove any regulatory impediments to the accelerating shift toward value-based reimbursement (VBR) and coordinated care, and further innovation in the U.S. healthcare delivery system. (Read more…) 
***

Conclusion

Your thoughts and comments on this ME-P are appreciated. Feel free to review our top-left column, and top-right sidebar materials, links, URLs and related websites, too. Then, subscribe to the ME-P. It is fast, free and secure.

Speaker: If you need a moderator or speaker for an upcoming event, Dr. David E. Marcinko; MBA – Publisher-in-Chief of the Medical Executive-Post – is available for seminar or speaking engagements.

Book Marcinko: https://medicalexecutivepost.com/dr-david-marcinkos-bookings/

Subscribe: MEDICAL EXECUTIVE POST for curated news, essays, opinions and analysis from the public health, economics, finance, marketing, IT, business and policy management ecosystem.

DOCTORS:

“Insurance & Risk Management Strategies for Doctors” https://tinyurl.com/ydx9kd93

“Fiduciary Financial Planning for Physicians” https://tinyurl.com/y7f5pnox

“Business of Medical Practice 2.0” https://tinyurl.com/yb3x6wr8

HOSPITALS:

“Financial Management Strategies for Hospitals” https://tinyurl.com/yagu567d

“Operational Strategies for Clinics and Hospitals” https://tinyurl.com/y9avbrq5

 ***

Product DetailsProduct Details

The Micro-Hospital Reimbursement Environment

The New Kid on the Block:

***
By Health Capital Consultants LLC
***
Micro-hospitals are licensed as general acute care hospitals, and they are reimbursed as such by public and private payors (e.g., under the inpatient prospective payment system [IPPS]).
***
***
However, given their small size and volume of services compared to traditional hospitals, micro-hospitals may have the advantage of remaining exempt from certain reimbursement regulations, e.g., mandatory quality reporting under VBR programs such as the Merit-based Incentive Program (MIPS). (Read more…) 
***

Conclusion

Your thoughts and comments on this ME-P are appreciated. Feel free to review our top-left column, and top-right sidebar materials, links, URLs and related websites, too. Then, subscribe to the ME-P. It is fast, free and secure.

Speaker: If you need a moderator or speaker for an upcoming event, Dr. David E. Marcinko; MBA – Publisher-in-Chief of the Medical Executive-Post – is available for seminar or speaking engagements.

Book Marcinko: https://medicalexecutivepost.com/dr-david-marcinkos-bookings/

Subscribe: MEDICAL EXECUTIVE POST for curated news, essays, opinions and analysis from the public health, economics, finance, marketing, IT, business and policy management ecosystem.

DOCTORS:

“Insurance & Risk Management Strategies for Doctors” https://tinyurl.com/ydx9kd93

“Fiduciary Financial Planning for Physicians” https://tinyurl.com/y7f5pnox

“Business of Medical Practice 2.0” https://tinyurl.com/yb3x6wr8

HOSPITALS:

“Financial Management Strategies for Hospitals” https://tinyurl.com/yagu567d

“Operational Strategies for Clinics and Hospitals” https://tinyurl.com/y9avbrq5

 ***

Product DetailsProduct Details

SCOTUS Nominee Brett Kavanaugh’s Paper Trail & Influence on U.S. Healthcare Laws

SCOTUS Nominee Brett Kavanaugh’s Paper Trail & Influence on U.S. Healthcare Laws

***
Health Capital Consultants LLC
***
The future of healthcare policy could be significantly affected by the appointment of President Donald Trump’s nominee, Judge Brett M. Kavanaugh, to the Supreme Court of the United States (SCOTUS).
***
***
SCOTUS has been highly influential in U.S. healthcare policy in the past, and going forward, it has the power to drastically change the healthcare system, perhaps most severely by declaring laws or past executive action to be unlawful or unconstitutional. (Read more…) 
***

Conclusion

Your thoughts and comments on this ME-P are appreciated. Feel free to review our top-left column, and top-right sidebar materials, links, URLs and related websites, too. Then, subscribe to the ME-P. It is fast, free and secure.

Speaker: If you need a moderator or speaker for an upcoming event, Dr. David E. Marcinko; MBA – Publisher-in-Chief of the Medical Executive-Post – is available for seminar or speaking engagements.

Book Marcinko: https://medicalexecutivepost.com/dr-david-marcinkos-bookings/

Subscribe: MEDICAL EXECUTIVE POST for curated news, essays, opinions and analysis from the public health, economics, finance, marketing, IT, business and policy management ecosystem.

