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Registration link: Unlocking the Potential of Patient Centered Care in Your Health Care Organization (6 CEUs for $40!) Tickets, Fri, Feb 23…

Description: 6.0 Face to Face Credits (Only $40 for members)


Date and Time

Fri, February 23, 2018

7:30 AM – 5:30 PM EST



Penn National Raceway in Grantville

777 Hollywood Boulevard

Grantville, PA 17028


Supporting Self-Care goes beyond simply supplying patients with information at time of checkout or discharge. It includes a commitment to patient-centered care, providing clear and useful information to patients, helping patients establish goals and plans to live a healthier life, creating a team of clinicians and administrative staff with clearly understood roles and responsibilities, and using office systems to support follow-up and tracking of patients. Managing chronic illness and changing behavior are challenging and take time for everyone involved—providers, patients, and caregivers. Yet, it is often patients themselves who are called on to manage the broad range of factors that contribute to their health. Common sense suggests—and health care experts agree—that people with chronic care needs should receive support to help them manage their health as effectively as possible. Using self-management support in primary care can have a positive effect on the care and health outcomes of people with chronic conditions, as well as provider and patient satisfaction. Helping patients to make good choices and maintain healthy behaviors requires a collaborative relationship between the primary care clinical team and patients and their families. Learning how to incorporate self-management support into practice can support patients in building the skills and confidence they need to lead healthier lives.

Feel welcome to join us for an avid daylong seminar with colleagues and leaders in your industry.



7:30 a.m. – 8:20 a.m. Registration

8:20 a.m. – 8:30 a.m. Welcome Message

8:30 a.m. – 10:00 a.m. Health Systems As Stewards Of Health: A Construct For Leading Transformation

10:00 a.m. – 10:15 a.m. Morning Break

10:15 a.m. – 11:45 a.m.  Patient-Centered Care: What It Means And How To Get There

11:45 a.m. – 1:15 p.m. Lunch Buffet (Future of ACHE 12:15 p.m. - 12:45 p.m.)

1:15 p.m. – 2:45 p.m.  The Value Of Teaching Patients To Administer Their Own Care

2:45 p.m. – 3:00 p.m. Afternoon Break (Bar Opens)

3:00 p.m. – 4:30 p.m.  Innovations In Healthcare – Telehealth

4:30 p.m. – 4:40 p.m. Closing Comments

4:40 p.m. – 5:30 p.m. Social / Slot dollars


Health Systems as Stewards of Health: A Construct for Leading Transformation


Colonel Hugh McLean, MBA, LSSBB, Chief of Health Plans Management, Office of U.S. Army Surgeon General


Gary Stelluti, Founder and Principal, HC Marketing

Jaan Sidorov, MD, MHSA, CEO and President of The Care Centered Collaborative 

Patient-Centered Care: What It Means And How To Get There


Peggy Creany, MBA, Administrative Director of Patient Experience, Penn State Health Medical Center


Kevin Smith, MBA, Vice President Product Management & Strategy at nThrive

Susan M. Robel, RN, BSN, MHA, NEA-BC, CPXP, Executive Vice President, System Chief Nursing and Patient Experience Officer (Geisinger)

Holli Masci, RN, BSN, DNP, Nurse Executive & Population Health Specialist, Guidepoint Global, Capella University

The Future of ACHE


Michael Fosina, FACHE, ACHE Governor for District 1

The Value of Teaching Patients to Administer Their Own Care


Anita Brazill, MPH, VP for Partnership and Business Development, The Care Centered Collaborative as PAMED


Diane Littlewood, MSN, RN, VP of Case Management, The Care Centered Collaborative

Manesha Johnson, MSN, RN, Nurse Educator and Clinical Coordinator, Genentech 

Innovations in Healthcare – Telehealth


Christian Caicedo, MD, MBA, CPE, FACHE, Senior Vice President, UPMC Pinnacle, President, Cumberland Division at UPMC Pinnacle


