How True Clinical Integration Of Hospitals And Physicians Is Impacted By The Federal Trade Commission Policy Statements

The PHO served as a vehicle through which competing hospitals and physicians could bargain collectively with health plans to obtain higher fees for themselves. The owner PHOs, member hospitals, and member physicians canceled contracts with payors and informed them that the PHO would be the sole entity through which they would enter into payor contracts. To contract with the PHO, payors allegedly have had to accept the fixed physician fee schedule and fixed discount of no more than 10 percent off hospital list prices.

In the hope of better coordinating the care of patients, improving quality and lowering costs, the ACA provides incentives for physicians and hospitals to work together in several ways, such as Accountable Care Organizations (ACO’s) or establishing bundled payments for episodes of care (Martin Gaynor, 2012 ) which has spurred consolidation (Becker, Gamble, & Rosin, 2015). Additionally, compliance with various federal programs such as Meaningful Use requires a significant investment in technology which can be fiscally challenging for smaller provider groups; driving acquisitions of these smaller entities by larger health systems. Other reasons cited by hospital administrators in the pursuit of consolidation is to ensure a steady stream of physician referrals (NPR, 2010), and to create economies of scale and increased efficiencies, the fruits of which result in reduced costs and therefore cheaper care for patients (ProMarket Writers, 2016). However, what most hospital

The Federal Trade Commission actively enforces antitrust laws to organizations within the healthcare field, including to Physician Hospital Organizations (PHOs). A PHO is a vehicle that enables hospitals and physicians to work cooperatively toward accomplishing several objectives (Physician, 2015). According to Susan Creighton (2004), competitive issues among PHOs can occur when a PHO acts as a contracting arrangement for a network of healthcare providers. The network can consist of groups of physicians, one hospital or several, and also some other entities that offer a bundle of healthcare services to insurance companies and other payors (Creighton, 2004). The FTC states that the core antitrust law principle is that it is illegal for competitors to agree on prices they will charge, except where they come together and integrate in a legitimate joint venture that results in efficiencies or other precompetitive benefits that outweigh the restriction of competition (Creighton, 2004). Agreements that violate the antitrust law can be determined as per se illegal. Per se illegal means that activities, such as horizontal price fixing, or group boycotts, have been conclusively presumed to restrain competition unreasonably even without a study of the market that they occurred in, or an analysis of their actual effect on competition, or their purpose (Burke, et al., 2009). South Georgia Health Partners are an example of a PHO that was charged by the commission on a per se illegal

FTC (federal trade commission) and its importance- being a part of antitrust law, FTC was enacted in 1914 and works hard to prevent unfair methods of health care practices or deceptive acts which disrupts the commerce and make competition healthy by which consumers are benefited from better innovative low cost care(1). FTC guides the participants in health care market ranging

of gag clauses in contracts amongst the MCOs and their providers. These clauses limit providers

The BSA network is a PHO which means it is a for-profit organization that includes a network of hospitals and their medical staff and is created to serve in a contract with managed care plans (Kongstvedt, 2012). This allows them to charge a price for the health-related services the physicians in the network provide the customers. However, based on the antitrust laws, the network is responsible for consulting and negotiating between the physicians and the payers of the network prior to proposing a fee schedule for the consumers (“FTC Bars Texas Physician Group from Joint Price Negotiations,”

“An Integrated Physician Model is the result of a series of partnership between hospitals and physician develop overtime” (Harrison, 2016). Primarily, it is a joint venture that has become many joint ventures. In addition, all of this joint ventures are connected through congruent goals, and that is to provide different level of care to all the patients. Integrated physician model also organizing themselves to improve the cost and quality by operating under a clinical guideline. This could include acute care hospital, home care, nursing homes, affiliated medical group, primary care clinics, employed physician and any independent medical groups.

The issue that the hospital faces when a patient necessitates emergent care and is a participant of a managed care organization is the potential of not receiving payment or not being in compliance with EMTALA (Fedor & Perez, 2001). Initially, many hospitals faced many unpaid claims by managed care entities because of their inability to contact the provider for authorization for care (Fedor & Perez, 2001). CMS advised hospitals to negotiate with managed care organizations with future contracts to include a provision for authorization after the patient has received stabilizing treatment with the purpose of remaining compliant with EMTALA (Fedor & Perez, 2001). By modifying contractual agreements between managed care organizations, the hospital can provide emergent care appropriately and ensure that claims are paid by managed

In my opinion, I believe this has affected the healthcare environment in the sense that the growth of CDHP and MCOs drives patients into influencing the prescribing physicians which then motivates many patients to become more aware of their respective health plans. On the same note, such integration has led to many patients going for cheaper medication such as for generic drugs (Bergeson & Dean, 2006). Moreover the integration has also limited the patient choice as it has limited the consumer driven

Both hospitals and physicians can sustain current tactics based on fee-for-service payment, avoid the up-front costs of care coordination, and permit diminishing reimbursement. Physicians will take home less income and hospitals will see their margins shrink. Because this option is very uneffective and futile, physicians have come up with a slightly more functional approach to improve the integrated- physician-model. The next choice is to work on improving care coordination, but within their corresponding silos. A physician group could develop a medical home model to coordinate care within its practice population.

The FTC is a bipartisan federal agency with a unique dual mission to protect consumers and promote competition. For one hundred years, our collegial and consensus-driven agency has championed the interests of American consumers. As we begin our second century, the FTC is dedicated to advancing consumer interests while encouraging innovation and competition in our dynamic economy.

Evidently, “Advertisements are playing a major role even in healthcare products, which creates an awareness as well as impact in the minds of the consumers” (Lilly & Kavitha, 2014, page.367). In 1975, the Federal Trade Commission (FTC) established the antitrust law that allows the healthcare industry to participate for the first time in the competitive and aggressive marketplace; earlier years this practice was considered unethical among the healthcare industry that at that time was labeled as a learned profession. According to Berkowitz (2017), the use of advertisement in the healthcare business has evolved considerably from consumers being concern about the cost that represents an advertisement to the hospital and the need to perform this

In the case, Phycor was a physician practice management (PPM) firm that focused on providing cost saving services while increasing revenue. Their goals included better negotiation with contracts between physicians and HMO’s and PPO’s (Burns, Bradley, & Weiner, 2011).Some key facts included was that the company offered disease management services and demand management to over 3 million individuals, including those of managed care organizations (Focus on Phycor’s, Inc., 1995). At one point, the company inquired millions of dollars and was able to invest in several companies. “Phycor was undeterred, but wanted to take advantage of the market conditions to gain competitive advantage” (Burns, et. al., 2011, p. 316). By the end of the century, things

The CMS’s conclusion here based In the preamble to our Phase II rulemaking, they concluded that a non-competition provision may not be placed on a recruited physician. 69 Fed. Reg. 16094, 16096-97 (Mar. 26, 2004] Phase III rulemaking that non-competition provisions should not be categorically prohibited from recruitment arrangements. They also stated: Upon review of the comments, however, they were persuaded that categorically prohibiting physician practices from imposing non-compete provisions may have the unintended effect of making it more difficult for hospitals to recruit physicians.

Answer: Broadly stated, the most important issues are fulfilling the expectations of the parties in a legally compliant manner. Too often, compliance professionals and legal counsel are brought in to the discussions after leadership for the hospital and the physician group have established the timing, scope and financial terms of the acquisition and subsequent employment of professionals and staff. A better approach, an approach that will assist the hospital and the physician group in meeting their objectives, is to discuss the legal parameters for the possible transaction early and often.