VALUATION: Medicare Advantage [Part C] Plans

Posted on June 15, 2023 by Dr. David Edward Marcinko MBA MEd CMP™

By Health Capital Consultants, LLC

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Valuation of MA Plans: Regulatory Environment

Healthcare provider organizations, including Medicare Advantage organizations (MAOs), face a range of federal and state legal and regulatory constraints, which affect their formation, operation, procedural coding and billing, and transactions.

CITE: https://www.r2library.com/Resource

This final installment of the three-part series on the valuation of Medicare Advantage (MA) plans will review the regulatory environment in which these plans operate. (Read more…)

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KAISER PERMANENTE: Acquires Geisinger Health

Posted on June 12, 2023 by Dr. David Edward Marcinko MBA MEd CMP™

By Health Capital Consultants, LLC

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On April 26, 2023, the California-based healthcare giant Kaiser Permanente announced a $5 billion “mega deal” to acquire Pennsylvania health system Geisinger Health. Kaiser also announced the formation of a new nonprofit health system, to be called Risant Health. Geisinger Health will be the first health system under the umbrella of Risant Health, although Kaiser aims to add approximately five more systems to the entity.

CITE: https://www.r2library.com/Resource

This Health Capital Topics article will review this mega deal and discuss what this transaction may mean for hospitals and health systems. (Read more…)

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Congress Mulling Medicare Site-Neutral Payment Policy

Posted on June 10, 2023 by Dr. David Edward Marcinko MBA MEd CMP™

By Health Capital Consultants, LLC

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Congress Mulling Medicare Site-Neutral Payment Policy

Congress is actively considering several bills related to site-neutral payment that has hospitals across the U.S. significantly concerned. The proposed legislation would lower the price that Medicare pays hospitals for common outpatient services, such as x-rays and general checkups, and match what it pays outpatient facilities such as physician offices. Facilities that are owned by hospitals (known as hospital outpatient departments, or HOPDs) earn more than twice what an independent outpatient facility earns for providing the same services.

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This Health Capital Topics article will review the changes that are being considered by Congress, as well as the responses from stakeholders. (Read more…)

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PUBLIC HEALTH EMERGENCY: Ends May 11th, 2023

Posted on May 11, 2023 by Dr. David Edward Marcinko MBA MEd CMP™

By Health Capital Consultants, LLC

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On January 30th, 2023, President Joseph Biden announced that the public health emergency (PHE) and national emergency declaration related to the COVID-19 pandemic will finally end on May 11, 2023, after being in place for over three years.

And so, this Health Capital Topics article will discuss the changes that will take place after both declarations cease, and the implications for stakeholders. (Read more…)

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UnitedHealth Group’s Physician Acquisition Efforts Accelerate

Posted on May 10, 2023 by Dr. David Edward Marcinko MBA MEd CMP™

By Health Capital Consultants, Inc

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On February 22, 2023, UnitedHealth Group’s (UHG’s) Optum division, the health insurance giant’s care delivery arm, acquired Crystal Run Healthcare, a New York based physician group of almost 400 physicians, nurse practitioners, and other providers

. CITE: https://www.r2library.com/Resource

This significant move is just the latest in UHG’s concerted effort over the past few years to acquire outpatient providers, surgery centers, and physician groups. This Health Capital Topics article will briefly survey some of the insurer’s recent acquisitions and initiatives to expand their physician services network. (Read more…)

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Supreme Court Justices Hear False Claims Act Case

Posted on May 2, 2023 by Dr. David Edward Marcinko MBA MEd CMP™

By Health Capital Consultants, LLC

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On April 18th, 2023, the U.S. Supreme Court heard oral arguments in two False Claims Act (FCA) cases, which cases center on the necessary state of mind needed to violate the FCA.

This Health Capital Topics article will review the oral arguments in the combined cases and how the justices seem posed to rule based on their questions and comments during the session. (Read more…)

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JUST IN: CA Doctor Settles FCA Allegations for $23.9 Million

A plastic surgeon in Beverly Hills, along with his son, and medical practices and billing company, have agreed to pay $23.9 million to resolve allegations that they violated the False Claims Act by submitting or causing the submission of false claims to both Medicare and Medicaid.

The civil settlement includes the resolution of claims brought under the qui tam, or whistleblower, provisions of the False Claims Act by parties who worked for the plastic surgeon (Dr. Aronowitz) and his associated medical practices and businesses. Whistleblowers include TDP, a billing company; Dr. Jason Morris, a podiatrist; and Harold Bautista, a billing department employee. Under the qui tam provisions, a private party can file an action on behalf of the government and receive a portion of any recovery.

Source: Sierra Sun Times [4/29/23]

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Corporate Moves in Healthcare Continue to Disrupt the Industry

Posted on April 12, 2023 by Dr. David Edward Marcinko MBA MEd CMP™

By Health Capital Consultants LLC

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Instead of waiting on regulatory reform, corporate America has sought to disrupt the healthcare industry over the last few years, by streamlining the delivery of healthcare (and associated costs) and taking advantage of technological advancements.