DOCTORS:

“Insurance & Risk Management Strategies for Doctors” https://tinyurl.com/ydx9kd93

“Fiduciary Financial Planning for Physicians” https://tinyurl.com/y7f5pnox

“Business of Medical Practice 2.0” https://tinyurl.com/yb3x6wr8

HOSPITALS:

“Financial Management Strategies for Hospitals” https://tinyurl.com/yagu567d

“Operational Strategies for Clinics and Hospitals” https://tinyurl.com/y9avbrq5

 ***

Product DetailsProduct Details

An Introduction to “Micro-Hospitals”

The New Kid on the Block: An Introduction to Micro-Hospitals

By Health Capital Consultants [HCC]; LLC

This Health Capital Topics article, the first installment of a five-part series, will introduce the concept of micro-hospitals and briefly discuss how they have evolved within the current healthcare delivery environment.

The following articles in this series will further examine micro-hospitals in relation to the Four Pillars that influence the value of entities within the healthcare industry, i.e., regulatory; reimbursement; competition; and, technology. (Read more…) 

***

Conclusion

Your thoughts and comments on this ME-P are appreciated. Feel free to review our top-left column, and top-right sidebar materials, links, URLs and related websites, too. Then, subscribe to the ME-P. It is fast, free and secure.

Speaker: If you need a moderator or speaker for an upcoming event, Dr. David E. Marcinko; MBA – Publisher-in-Chief of the Medical Executive-Post – is available for seminar or speaking engagements.

Book Marcinko: https://medicalexecutivepost.com/dr-david-marcinkos-bookings/

Subscribe: MEDICAL EXECUTIVE POST for curated news, essays, opinions and analysis from the public health, economics, finance, marketing, IT, business and policy management ecosystem.

DOCTORS:

“Insurance & Risk Management Strategies for Doctors” https://tinyurl.com/ydx9kd93

“Fiduciary Financial Planning for Physicians” https://tinyurl.com/y7f5pnox

“Business of Medical Practice 2.0” https://tinyurl.com/yb3x6wr8

HOSPITALS:

“Financial Management Strategies for Hospitals” https://tinyurl.com/yagu567d

“Operational Strategies for Clinics and Hospitals” https://tinyurl.com/y9avbrq5

Product DetailsProduct Details

Ground Breaking Book Explains Why Accountable Care Organizations May Be the Answer the Health Care Industry Has Been Seeking!

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Book Reviews, with Testimonial, by ME-P Founding Publisher Dr. David Edward Marcinko MBA CMP®

PRESS RELEASE!

August 23, 2013CRC Press / Productivity Press is pleased to announce the publication of  Accountable Care Organizations: Value Metrics and Capital Formation authored by nationally recognized healthcare expert, Robert James Cimasi. This dynamic book explores the historical background and evolution of the highly anticipated ACO model which is rapidly expanding since its adoption as part of the Affordable Care Act, commonly referred to as Obama Care. The book describes the basis for the development of value metrics and capital formation analyses that are foundational to assessing capacity for change in healthcare organizations considering the development of an ACO, as well as, the current efficacy of the model.

Book Reviews

“Bob Cimasi has done it again. As a thought leader in contemporary healthcare matters, his new book, Accountable Care Organizations: Value Metrics and Capital Formation, establishes and explains, in plain terms, the operational and financial DNA and genomic construct and understanding for any organization considering the development and operations of an ACO…a must read and resource for any healthcare industry executive.”

-Roger W. Logan, MS, CPA/ABV, ASA, Senior Vice President of Phoenix Children’s Hospital

“Accountable Care Organizations is the first comprehensive text on capital formation and value metrics for this new healthcare business model… I can think of no one more qualified to write it than Bob Cimasi at Health Capital Consultants … it is destined to become a classic work … read, review, refer, and profit by this valuable resource.”

-Dr. David Edward Marcinko MBA CMP® of the Institute of Medical Business Advisors, Inc Atlanta, GA

“As both a healthcare management educator and as a consultant who has worked on health and professional services transactional advisory work for many years, I applaud the ambitious undertaking of Bob Cimasi’s latest book, Accountable Care Organizations: Value Metrics and Capital Formation. Cimasi’s description of the complex history and evolution of the US health system provides a useful framework for students and professionals who may lack a detailed background in the field. This should help them better understand both how we have arrived at the ACO approach, and how it might work. This addressing capital and valuation information is also uncommon in the literature on ACOs. It should provide a valuable contribution to the field, especially given that a some surveys of healthcare leaders have pointed to access to capital and to a lesser but still important degree, agreement on valuation, as concerns as they consider acquisitions, mergers, and other affiliations towards forming/joining ACOs or similar organizations to help deal with the changing reimbursement and competitive environment.”