Natasa Sokolovich, JD, MS, Executive Director - Telehealth, UPMC 

Hai Tran, MBA, Chief Operations and Financial Officer, Specialists On Call



Sliced Seasonal Fruit and Fresh Berries; Freshly Baked Muffins; Assorted Yogurts; Fruit Juice, Coffee, and Tea


Tossed Seasonal Greens Salad; Home Style Chicken Noodle Soup; New York Style Deli Sandwiches & Wraps; Homemade Potato Salad; Italian Pasta Salad; Fresh Fruit Salad; Dessert


Hors d'Oeuvres including Bourbon Glazed Petite Steak Skewers, Crab Filled Mushroom Caps, and Bruschetta Rustica; Cash Bar

Dear NCHE Member,


Your commitment to the future of healthcare is evident by your membership in the National Capital Healthcare Executives (NCHE). As a respected leader in the industry, you’re invited to join fellow forward-thinking healthcare executives at the year’s preeminent forum for the advancement of our nation’s healthcare: U.S. News Healthcare of Tomorrow.


Now in its fifth year, this premier event is presented by U.S. News, a pioneering source of healthcare reporting and industry analysis, and is highly regarded for the caliber of its speakers and attendees. NCHE values the Healthcare of Tomorrow forum for its alignment with our mission to advance healthcare leadership and management excellence, and we’re proud to partner with U.S. News on this must-attend event for the fifth year in a row.


Join your fellow thought leaders and industry influencers around the table for high-level discussion on the most pressing issues facing healthcare today. And hear from renowned leaders from across the healthcare spectrum in engaging keynote sessions. Plus, thanks to your membership in NCHE, you are eligible to receive a 50% discount off registration. It’s a worthwhile investment of your time and money and an unrivaled opportunity to connect with the brightest minds in the business.


Space is limited, so take advantage of this offer today. Simply visit and register today using discount code NCHE50.


Have your voice heard today to advance the Healthcare of Tomorrow.


The National Capital Healthcare Executives (NCHE) is pleased to announce the 2017 Scholarship Program!  This graduate-level competition challenges our future healthcare leaders to critically assess existing challenges and propose innovative solutions in a short essay. The winning essayist will receive a scholarship in the form of a $2,000 check and will be publicly recognized at the annual NCHE C-Suite Roundtable on Thursday, October 26, 2017.  Depending on the number and quality of applications, additional prizes may be awarded to runners up.


Please see the attached application form for complete details.  Submissions must be received by NCHE at no later than 11:59 PM EST on Saturday, October 14, 2017. 


NCHE Scholarship Program

Posted by bdeady Sep 20, 2017

The National Capital Healthcare Executives (NCHE) Scholarship Program is one of NCHE's longest-standing initiatives.  This essay competition recognizes a future healthcare leader with a $2,000 scholarship during the annual C-Suite Roundtable which will take place on Thursday, October 26, 2017. 


The NCHE Board of Directors invites graduate students who meet the following NCHE scholarship eligibility criteria to apply:


  • Member or Student Member of ACHE
  • Currently enrolled in and attending a graduate-level health administration degree program at one of the following DC or Northern Virginia universities:
    • Georgetown University
    • George Washington University
    • Marymount University
    • George Mason University

Student members of the NCHE Board or the NCHE Student Committee who meet the above criteria may also apply but must recuse themselves from the NCHE scholarship application review and selection process.  The winner must be present at the Scholarship Award Presentation during the C-Suite Roundtable in order to receive an award.  Please see official application for complete rules and requirements.  NCHE 2017 Student Award Application

Good Afternoon,


I wanted to invite you and your chapter to the Central Virginia Healthcare Executives Group Board of Governor’s Exam Review Course on August 19th. This is a great opportunity for continuing education and preparing for the exam. If you would be willing to send this information out to your chapter, that would be great. Thank you so much!