CITE: https://www.r2library.com/Resource/Title/0826102549

This entrepreneurial approach to problem-solving may provide meaningful competition to traditional healthcare organizations, which may result in higher quality, more affordable healthcare. Some of the biggest companies in the U.S. – CVS Health, Walgreens, Amazon, Walmart, and Best Buy – are expanding their healthcare empires through acquisitions and other strategic moves. (Read more…)

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Coordinated Actions Indicate Growing Scrutiny of Tele-Medicine

Posted on April 12, 2023 by Dr. David Edward Marcinko MBA MEd CMP™

By Health Capital Consultants, LLC

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GROWING SCRUTINY OF TELE-MEDICINE

On July 20, 2022, the Office of Inspector General (OIG) of the U.S. Department of Health & Human Services (HHS) released a Special Fraud Alert on telemedicine. On the same day, the U.S. Department of Justice (DOJ) announced a “nationwide coordinated law enforcement action” against 36 defendants, and the Centers for Medicare & Medicaid Services (CMS) Center for Program Integrity announced administrative actions against 52 providers, related to alleged telemedicine arrangements. These coordinated actions indicate a growing scrutiny of telemedicine arrangements by federal government regulators. (Read more...)

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Is the Return of Physician-Owned Hospitals Imminent?

Posted on April 4, 2023 by Dr. David Edward Marcinko MBA MEd CMP™

By Health Capital Consultants, LLC

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Is the Return of Physician-Owned Hospitals Imminent?

Recent congressional actions and a white paper authored by officials from the Department of Justice (DOJ), Federal Trade Commission (FTC), and the American Medical Association (AMA) are pushing for the removal of barriers for physician-owned hospitals (POHs), potentially paving a path by which these controversial facilities can be established and expanded going forward. (Read more…)

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VALUATION of Internal Medicine Services

Posted on March 11, 2023 by Dr. David Edward Marcinko MBA MEd CMP™

Valuation of Internal Medicine Services: Reimbursement

BY HEALTH CAPITAL CONSULTANTS, LLC

As noted in the first installment of this five-part series, internal medicine is the largest specialty among physicians and an understanding of the various environments in which these physicians operate is crucial in determining their numerous value drivers.

In particular, healthcare reimbursement, the process by which private health insurers and government agencies pay for the services of healthcare providers (including internists), is perhaps one of the most important environments to understand, as it comprises a provider’s expectation of future return on investment.

CITE: https://www.r2library.com/Resource/Title/0826102549

This installment will discuss the reimbursement of internal medicine services. (Read more…)

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FTC: Proposes Banning [Healthcare] Non-Compete Employment Contract Clauses

Posted on February 12, 2023 by Dr. David Edward Marcinko MBA MEd CMP™

By Health Capital Consultants, LLC

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FTC Proposes Banning Non-Compete Clauses

On January 5, 2023, the Federal Trade Commission (FTC) published a proposed rule that would ban employers from imposing non-competes on their employees. The FTC asserted that this practice is widespread and often exploitative, and such actions can suppress wages, hamper innovation, and block entrepreneurs from starting their own businesses. Notably, while the proposed rule will affect all industries, not just healthcare, this proposal comes at a time when healthcare employers across the U.S. are struggling with staffing shortages.

CITE: https://www.r2library.com/Resource/Title/0826102549

This Health Capital Topics article will discuss the proposed rule, reactions from healthcare industry stakeholders, and potential implications. (Read more…)

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2022 Healthcare M&As in Review

Posted on February 8, 2023 by Dr. David Edward Marcinko MBA MEd CMP™

INDICATIONS FOR 2023

By Health Capital Consultants LLC

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2022 M&A in Review: Indications for 2023

After a record year in 2021 transactional activity, where healthcare mergers and acquisitions (M&A) were up by 56%, the market continued to thrive in 2022. Preliminary results revealed that 2022 M&A deals hit a record high of 2,409 deals, 150 transactions over what was observed in 2021. Despite economic challenges (e.g., rising interest rates and borrowing costs, inflation, and labor costs), the healthcare transactional market has remained active.

CITE: https://www.r2library.com/Resource/Title/0826102549

This Health Capital Topics article will review the U.S. healthcare industry’s M&A activity in 2022, and discuss what these trends may mean for 2023. (Read more…)

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ADVISORY OPINION: Allows Nurse Practitioner Support in Hospitals

Posted on February 7, 2023 by Dr. David Edward Marcinko MBA MEd CMP™

NURSE PRACTITIONERS [NPs]

By Health Capital Consultants, LLC

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Advisory Opinion Allows Nurse Practitioner Support in Hospitals

On December 19, 2022, the Department of Health and Human Services (HHS) Office of Inspector General (OIG) published Advisory Opinion (AO) No. 22-20, analyzing the utilization of nurse practitioners (NPs) in lieu of attending physicians within medical units. The OIG concluded that the arrangement utilizing NPs in certain medical units, subject to several safeguards, presented a low risk for fraud or abuse.

CITE: https://www.r2library.com/Resource/Title/0826102549

As noted by legal experts, this AO deviates from OIG’s typical approach to limiting arrangements involving potential remuneration from a hospital to its referring physicians. (Read more…)

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MEDICAL PRIOR AUTHORIZATION: Proposed Modernization from CMS

Posted on December 30, 2022 by Dr. David Edward Marcinko MBA MEd CMP™

By Health Capital Consultants, LLC

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CMS Proposes Modernizing Prior Authorizations

On December 6, 2022, the Centers for Medicare & Medicaid Services (CMS) proposed a modernization of the prior authorization process for health insurance. The proposed rule seeks to require certain insurers to implement electronic prior authorization, shorten decision timeframes, and make the process more transparent and efficient.