-R. Brooke Hollis, MBA/HHSA, Executive Director, Sloan Program in Health Administration, Cornell University and Managing Member, Hollis Associates Acquisition Advisors, LLC

The book examines the Four Pillars of Value in the Healthcare Industry: regulatory, reimbursement, competition and technology in addressing the value metrics of ACOs, including requirements for capital formation, financial feasibility, and economic returns. It focuses the discussion of non-monetary value on a review of aspects of population health within the context of such objectives as improved quality outcomes and access to care. It also examines the positive externalities of the ACO model, including results for third parties outside the basic construct of the ACO contracts shared savings payments. The potential role and opportunities for consultants in assisting their provider clients in the consideration, development, implementation, and operation of an ACO are also discussed.

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Accountable Care Organizations

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About the Author:

Robert James Cimasi, MHA, ASA, FRICS, MCBA, AVA, CM&AA, CMP® is CEO of Health Capital Consultants (HCC), a nationally recognized healthcare financial and economic consulting firm headquartered in St. Louis, Missouri, since 1993. Cimasi has more than 30 years of experience in serving clients in over 45 states, with a professional focus on the financial and economic aspects of healthcare service sector entities including feasibility analysis and forecasting; valuation consulting and capital formation services; healthcare industry transactions including joint ventures, mergers, acquisitions, and divestitures; certificate-of-need and other regulatory and policy planning consulting; and, litigation support and expert testimony.

Mr. Cimasi has served for many years as faculty in both an academic and professional basis for continuing education courses, and he has provided testimony before federal and state legislative committees and has served as an expert witness in numerous court cases. He is a nationally known speaker on healthcare industry topics, the author of several books, including A Guide to Consulting Services for Emerging Healthcare Organizations (John Wiley & Sons, 1999), The U.S. Healthcare Certificate of Need Sourcebook (Beard Books, 2005), The Adviser’s Guide to Healthcare (AICPA, 2010), and Healthcare Valuation: The Financial Appraisal of Enterprises, Assets, and Services (John Wiley & Sons, 2013), as well as numerous chapters, published articles, research papers and case studies, and is often quoted by healthcare industry press.

 

UPDATE:
Top Five Videos Trending in The Last Month On HealthShareTV
  1. Accountable Care Directory 2014
  2. Achieving Quality in Accountable Care Organizations
  3. High-Performing Care Coordination in a Patient/Family-Centered Medical Home
  4. ‘Aetna’s Medicare Advantage Collaborative Initiatives’
  5. Aligning High Performance in Medication Safety to Improve Patient Outcomes and Reduce Readmissions

Source: HealthShareTV

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Integration as a Competitive Strategy in Healthcare Reform

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Understanding Horizontal and Vertical Integration

[By Robert James Cimasi MHA, AVA, CMP™]

Health Capital Consultants, LLC

St. Louis MO

Several potential benefits are associated with the integration of companies in the same or related industries. These synergistic benefits depend upon the type of companies and their integration strategies, as well as whether the anticipated transaction is a manifestation of horizontal consolidation or vertical integration.

Horizontal consolidation is “the acquisition and consolidation of like organizations or business ventures under a single corporate management, in order to produce synergy, reduce redundancies and duplication of efforts or products, and achieve economies of scale while increasing market share.”

Vertical integration involves the joining of organizations that are fundamentally different in their product and/or services offerings, i.e., “the aggregation of dissimilar but related business units, companies, or organizations under a single ownership or management in order to provide a full range of related products and services.”

Healthcare Locality

As healthcare is essentially a local business, horizontal integration within the local market has been limited by antitrust laws. Therefore, in order to control greater market share, a hospital’s strategy has required vertical integration. Healthcare providers and organizations have placed much emphasis on the benefits of vertical system integration in the last 10 or more years, whereby a single healthcare organization owns all of the elements needed to provide a continuum of care for all the needs of a given patient population. Much of this effect has stemmed from the desire to be able provide a “continuum of care,” i.e., to be able to single source contract for the healthcare needs of a patient population and to profit from implementing preventative healthcare and utilization management measures. The relative economic benefits of this type of vertical integration versus horizontal integration strategies remain the subject of great debate in academia and among the strategic managers of other industries. One lesson that may be drawn from other industries is that neither of these forms of integration is universally applicable or beneficial to every organization and market. There are also great costs to integration, which must be outweighed by the benefits. Each specific benefit should be identified and researched when examining the probable effects of integration, consolidation, mergers or divestitures as a competitive strategy.

Rapid Consolidation Periods

During the rapid consolidation and integration of healthcare providers, insurers, and purchasers, in recent years, there was much discussion of a concept termed “managed competition.” This term appears to have been an outgrowth of the term “managed care” and was viewed by many as the logical result of the integration of healthcare markets nationally. The concept of “managed competition” apparently related to an idealized vision of competition between very large, integrated providers (organized into integrated delivery systems), large, national managed care payors, and purchasing group coalitions that could achieve a balance of power between these interacting groups. However, many believe that the result of such an arrangement would more likely be a reduction in competition between members of each of these three groups and the creation of powerful bureaucratic and intractable organizations. Further, this scenario does not appear to effectively remove any of the existing barriers to competition and therefore doesn’t introduce any additional incentives for innovation to produce value for consumers which, of course, is the “sine qua non” of competition.