Be sure to register soon -- the deadline is approaching and you don't want to miss out on this great opportunity!

Join CVHEG, in Richmond, VA, for a great opportunity to partake in an extensive review session for the Board of Governor's Examination. Connect with your peers and colleagues to discuss the exam and learn about the topics that are covered. A panel of experts will be there to speak and guide discussion. Topics for this session will cover the main competencies of the exam! Breakfast and lunch will be served.

This review session also is a great general course on topics of health administration and counts as Category 2 Hours!

This program has been developed and is presented locally by Central Virginia Healthcare Executives Group.

Tickets are $35 per person and includes breakfast and lunch. Registration deadline is 5 p.m. on August 11, 2017.

Who: ACHE Members or Other Interested Parties

What: Board of Governor's Exam Review Session

When: August 19th, 7:30am - 4pm

Where: William H. Grant House, MCV Campus


Why: To prepare and review for the Board of Governor's Exam

Click here to register:

Hope to see you there!


-Central Virginia Healthcare Executives Group Planning Committee

The National Capital Healthcare Executives’ Nominating Committee is searching for committed volunteers to serve in voting and non-voting positions beginning in January 2017.


2017 Nominating Committee:

The voting Board positions are two year terms, requires participation in board meetings (currently scheduled for Saturdays 6 times a year) and Chapter events, and requires members to be in good standing with the American College of Healthcare Executives. The NCHE board is a working board. Vacant positions are listed below.


Please let us know you are interested in taking an active role in your professional organization in 2017 by sending an application (attached) and resume or CV by November 15, 2016 to


Board Officers (Voting):

  • Secretary


Board of Directors (Voting):

  • Director of Programs
  • Director of Marketing and Communications
  • Director of Operations
  • Director of Sponsorship
  • Director of Volunteers


Other Volunteer Opportunities (Non-Voting):

  • Programs Committee
  • Operations Committee
  • Volunteer Coordination Committee
  • Membership Committee (includes Advancement, Awards Coordinator, Recruitment)
  • Sponsorship Committee
  • Marketing and Communications Committee
  • Advisory Board
  • Other (mentor, web/newsletter contributor, individual or corporate sponsor/donations etc.)


The nominating committee will consider all applications received by November 15th and present the panel of candidates for Board Officers to NCHE membership for a vote from 16-30 November. The candidates for Board of Directors will be confirmed by the current Board Officers during the same period. The candidates who receive a simple majority will be elected to the board. The 2017 Board will be notified of their selection by the Nominating Committee Chair on December 1st and will be announced to NCHE membership at the December 2016 Educational Event.


Our Volunteer Coordinator will work with nominees for Other Volunteer Opportunities to find a fit for you in the organization.


If you have questions you may also contact the nominating committee chairman, Michelle Comeaux at 


Thank you as always for your time.

Please join us for an evening with policy specialist Professor Don Lavanty. He will explore the post-election world of healthcare reform.  Based on his wealth of healthcare policy knowledge and expertise, Professor Lavanty will provide his analysis of the new healthcare environment.  The evening also celebrates the efforts made by many to endow the Don Lavanty Scholarship.

Reinsch Auditorium
Marymount University
2807 North Glebe Rd.
Arlington, VA 22207

Date & Time
Thursday, November 17th 6-8 pm
6-6:30 pm        Wine & hors d'oeuvres
6:30-7:30 pm   Presentation
7:30-8:00 pm   Coffee & Dessert reception

This event is underwritten by Marymount University as part of the University's commitment to enhancing our community's experience. If you would like to make a donation to the scholarship, there are opportunities to do so on the registration page and at the event. Pre-registration is kindly requested by


Registration link: Marymount University Alumni Association - An Evening with Professor Don Lavanty



Network with NCHE and U.S. News

Posted by bdeady Sep 20, 2016

As a member of the National Capital Healthcare Executives, you dedicate your time to advancing healthcare leadership and management excellence to ensure a healthy future for all. To aid you in this worthwhile endeavor, NCHE has partnered once again with U.S. News Healthcare of Tomorrow, the premier event for networking and career enrichment for the nation’s leading healthcare executives. This is a not-to-be-missed opportunity to engage with other leaders from across the country, advance your career and support the state of the industry.