CITE: https://www.r2library.com/Resource/Title/082610254

The rule includes “five key provisions and five Requests for Information,” aiming to “improve patient and provider access to health information and streamline processes related to prior authorization for medical items and services.” This Health Capital Topics article will review those provisions and requests for information, as well as stakeholder responses to the proposals. (Read more…)

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MEDICARE: Physician Payments Cuts?

Posted on December 27, 2022 by Dr. David Edward Marcinko MBA MEd CMP™

By Health Capital Consultants, LLC

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Congress Overrides Some – But Not All – Medicare Physician Payment Cuts

On December 20, 2022, the U.S. Congress announced its deal to fund the federal government through 2023, averting an imminent government shutdown. The 4,155-page, $1.7 trillion spending bill spans a vast array of funding initiatives and other bipartisan measures, including a number of noteworthy healthcare provisions.

CITE: https://www.r2library.com/Resource/Title/082610254

Perhaps most significantly, Congress intervened in the impending cuts to the Medicare Physician Fee Schedule (MPFS), overriding some, but not all, of the payment reductions. This Health Capital Topics article will discuss the congressional measures to ameliorate the payment cuts to physicians in 2023, as well as the other healthcare provisions included in the omnibus spending bill. (Read more…)

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HEALTHCARE SPENDING: Exorbitant in 2020 due to COVID-19

Posted on December 12, 2022 by Dr. David Edward Marcinko MBA MEd CMP™

By Health Capital Consultants, LLC

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Exorbitant Healthcare Spending in 2020 due to COVID-19

On December 15, 2021, the Centers for Medicare & Medicaid Services (CMS) released a report detailing healthcare spending in the U.S. in 2020, which confirmed the outsized impact the COVID-19 pandemic has had on the nation’s healthcare industry and on federal spending. Overall, healthcare spending increased 9.7% in 2020 (to $4.1 trillion), double the 2019 increase of 4.3%. Healthcare spending also became a larger share of the U.S. gross domestic product (GDP) in 2020. This Health Capital Topics article will review the notable findings included in CMS’s report. (Read more…)

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AMAZON: Healthcare Act II

Posted on December 1, 2022 by Dr. David Edward Marcinko MBA MEd CMP™

By Heath Capital Consultants, LLC

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The launch of Amazon Clinic comes less than two months after the announcement that Amazon Care would be shut down. Amazon Clinic, the retail giant’s virtual and in-person medical care service, was rolled out in 2019 as a pilot employee benefit for their own employees and quickly expanded to servicing non-Amazon employers across the U.S. (including large companies such as Hilton, TrueBlue, and Silicon Labs) by 2021.

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The service combined virtual and in-person care, offering home health services, telehealth appointments, and prescription delivery. (Read more…)

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PHARMA: Will Americans Finally See Drug Prices Decrease?

Posted on November 4, 2022 by Dr. David Edward Marcinko MBA MEd CMP™

By Health Capital Consultants, LLC

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According to the White House, “Americans pay two to three times as much as people in other countries for prescription drugs, and one in four Americans who take prescription drugs struggle to afford their medications. Nearly 3 in 10 American adults who take prescription drugs say that they have skipped doses, cut pills in half, or not filled prescriptions due to cost.” In an effort to combat this growing crisis, both the federal government and private companies have taken a number of steps over the past year aiming to lower drug prices. This Health Capital Topics article will review those actions and the potential unintended consequences of these actions.

(Read more…)

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HEALTH INSURANCE: Non-Traditional Players & Disruptors

Posted on November 2, 2022 by Dr. David Edward Marcinko MBA MEd CMP™

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By Health Capital Consultants

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Non-Traditional Players Moving into the Insurance Space

In the past two months, two retail giants – Walmart and Apple – have announced plans to enter the health insurance space. This direct entry into the health insurance market by non-traditional players has been encouraged in part by health insurer-retailer partnerships, which gained traction due to rising demand for Medicare Advantage (MA) in particular and the expansion of the types of benefits that MA plans may offer.

This Health Capital Topics article will discuss reasons behind the insurer-retailer partnerships and how Walmart and Apple plan to disrupt the health insurance market.(Read more…)

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What is a Medical OBL?

Posted on October 22, 2022 by Dr. David Edward Marcinko MBA MEd CMP™

Office Based Laboratories

By Health Capital Consultants, LLC

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DEFINITION: OBLs, also known as office-based endovascular centers, access centers, or office interventional suites, are physician offices wherein a number of services are offered.

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Similar to ASCs, OBLs can be single specialty or multi-specialty and can have a number of ownership structures. However, unlike ASCs, OBL procedures (because they are located in a physician office) are reimbursed under the Medicare Physician Fee Schedule.

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OBLs are typically operated and utilized by vascular surgeons, interventional radiologists, cardiologists, or other specialists, and services provided include: cardiovascular, endovascular, venous, and non-vascular services; cardiac procedures, such as diagnostic coronary angiograms, coronary stenting, electro physiology services; device implants, including pacemakers, defibrillators, loop recorders, and biventricular pacers; lower extremity endovascular revascularizations, such as chronic total occlusion and complex limb salvage procedures; renal and mesenteric revascularizations; and, subclavian stenting.23 Of these procedures, peripheral vascular intervention, cardiac services, and interventional radiology made up the majority of the OBL market share in 2019.

