Health Care Reform

Improving the quality of health care services delivered and reducing the cost of such services must be among the primary goals of health care reform. At first blush, these goals may seem incompatible, but a proposal currently pending before the United States Senate includes provisions that would reform the health care delivery system through the use of accountable health care organizations (“ACOs”). Accordingly, the purpose of this article is to explain how ACOs could operate and to encourage our health care provider clients to focus on this potential linchpin of the reform of our health care system.

 Over the past several years, the government has recovered billions of dollars from pharmaceutical companies for alleged fraud and abuse activities, such as off-label promotion, anti-kickback violations, and false claims for government reimbursement. The emphasis on health care reform and new legislation expanding government resources to combat fraud and abuse likely means more scrutiny over the pharmaceutical industry and an increase in similar fraud and abuse cases.

In May 2009, identical legislation was introduced in the Senate and the House of Representatives proposing to increase the number of Medicare-supported residency positions across the United States by 15%, or approximately 15,000 positions. The bill also proposes changes in the distribution of currently available positions and encourages the creation of new positions in primary care and general surgery programs. In preparation for such legislation, all institutions sponsoring graduate medical education programs must have a strategic vision for the size and mix of their current and future residency programs.

On February 24, 2010, the House of Representatives voted overwhelmingly to remove the exemption from federal antitrust laws granted to health insurers by the McCarran-Ferguson Act.  Despite the lopsided vote (406 to 19, with most Republicans joining all Democrats), the measure’s prospects in the Senate were described as “uncertain.”

The “medical home” model of patient care has been the subject of much attention in recent years, as many experts believe it has the potential to simultaneously reduce the cost of health care and improve the overall health and well-being of patients.
The foundation of the medical home model is the primary care physician, who is responsible for coordinating all aspects of an integrated treatment plan for patients with chronic conditions, from ordering laboratory tests to seeking consults from subspecialists. Proponents of the medical home model believe that centralization of care will substantially reduce the ordinary expenses incurred under the fragmented patient care system that currently exists in America. Under the existing American patient care model, patients typically visit several different physicians, hospitals, and specialists throughout their lives, often resulting in expensive and unnecessary duplicative tests, and even more seriously, in contraindicated medications and treatments. The theory behind the medical home model is that by providing a central base, or “home,” for the coordination of patient care, doctors can improve rapport and relationships with patients as well as prevent unnecessary visits to the emergency room or hospital.