This year’s fourth-annual event showcases the highly regarded work of U.S. News, the nation’s preeminent source of healthcare reporting, analysis and industry insights. Working toward our mission of collaboration, NCHE is honored to participate again in a leadership forum that is consistently rated highly for the quality of its speakers and the caliber of its attendees.


Join your fellow leaders—medical experts, hospital executives, policymakers, insurers, consumer advocates and industry analysts—for an engaging three days of thought leadership, sharing best practices and devising solutions to some of healthcare’s most pressing issues, including reform, Big Data, patient safety, Medicare and more. As an added bonus, thanks to NCHE’s support of the event, NCHE members will receive a 50% off discount on registration.


Converge, collaborate and advance your career. Register at using the code NCHE50 and get in today on the Healthcare of Tomorrow. 


NCHE Scholarship Program

Posted by bdeady Sep 19, 2016

The National Capital Healthcare Executives (NCHE) Scholarship Program is one of NCHE's longest-standing initiatives.  This essay competition recognizes a future healthcare leader with a $2,000 scholarship during the annual C-Suite Roundtable which will take place at George Washington University on Monday, October 17, 2016. 


The NCHE Board of Directors invites graduate students who meet the following NCHE scholarship eligibility criteria to apply:

  • Member or Student Member of ACHE
  • Currently enrolled in and attending a graduate-level health administration degree program at one of the following DC or Northern Virginia universities:
    • Georgetown University
    • George Washington University
    • Marymount University
    • George Mason University
    • Johns Hopkins University (DC campus)


Student members of the NCHE Board or the NCHE Student Committee who meet the above criteria may also apply but must recuse themselves from the NCHE scholarship application review and selection process.  The winner must be present at the Scholarship Award Presentation during the C-Suite Roundtable in order to receive an award.  Please see official application for complete rules and requirements.


The application is attached to this post!  Good luck!

Dear Dr. Friedman,


I would like to extend an invitation to members of the National Capital Healthcare Executives chapter.


The non-profit alliance, CAQH, is hosting an event on September 28 (evening only) and 29 in Washington, DC.  Our goal is to engage healthcare leaders in discussion on industry needs, challenges and ideas for collaboration related to healthcare provider data.  We are inviting senior-level individuals from health plans, hospitals and health systems, government, provider and trade associations, consumer groups and foundations to share in this dialog.


We would welcome attendance from leaders at local area hospitals and health systems who are interested in discussing their needs for accurate, timely and complete information on physicians and other healthcare providers – for use in network management, credentialing and privileging, quality measures and reporting, and reimbursement (among other use needs).  Relevant organizational positions may include Vice Presidents and Directors of Network Operations, Provider Relations, and/or Credentialing.


CAQH has developed a white paper in collaboration with Manatt Health, a leading healthcare policy and research firm, to provide a framework for the Summit discussion.


Registration is complementary []; the Summit agenda and list of speakers is attached and also availableonline.


On behalf of CAQH, we would appreciate any assistance you could provide in making your Chapter members aware of this event. 


Please let me know if you have any questions or would like to discuss further.


Best regards,



Karen Waller

Director, Communications and Marketing

CAQH – Streamlining the Business of Healthcare

1900 K Street, NW |Suite 650 |Washington, DC 20006

Phone 202.517.0366| Fax 202.517.0397 | |


One of the most basic health care delivery reforms is paying not just for units of service but for how well providers perform in delivering those services.   Many public and private health care systems are supplementing the basic mode of payment with bonus payments to physicians and hospitals that achieve a specified high level of performance on certain measures that promote high value with cost reduction. 