While slower to materialize than ASCs, OBLs have increased rapidly over the past few years, for reasons similar to ASCs, e.g., opportunities for physician ownership, the “expedient patient experience” and “favorable outpatient procedural reimbursement.”

In 2020, the global OBL market was valued at $9 billion. Similar to ASCs, an increasing focus on outpatient procedures (due to their cost-saving potential)

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VALUATION: Clinic and Medical Practice Worth

Posted on October 10, 2022 by Dr. David Edward Marcinko MBA MEd CMP™

Plastic Surgery Proto-Type

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[Medical Practice Worth, Valuation, Sales and Succession Planning]

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MSSP: Performance Results Indicate Another Successful Year

Posted on October 3, 2022 by Dr. David Edward Marcinko MBA MEd CMP™

By Health Capital Consultants, LLC

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MSSP Performance Results Indicate Another Successful Year

On August 30, 2022, the Centers for Medicare & Medicaid Services (CMS) released the financial and quality performance results for the Medicare Shared Savings Program (MSSP) Performance Year (PY) 2021.

The results revealed net savings of $1.66 billion for Medicare, marking the fifth consecutive year of savings. In total, 58% of MSSP accountable care organizations (ACOs) achieved savings as a result of their performance. This Health Capital Topics article will discuss the 2021 performance results, which are being released on the eve of seismic changes to the MSSP. (Read more…)

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SPAC Popularity Soaring in Healthcare

Posted on September 21, 2022 by Dr. David Edward Marcinko MBA MEd CMP™

By Health Capital Consultants, LLC

Todd A. Zigrang, MBA, MHA, FACHE, CVA, ASA

[President]

The popularity of special purpose acquisition companies (SPACs) has been soaring in recent years. There are 35 times as many SPACs operating in 2020 as in 2010, and these companies seem poised for greater exponential growth in the future.

While many experts are predicting a continued, rapid increase in SPACs, this article will also examine the factors that could possibly slow SPAC growth and diminish their future prospects. SPACs span several market areas, including biotechnology and healthcare; this article will review SPAC trends generally as well as healthcare SPACs in particular. (Read more…)

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More About the End of AMAZON CARE!

Posted on September 6, 2022 by Dr. David Edward Marcinko MBA MEd CMP™

By Health Capital Consultants, LLC

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The End of Amazon Care: A Setback in Amazon’s Healthcare Experiment?

On August 24, 2022, Amazon announced its plans to shut down Amazon Care at the end of 2022. The e-commerce giant determined that Amazon Care, a medical care service it uses internally and sells to employer health plans, was not the “right long-term solution for [Amazon’s] enterprise customers” because it is not a “complete enough offering for the large enterprise customers [Amazon has] been targeting.”

This Health Capital Topics article will discuss the history of Amazon Care and what this move may mean for Amazon’s larger healthcare efforts. (Read more…)

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DICTIONARY: Health Economics and Finance

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Valuation of Remote Therapeutic Monitoring [Reimbursement Environment]

Posted on September 2, 2022 by Dr. David Edward Marcinko MBA MEd CMP™

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By Health Capital Consultants, LLC

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VALUATIONS

Valuation of Remote Therapeutic Monitoring: Reimbursement Environment

The U.S. government is the largest payor of medical costs, through Medicare and Medicaid, and has a strong influence on physician reimbursement. In 2020, Medicare and Medicaid accounted for an estimated $829.5 billion and $671.2 billion in healthcare spending, respectively.

The prevalence of these public payors in the healthcare marketplace often results in their acting as a price setter, and being used as a benchmark for private reimbursement rates. (Read more…)

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DICTIONARY: Health Economics and Finance

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FTC Discourages Healthcare COPA Laws

Posted on September 1, 2022 by Dr. David Edward Marcinko MBA MEd CMP™

By Health Capital Consultants, LLC

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FTC Discourages Certificates of Public Advantage Laws

On August 15, 2022, the Federal Trade Commission (FTC) published a policy paper and fact sheet regarding the use of Certificates of Public Advantage laws (COPAs) by states in regulating healthcare mergers. Specifically, the FTC asserts that COPAs can negatively impact healthcare costs, quality of care, and hospital staff wages.

This Health Capital Topics article will discuss the policy paper and how this publication appears to fit in with the FTC’s recent moves to increase competition in healthcare.(Read more…)

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Filed under: "Doctors Only", Experts Invited, Health Insurance, Health Law & Policy, Healthcare Finance | Tagged: COPA, COPA Laws, FTC, Health Capital Consultants LLC | Leave a comment »

CMS Issues 2023 Physician Fee Schedule Proposed Rule

Posted on August 5, 2022 by Dr. David Edward Marcinko MBA MEd CMP™

PHYSICIAN REIMBURSEMENT

CMS Issues 2023 Physician Fee Schedule Proposed Rule

On July 7, 2022, the Centers for Medicare & Medicaid Services (CMS) released its proposed Medicare Physician Fee Schedule (MPFS) for calendar year (CY) 2023. Arguably the most noteworthy provision in the proposed rule is the agency’s suggested cut to physician payments. However, the rule also includes a number of other policy proposals, including changes to Medicare accountable care organizations (ACOs), behavioral health care, cancer screening, and dental care. (Read more…)

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Biden Administration to Overhaul Vertical [Health Systems] Merger Guidelines

Posted on July 20, 2022 by Dr. David Edward Marcinko MBA MEd CMP™

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By Health Capital Consultants, LLC

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Biden Administration to Overhaul Vertical Merger Guidelines

The U.S. healthcare industry has seen a rise in vertical integration transactions since the passage of the ACA, especially among physician groups integrating with health systems or insurers, as providers seek to fill gaps in their continuum of care. In response to these trends and resulting market imbalances, the Biden Administration is aggressively pursuing antitrust enforcement by updating and revising U.S. antitrust law guidance.

