How to Participate in Collaborative Healthcare Without Violating Stark Law

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With the passing of the Affordable Care Act, American healthcare is shifting its focus from a reactive, acute- based treatment mentality, to a healthy- lifestyle and care-at-home approach.

Through the launch of several new programs including bundled payments and a long list of incentives for doctors and hospitals to minimize hospitalization and nursing home usage, the shift to caring for patients in their homes is well underway.

Among the emerging trends as a result of this shift are hospitals, traditionally the most influential entities in the delivery process, partnering not just with physicians and nursing homes, but also with wellness professionals, assisted living facilities, chiropractors, home health, and even nonmedical home care companies.

These partnerships and innovative new ventures are leading to ethical and legal questions that must be addressed with caution.

To be successful in a value-based care-model, which focuses on population health, it is imperative that providers disregard their philosophies of the past, which focused on caring for patients once they arrive at the hospital.

The goal is to develop a network of providers and partners whose primary focus is on educating and empowering individuals to live healthy lifestyles, and utilize technology that can help them prevent and avoid unnecessary hospitalization.

Needed precautions

With their focus on preventive care, chiropractors are a natural fit for this new collaborative approach. But they and other providers should be aware of legal roadblocks and take steps to ensure compliance.

A perfect example of the risks that can arise as these partnerships evolve are the Stark and anti-kickback laws. Stark law, named for Congressman Pete Stark, who sponsored the original legislation, is designed to prevent physician self-referrals. This is the practice of a doctor referring a patient to a hospital, nursing home, or other medical facility in which he or she has a financial interest—be it ownership, investment, or a structured compensation arrangement.

This is similar to the challenges chiropractors have had to work through to ensure transparency and accurate documentation of the care they provide related to workers’ compensation claims. Now hospitals and nursing homes are under increasing scrutiny to justify a patients’ need before admitting them.

When a patient is admitted who does not meet the criteria for needing care, the federal government not only withholds payment but in many cases invokes an additional penalty to the hospital or nursing home.

As an example of this punitive approach to institutionalized care, consider a chiropractor seeing a patient in the clinic after an auto accident, who then refers the patient to the hospital without contacting the patient’s physician or hospital in advance to alert them and discuss the appropriateness of an emergency department referral as opposed to other options.

This could lead to legal scrutiny (and possibly fines) for both the chiropractor and the hospital.

Hospitals are now subject to a penalty for unnecessary patient readmission. They would prefer a partnership with chiropractic offices in which there were open channels of communication and shared access to computer platforms and electronic medical records. This allows for discussion between physicians, caretakers, and providers that may allow the patient to avoid hospitalization.

Changing focus

The new focus on collaborative and community care presents opportunities for chiropractors and other wellness-focused providers—provided they participate in collaborative planning and abide by legal requirements under Stark and other regulations.

“It is imperative that providers and doctors engage in discussions with other community partners to enhance the care continuum as patient-centered care and population health become more of a reality,” says Nick Merkin, CEO of Compliagent, a healthcare consulting firm. “Hospitals, nursing homes, and doctors, including chiropractors, should seek legal advice and contract with a qualified healthcare attorney when negotiating any of these arrangements to enhance the care continuum.

“Violations of Stark and anti-kickback regulations are often accompanied by serious fines and consequences, which are avoidable when a qualified healthcare attorney is structuring the arrangement,” Merkin adds.

If you want to get involved in this community collaborative approach, the first step is to connect with a local hospital and medical group to identify the need. Once that need has been identified, seek a qualified attorney who is experienced in negotiating hospital and physician agreements.

This approach will continue to emerge in communities across the country to best meet the needs of population health and value-based care.”

 

josh-luke

Josh Luke, PhD, is an author, speaker, futurist, and healthcare expert. He is a USC professor who became a hospital CEO at age 32, and is the author of the new book Ex-Acute, A Former Hospital CEO Tells All on What’s Wrong with American Healthcare: What Every American Needs to Know. He can be contacted through joshluke.org.

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