Disadvantages

The disadvantages of integration are becoming apparent, including:

  • the loss of autonomy;
  • increased bureaucracy;
  • difficulty in aligning incentives; and
  • other failed expectations.

Many organizations that sought strategic advantage through integration are ending those arrangements and now divesting acquired organizations.

Other Industries

In other industries, specialized providers of goods and services are increasingly able to offer customers a full range of services through affiliation and affinity with other independent specialists, made more seamless through the use of increasingly sophisticated communications and computing technologies. However, this move to “dis-integration” must also be carefully considered if organizations are not to make further costly organizational changes inspired by a rushed judgment of general market trends.

Porter Speaks

Michael Porter (et al.) wrote in the Harvard Business Review that,

In industry after industry, the underlying dynamic is the same: competition compels companies to deliver increasing value to customers. The fundamental driver of this continuous quality improvement and cost reduction is innovation. Without incentives to sustain innovation in health care, short-term cost savings will soon be overwhelmed by the desire to widen access, the growing health needs of an aging population, and the unwillingness of Americans to settle for anything less than the best treatments available. Inevitably, the failure to promote innovation will lead to lower quality or more rationing of care — two equally undesirable results.

Assessment

Therefore, if the emerging healthcare industry is to respond successfully to the Affordable Care Act [ACA] and related market pressures to reduce costs, then the healthcare market must first create incentives for innovation. The barriers to competition cannot include barriers to innovation as many do now. Physicians, nurses, healthcare purchasers, managers, and legislators must ensure innovation takes the forefront of any reform, if it is to be effective.

Conclusion

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Barriers to Free Market Competition in Healthcare Delivery

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Why Supply and Demand Doesn’t Work in Medicine

By Dr. David Edward Marcinko; MBA

[Publisher-in-Chief]

Much has been written here, and elsewhere, about free market competition in healthcare; especially in light of the current national political debates. Yet, these markets are not free.

Like Evolution – Healthcare Competition is Only a Theory

Perfectly competitive healthcare markets are not free; they exist only in economic theory as a useful comparative artifice. In reality, industries and markets have varying constraints on competition. The healthcare industry has often been characterized as unique with its many significant barriers to free market competition, such as market controls on price and quality.

According to colleague Robert James Cimasi, of Health Capital Consultants LLC, in St. Louis MO; there are three main reasons for these barriers in healthcare:

Competitive Healthcare Barriers 

  1. The nature of healthcare creates an unpredictable, urgent, and “infinite” level of demand.
  2. The ubiquitous involvement of insurance companies, private and governmental, as intermediary organizations in the purchase of healthcare interferes with consumer motivations and consequently their choice of providers and services.
  3. The difficulties in measuring healthcare quality and beneficial outcomes (both of quantifying and qualifying them) and the lack of information on the relative costs of healthcare providers and services also inhibit consumer selection, further removing incentives to providers to increase quality and lower costs. 


Barriers to Healthcare Competition               

Included among the many other barriers to competition in healthcare delivery are the following:

  • Patients don’t purchase services directly from providers;
  • Patients don’t compare prices between providers;
  • The government is the largest purchaser of healthcare;
  • Private purchasers often lack market power;
  • Patients, purchasers and providers lack information;
  • Occupational licensing;
  • Many providers have monopoly or near-monopoly power (yet antitrust laws prevent some potentially beneficial integration);
  • Providers are rewarded for increasing costs;
  • Capital investments are overly subsidized (It should be noted that Stigler argues that an industry will not use its power to collect money from the government unless the list of beneficiaries can be limited, due to the fact the amount of subsidies will be divided among a growing number of rivals.*
  • Certificate of Need (CON), regulation, and licensing laws are an entry barrier to competing and substitute providers and services; and
  • Exit barriers protect low-quality providers.

Assessment

Of course, the supply side is also flagrantly encouraged by excessive medical testing, procedural interventions and surgery; mostly excused by malpractice phobia as a well as the personal financial interests of involved stakeholders.

References

Stigler, George J. “The Theory of Economic Regulation.” The Bell Journal of Economics and Management Science. Vol. 2, No. 1 (Spring 1971): 5.

Conclusion

Your thoughts and comments on this ME-P are appreciated. Feel free to review our top-left column, and top-right sidebar materials, links, URLs and related websites, too. Then, subscribe to the ME-P. It is fast, free and secure.

Speaker: If you need a moderator or speaker for an upcoming event, Dr. David E. Marcinko; MBA – Publisher-in-Chief of the Medical Executive-Post – is available for seminar or speaking engagements. Contact: MarcinkoAdvisors@msn.com

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