This Health Capital Topics article will discuss the vertical integration movement and the proposed changes to antitrust laws that may affect the future of healthcare. (Read more…)

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CITE: https://www.r2library.com/Resource/Title/0826102549

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FTC Scrutiny Results in Several Scrapped Hospital Deals

Posted on July 8, 2022 by Dr. David Edward Marcinko MBA MEd CMP™

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By Health Capital Consultants, LLC

FTC Scrutiny Results in Several Scrapped Hospital Deals

A series of Federal Trade Commission (FTC) challenges to hospital mergers and acquisitions in 2022 indicates heightened regulatory scrutiny of hospital deals. Perhaps emboldened by the July 2021 executive order that focused attention on antitrust enforcement of hospital consolidation, the agency has voted to challenge a number of transactions, which has lead hospitals to call off the deals rather than challenge the government.

This Health Capital Topics article reviews three of the largest transactions called off this year, two of which were announced in June. (Read more…)

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VALUATION: Home Health Agencies [Technological Environment]

Posted on July 4, 2022 by Dr. David Edward Marcinko MBA MEd CMP™

By Health Capital Consultants, LLC

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Valuation of Home Health Agencies: Technological Environment

With home healthcare providers increasingly being viewed as a critical link in the array of patient-centered healthcare services aimed to bring care back into the community, technology will likely play a more prominent role in managing patient populations in need of home healthcare services.

CITE: https://www.r2library.com/Resource/Title/082610254

The final installment of this five-part series on the valuation of home health agencies (HHAs) will discuss the growing role of technology in home healthcare and the challenges of utilizing this technology post-COVID-19. (Read more…)

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SUPREME COURT: Rules Against HHS Drug Pricing [340-B] Program

Posted on June 26, 2022 by Dr. David Edward Marcinko MBA MEd CMP™

By Health Capital Consultants, LLC

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U.S. Supreme Court Rules Against HHS in 340B Case

On June 15, 2022, the U.S. Supreme Court released its decision regarding the cuts made by the Department of Health and Human Services (HHS) to the 340B Drug Pricing Program, finding that HHS acted outside its statutory authority in changing reimbursement rates for one group of hospitals without first surveying them on their costs.

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BUSINESS MANAGEMENT STUDY: Physician Vertical Integration

Posted on June 9, 2022 by Dr. David Edward Marcinko MBA MEd CMP™

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BY HEALTH CAPITAL CONSULTANTS, LLC.

DEFINITION: Vertical integration is an arrangement in which the supply chain of a company is integrated and owned by that company. Usually each member of the supply chain produces a different product or service, and the products combine to satisfy a common need.

CITE: https://www.r2library.com/Resource/Title/0826102549

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Study: Vertical Integration Not Financially Beneficial for Physicians

A study released in the December 2021 issue of Health Affairs examined the correlation between hospital/health system ownership of physician practices and physician compensation. While a number of studies have analyzed the “rapidly growing trend” of vertical integration from the hospital/health system perspective, this is the first study to evaluate vertical integration from the physician practice perspective.

This Health Capital Topics article will discuss the study’s findings and potential implications. (Read more…)

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Filed under: "Doctors Only", Breaking News, Career Development, Experts Invited, Glossary Terms, Health Economics, Health Insurance, Healthcare Finance, Managed Care, Practice Management | Tagged: Health Affairs, Health Capital Consultants LLC, Medical Vertical Integration, physician compensation, Physician Vertical Integration, Vertical Integration | Leave a comment »

The GAP between Medicare and Commercial Hospital Prices

Posted on May 12, 2022 by Dr. David Edward Marcinko MBA MEd CMP™

THE GAP INCREASES!

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By Health Capital Consultants, LLC

Gap between Medicare and Commercial Hospital Prices Increases

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A recent study examined the growth in hospital prices paid by commercial health insurance companies compared to Medicare over a seven-year period and found that commercial health plan rates were, on average, 180% higher than Medicare rates as of 2019.

While the national ratio between commercial and Medicare hospital payment growth rates remained relatively stable during the seven-year study period, ratios varied widely on a regional basis. This Health Capital Topics article will discuss this recent study and its implications. (Read more…)

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Filed under: Accounting, Experts Invited, Health Economics, Health Insurance, Healthcare Finance | Tagged: GAP between Medicare and Commercial Hospital Prices, Health Capital Consultants LLC, hospital prices, medicare | 1 Comment »

Valuation of Home Health Agencies [The Reimbursement Environment]

Posted on May 1, 2022 by Dr. David Edward Marcinko MBA MEd CMP™

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By Health Capital Consultants, LLC

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Valuation of Home Health Agencies: Reimbursement Environment

The U.S. government is the largest payor of medical costs, through Medicare and Medicaid, and has a strong influence on reimbursement for home healthcare services. In 2020, Medicare and Medicaid accounted for an estimated $829.5 billion and $671.2 billion in healthcare spending, respectively. The outsized prevalence of these public payors in the healthcare marketplace often results in their acting as a price setter, and being used as a benchmark for private reimbursement rates. This effect may be even stronger in the home health industry.

