OR Manager November/December 2021 - 14

OR business management
Continued from page 13
Payment for Care Improvement
Initiative
* episode payment models
* accountable care organizations
* clinically integrated networks
* population health
* value-based entities.
Long commented that
recently he
was talking with a group about their
accountable care organization, which
had $2.2 billion in savings in 2020.
" Basically, " he says, " this indicates that
we are seeing progress and involvement
with physicians, but there are still a
wide variety of opinions out there from
physicians and providers about how to
align financial incentives over time. "
Co-management agreements
Co-management agreements are contractual
relationships usually designed
around service lines. They have two
payment structures-fixed (hourly payments)
and variable (incentive payments).
In
the past, Long says, when considering
the fixed and variable, for example,
if it was worth a million dollars,
frequently it was a 60%-40% split or a
70%-30% split, where the higher percentage
was associated with the fixed
time, and the performance-based was
associated with the lower percentage.
The Stark physician self-referral law,
which was enacted by Congress in
1989 as the Ethics in Patient Referrals
Act (42 USC § 1395nn) would not allow
organizations to increase the performance-based
percentage beyond 40%.
Organizations now have the ability to
flip those percentages and associate
a higher percentage of the payment to
performance-based criteria, Long says.
When the Accountable Care Act went
through, it eliminated the rule that required
organizations to keep that percentage
on the lower side of the equation.
In
January 2021, an updated guidance
on the Stark self-referral and antikickback
statues, titled " Regulatory
Sprint to Coordinated Care, " went into
effect. It creates new, permanent exceptions
to the Stark law for value-based
arrangements, and the exceptions apply
to different populations of patients (ie,
Medicare patients).
" It looks at different populations and
how physicians are treating patients
within a certain population, as well as
what their incentives are to coordinate
and collaborate on care and to share access, "
says Long.
The immediate response was that
there was no way the government would
make such changes and everyone went
on an immediate pause, he says. However,
the guidelines that were produced
Steps in gainsharing
ended up being much greater than
expected.
OIG opinion-based agreements
More than 15 opinions have come from
the OIG that talk about gainsharing initiatives.
Many of them involve orthopedics,
neurosurgery, and cardiology, and
they are focused on supplies and drugs.
However, says Long, there are still
questions about whether these initiatives
have been approved. " There is
no specific legal document that says
gainsharing is free and clear. You have
to look at facts and circumstances and
follow specific guidelines. "
Long noted that there are six steps
in gainsharing, and that the steps
should loop around (sidebar, " Steps in
gainsharing " ).
The steps are:
* measure current cost and volumes
for savings baselines; establish
quality metrics
* identify and quantify waste reduction
and maximum savings opportunities
* prepare hospital, physician, and
third-party program administrator
contracts by group
* Sign
* develop a specific plan with physicians
to reduce costs
* provide quarterly performance reviews
and benchmarks-know how
much has been saved
* pay physicians at the end of the
program year
* Rebase.
Then start over with step one of measuring
cost and volumes.
Source: Pinnacle Healthcare Consulting. Used with permission.
14
OR Manager | Nov/Dec 2021
The OIG says organizations will have
to look at a rebasing scenario each
year and share savings up to 50%, says
Long. Not every organization that does a
gainsharing agreement shares all 50%,
however. Some do 40%, some do 30%,
and some do 20%, but this is still a
big opportunity for orthopedic, neurosurgery,
and cardiology supplies, he says.
Things an OIG gainsharing program
cannot do are:
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OR Manager November/December 2021

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