The third installment of this home health valuation series will discuss the reimbursement environment in which these organizations operate. (Read more…)

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CITE: https://www.r2library.com/Resource/Title/0826102549

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Filed under: "Doctors Only", Ethics, Experts Invited, Glossary Terms, Health Economics, Health Insurance, Health Law & Policy, Healthcare Finance | Tagged: Health Capital Consultants LLC, home health, home health agencies, Medicaid, medicare | Leave a comment »

DOJ Recoveries for False Claims Act Cases Doubled in 2021

Posted on March 28, 2022 by Dr. David Edward Marcinko MBA MEd CMP™

BY HEALTH CAPITAL CONSULTANTS, LLC.

DEFINITION: The False Claims Act, also called the “Lincoln Law”, is an American federal law that imposes liability on persons and companies who defraud governmental programs. It is the federal Government’s primary litigation tool in combating fraud against the Government. The law includes a provision that allows people who are not affiliated with the government, called “relators” under the law, to file actions on behalf of the government. Persons filing under the Act stand to receive a portion of any recovered damages.

CITE: https://www.r2library.com/Resource/Title/0826102549

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DOJ Recoveries for False Claims Act Cases Doubled in 2021

On February 1, 2022, the U.S. Department of Justice (DOJ) announced their recovery of $5.6 billion in settlements and judgments from civil cases involving fraud and false claims for fiscal year (FY) 2021. Over $5 billion was recouped from the healthcare industry for federal losses alone, and included recoveries from drug and medical device manufacturers, managed care providers, hospitals, pharmacies, hospice organizations, laboratories, and physicians.

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This figure is more than double the amount of healthcare-related recoveries secured in FY 2020, which totaled $1.8 billion. (Read more…)

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Most Physician Compensation Plans Still Productivity-Based

Posted on March 15, 2022 by Dr. David Edward Marcinko MBA MEd CMP™

By Health Capital Consultants, LLC

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Study: Most Physician Compensation Plans Still Productivity-Based

A study conducted by the RAND Corporation and published in the January 2022 issue of the Journal of the American Medical Association (JAMA) seeking to determine whether health systems primarily incentivize volume or value in their physician compensation models found that almost all physicians are still compensated through a volume-based model that rewards productivity over the value of care provided.

CITE: https://www.r2library.com/Resource/Title/0826102549

These study results are in direct contradiction to the longstanding narrative that the U.S. healthcare delivery system is shifting away from volume-based reimbursement and toward VBR. (Read more…)

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Filed under: "Doctors Only", Career Development, Experts Invited, Glossary Terms, Health Economics, Healthcare Finance | Tagged: ACO, AMA, doctor pay, Health Capital Consultants LLC, physician compensation, physician pay, Physician Productivity Pay, physician salary, Rand, VBR | Leave a comment »

Healthcare Industry Hit with the Great Resignation & Retirement

Posted on March 8, 2022 by Dr. David Edward Marcinko MBA MEd CMP™

Healthcare Industry Hit with the Great Resignation & Retirement

BY HEALTH CAPITAL CONSULTANTS, LLC

The COVID-19 pandemic has served as a catalyst for two current healthcare workforce trends: the Great Retirement and the Great Resignation.

CITE: https://www.r2library.com/Resource/Title/0826102549

While the Great Resignation among physicians and other clinicians has been well reported, a potential onslaught of retirements by senior executives may further impact hospitals and health systems at an already precarious time.

This Health Capital Topics article will discuss some of the key challenges and issues surrounding healthcare’s Great Retirement and Great Resignation. (Read more…)

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Risk Management, Liability Insurance, and Asset Protection Strategies for Doctors and Advisors : Best Practices from Leading Consultants and Certified Medical Planners™ book cover

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HEALTHCARE: 2021 M&A in Review

Posted on February 27, 2022 by Dr. David Edward Marcinko MBA MEd CMP™

Indications for 2022

BY HEALTH CAPITAL CONSULTANTS, LLC

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2021 M&A in Review: Indications for 2022

After an understandable slowdown in 2020, due to the onset of the COVID-19 pandemic, merger & acquisition (M&A) activity in the healthcare industry accelerated in 2021, and the industry is expected to continue the high number of deals and high deal volume in 2022.

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This Health Capital Topics article will review the U.S. healthcare industry’s M&A activity in 2021, and discuss what these trends may mean for 2022. (Read more…)

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CITE: https://www.r2library.com/Resource/Title/0826102549

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MedPAC: Recommends Payment Updates for 2023

Posted on February 13, 2022 by Dr. David Edward Marcinko MBA MEd CMP™

Medicare Payment Advisory Commission

By Health Capital Consultants, LLC

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MedPAC Recommends Payment Updates for 2023

DEFINITION: The Medicare Payment Advisory Commission is an independent, non-partisan legislative branch agency headquartered in Washington, D.C. MedPAC was established by the Balanced Budget Act of 1997.

CITE: https://www.r2library.com/Resource/Title/082610254

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In a January 2022 meeting of MedPAC, commissioners reviewed various recommendations related to the Medicare fee schedule for various health sectors, and unanimously agreed to update Medicare payments to hospitals and keep physician payment rates the same for 2023. This Health Capital Topics article will review the recommendations made by MedPAC for each of the health sectors and their respective payment systems. (Read more…)

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Supreme Court Hears Oral Arguments on 340B Drug Pricing Cuts

Posted on January 19, 2022 by Dr. David Edward Marcinko MBA MEd CMP™

BY HEALTH CAPITAL CONSULTANTS, LLC

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Supreme Court Hears Oral Arguments on 340B Cuts

On November 30, 2021, the U.S. Supreme Court heard oral arguments regarding the challenges arising from the cuts made by the Centers of Medicare & Medicaid Services (CMS) to the 340B Drug Pricing Program.

The 340B Drug Pricing Program allows hospitals and clinics that treat low-income, medically underserved patients to purchase certain “specified covered outpatient drugs” at discounted prices (applying a ceiling to what drug manufacturers may charge certain healthcare facilities) – 25% to 50% of what providers would typically pay – and then receive reimbursement pursuant to the rates set forth in the Outpatient Prospective Payment System (OPPS) at the same rate as all other providers. (Read more…)

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HEALTH ECONOMICS CITE: https://www.r2library.com/Resource/Title/0826102549

PODCAST: https://medicalexecutivepost.com/2021/08/27/podcast-hospital-340-b-drug-programs/

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New Study Compares Medicare-Commercial Payment Gaps by Specialty

Posted on December 14, 2021 by Dr. David Edward Marcinko MBA MEd CMP™

New Study Compares Medicare-Commercial Payment Gaps by Specialty

BY HEALTH CAPITAL CONSULTANTS

Utilizing data from FAIR Health, the Urban Institute conducted an October 2021 study which reviewed commercial insurance claims across the U.S. (for approximately 60 insurers and third-party administrators covering over 150 million Americans under age 65) from March 2019 through February 2020.

CITE: https://www.r2library.com/Resource/Title/0826102549

This study assessed the gap between commercial insurance payments and Medicare payments for professional physician services to determine whether the payment gap between Medicare and commercial insurance differs by specialty. (Read more…)

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Filed under: Breaking News, Career Development, Experts Invited, Health Insurance, Health Law & Policy, Healthcare Finance | Tagged: CMS, Health Capital Consultants LLC, medical payment gaps specialty, medicare, medicare commercial payments | 1 Comment »

VALUATION of Internal Medicine Services

Posted on November 27, 2021 by Dr. David Edward Marcinko MBA MEd CMP™

Valuation of Internal Medicine Services: Reimbursement

BY HEALTH CAPITAL CONSULTANTS, LLC

CITE: https://www.r2library.com/Resource/Title/0826102549

This installment will discuss the reimbursement of internal medicine services. (Read more…)

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Healthcare Costs Projected to Grow in 2022

Posted on October 29, 2021 by Dr. David Edward Marcinko MBA MEd CMP™

Healthcare Costs Projected to Grow in 2022

A June 2021 PricewaterhouseCoopers (PwC) report found that healthcare costs have been on a steady decline for the past decade, but trailing effects from the COVID-19 pandemic could cause increases above anticipated rates over the next several years.

In 2007, the annual cost growth for healthcare spending was 11.9% and declined steadily until 2017, where it floated between 5.5% and 6.0% until 2020. However, projected healthcare cost growth for 2022 is expected to reach 6.5% due to factors such as deferred or forgone care, increased mental health issues, preparation for future pandemics, and investment in digital tools. (Read more...)

ASSESSMENT: Your thoughts are appreciated.

Citation: https://www.r2library.com/Resource/Title/0826102549

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Filed under: Experts Invited, Glossary Terms, Health Economics, Health Insurance, Health Law & Policy, Healthcare Finance | Tagged: Health Capital Consultants LLC, health care costs, Healthcare Costs Grow in 2022, PwC | 1 Comment »

Benefits of Healthcare Participation in Multiple Medical Payment Models

Posted on October 11, 2021 by Dr. David Edward Marcinko MBA MEd CMP™

BY HEALTH CAPITAL CONSULTANTS, LLC

New Research Explores Benefits of Participation in Multiple Payment Models

An August 2021 study published in the Journal of the American Medical Association (JAMA) analyzed medical and surgical episodes of care in U.S. hospitals to determine whether outcomes differed in hospitals that participated in Medicare’s Bundled Payments for Care Improvement (BPCI) Initiative depending on whether the patient being treated was attributed to a Medicare Shared Savings Program (MSSP) accountable care organization (ACO).

This Health Capital Topics article will discuss the study’s findings and potential policy implications. (Read more…)

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Comprehensive Financial Planning Strategies for Doctors and Advisors: Best Practices from Leading Consultants and Certified Medical Planners™

ORE: https://www.routledge.com/Comprehensive-Financial-Planning-Strategies-for-Doctors-and-Advisors-Best/Marcinko-Hetico/p/book/9781482240283

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ANNUAL FINANCIAL STATEMENT REPORTS: Health Insurance Companies

Posted on October 5, 2021 by Dr. David Edward Marcinko MBA MEd CMP™

FOR PHYSICIAN INVESTORS

By David Belk MD

Health Insurance Company Financial Index

Below is a listing of the Nine largest for-profit health insurance Companies. The Annual financial statements are linked to the year for each Company and a four page summary report is linked to the name of the health insurance company at the top of the listing.

CITE: https://www.r2library.com/Resource/Title/0826102549

The relevant pages in each financial statement I used to prepare my summaries are listed next to each year’s statement. Aetna and Coventry’s summaries are combined because they merged in 2012. Health Net also Merged with Centene in 2016 leaving only seven major health insurance companies.

A composite summary for the data for all eight companies is here

Composite Data Table

Click on the name of the health insurance company to open the accordion and view the financial statements.

LINK: https://truecostofhealthcare.org/health-insurance-financial-index/

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Tele-Health Financial Expansion

Posted on September 28, 2021 by Dr. David Edward Marcinko MBA MEd CMP™

BY HEALTH CAPITAL CONSULTANTS, LLC

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Additional $20 Million Directed to Rural Telehealth Expansion

It has been well documented that the COVID-19 pandemic resulted in unprecedented increases in telemedicine utilization across the U.S. However, rural providers and patients, as evidenced by their lower rates of telemedicine usage during this time, have not been able to take advantage of the opportunities provided by telemedicine to the same extent as urban providers.

On August 18, 2021, the Health Resources and Services Administration (HRSA) of the Department of Health and Human Services (HHS) announced the latest attempt to ameliorate this issue – the distribution of nearly $20 million to 36 recipients for the purpose of strengthening telehealth services in rural and underserved communities and expanding innovation and quality. (Read more…)

CITE: https://www.r2library.com/Resource/Title/0826102549

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Study Finds COVID-19 Accelerated Physician Practice Acquisitions

Posted on September 1, 2021 by Dr. David Edward Marcinko MBA MEd CMP™

Study Finds COVID-19 Accelerated Physician Practice Acquisitions

By Health Capital Consultants, LLC

A recent study from Physicians Advocacy Institute (PAI), prepared by Avalere Health, associated the growing number of both physician practice acquisitions and employed physicians between 2019 and 2021 with the COVID-19 pandemic.

To study COVID-19’s impact on physician employment trends, the June 2021 study evaluated the IQVIA OneKey database that contains physician practice and health system ownership information.

To assess these trends at a national and regional level, Avalere researchers studied the two-year period from January 1, 2019 to January 1, 2021. (Read more…)

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Filed under: Breaking News, Experts Invited, Funding Basics, Health Economics, Health Insurance, Health Law & Policy, Healthcare Finance | Tagged: Avalere Health, covid, Health Capital Consultants LLC, IQVA One Key, PAI, pandemic, Physician Practice Acquisitions, PPMC | Leave a comment »

PODCAST: Stark and AKS Final Rules

Posted on August 28, 2021 by Dr. David Edward Marcinko MBA MEd CMP™

ANTI-KICKBACK STATUTE Overview and Impact

Do you want to learn more about the Stark Law and Anti-Kickback Statute Final Rules and how they impact your practice? Join us for a one-hour webinar, presented with Hancock Daniel.

By Health Capital Consultants, LLC

PODCAST: https://www.healthcapital.com/resources/stark-and-aks-final-rules-overview-and-impact

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Filed under: "Advisors Only", "Doctors Only", Accounting, Ethics, Experts Invited, Health Economics, Health Insurance, Health Law & Policy, Healthcare Finance, Videos | Tagged: Anti-Kickback Statute, Hancock Daniel, Health Capital Consultants LLC, Stark laws | Leave a comment »

Bundled Payment Model Success Unaffected by Type of Participation

Posted on August 27, 2021 by Dr. David Edward Marcinko MBA MEd CMP™

BY HEALTH CAPITAL CONSULTANTS, LLC

Bundled Payment Model Success Unaffected by Type of Participation

Historically, Medicare has offered value-based payment models to healthcare organizations on both a voluntary and a mandatory participation basis. Because voluntary participants could self-select into programs to reduce spending, it was assumed that they achieved greater savings than mandated participants, but until recently, no data had tested this.

However, a June 2021 study in the Journal of the American Medical Association (JAMA) found no difference in risk-adjusted episodic spending between voluntary and mandatory payment model participants. (Read more…)

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Filed under: "Doctors Only", Accounting, Experts Invited, Health Economics, Health Insurance, Health Law & Policy, Healthcare Finance | Tagged: Accountable Care Organizations, ACOs, Bundled Medical Payments, capitation, Health Capital Consultants LLC, JAMA, value based care, VBC | Leave a comment »

CMS Releases 2022 Physician Fee Schedule Proposed Rule

Posted on August 9, 2021 by Dr. David Edward Marcinko MBA MEd CMP™

CMS RELEASES CY 2022 Physician Fee Schedule Proposed Rule

On July 13, 2021, the Centers for Medicare & Medicaid Services (CMS) released its proposed Medicare Physician Fee Schedule (MPFS) for calendar year (CY) 2022.

CITE: https://www.r2library.com/Resource/Title/0826102549

In addition to numerous payment updates in the MPFS, such as significant updates to the Merit-based Incentive Payment System (MIPS), new policies may preserve expanded telemedicine services through 2023 and clinicians may incur more difficulty earning bonuses under the Quality Payment Program (QPP) eligibility threshold. CMS also includes in the proposed rule a request for information to address COVID-19 vaccine reimbursement proposals. (Read more...)

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Filed under: "Doctors Only", Experts Invited, Health Economics, Health Law & Policy, Healthcare Finance | Tagged: CMS, Health Capital Consultants LLC, Medicare Physician Fee Schedule, MIPS, MPFS, Physician Fee Schedule, QPP, quality payment program, teleHealth | Leave a comment »

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