Providing economic incentives to providers and patients is critical in advancing the value-based strategy.   Incentives have conventionally ranged from ad hoc rewards for simple behaviors such as coming in for health check-ups to sophisticated incentive programs that reward healthy behaviors.  The concept of healthy behavior, or behavioral change, is less widely used in developing incentive plans but it has significant untapped potential.  The incorporation of game theory and behavioral economic principles to improve performance goals ought to be a fundamental aspect for health systems to deliver high-value care.


Breaking the status-quo by establishing a status-quo

In behavioral economics, the status-quo is an emotional bias giving predilection for the current state of affairs where the baseline is taken as a reference point and any change from that is perceived as a loss.  This concept helps us understand why people are likely to select the inferior option when that option is presented as the status-quo.  Medical informatics can play a critical role in leveraging the status-quo bias to influence behaviors.

Here are just two applications to consider to facilitate the status-quo for cost reduction:


1) Medicare Advantage Payments

Electronic Medical Records (EMR) can be used to optimize Medicare advantage payments.   Medicare advantage payments are linked to a risk score calculation developed by the Hierarchical Condition Category (HCC) through the department of Health and Human Services (HHS) and implemented by Centers for Medicare and Medicaid Services (CMS).  The risk score helps determine the relative health risk, or disease burden per se, for each patient to calibrate payments to health plans so that economic resources to those patients with the highest needs (risks) are supported.  As such, an HCC risk scoring tool on disease status ought to be “built in” to the assessment portion of the “SOAP” note, while those with no value should be alerted with hyperlinks to alternative risk bearing diagnosis.  This would create a status quo bias that favors appropriate billing with cost effective care and resource allocation.


2) Brand Name Drugs

Generic drugs are readily available with the same proven efficacy at a fraction of a cost to their brand name derivative counterparts.  Brand name drug is the inferior option when the generic version is available.   An implementation of an EMR that automatically defaults orders to the generic drug would develop good cost effective prescribing habits.


The relative social rankings phenomenon

The relative social ranking concept points to the notion that people are heavily influenced by their perception of how their performance compares with those around them.  A physicians' sense of competitiveness can be deployed by distributing identified rankings to physicians within one's group, or even to the general public.  However, it is equally, or perhaps more important to define how social ranking is presented to accurately determine “high performers” while preventing gaming of the system.  This is a difficult task as in essence it is quantifying a quality.  Defining ranking by health outcomes or health benchmarks is not an uncommon practice, as is with patient satisfaction scores.  Less widely quantifiable social ranking is with operational efficiency.  Let us further examine the various aspects of systems that track various quality measures:


  • Measuring Health Outcome

  The Healthcare Effectiveness Data and Information Set (HEDIS) is a tool used by more than 90 % of America's health plans to measure performance on important dimensions of care and service.  HEDIS measures address a range of health issues including: asthma medication use; persistence of beta-blocker treatment after a heart attack; controlling high blood pressure; comprehensive diabetes care; breast cancer screening; antidepressant medication management; immunization status; and advising smokers to quit. 


  • Measuring Patient Satisfaction

There are numerous tools including surveys that measure patient satisfaction.  A wifely used service is by the Consumer Assessment of Healthcare Providers and Systems (CAHPS) that surveys consumers and patients to report on and evaluate their experiences with health care.  These surveys cover topics that are important to consumers and focus on aspects of quality that consumers are best qualified to assess, such as the communication skills of providers and ease of access to health care services.   This data can be specific to providers, medical groups, and health plans.


  • Measuring Operational Efficiency

Numerous EMRs have embedded into their system the ability to track and analyze how efficiently a provider is checking messages, refilling prescriptions, reviewing charts, and finishing their notes.  An analysis report can be given to the provider to show how effectively they are using the system.


Reforming Social Ranking

A reform is warranted here to redefine how social ranking is presented in a way that accurately defines the value of a provider.  These various measurements of quality are currently fragmented and need to be pooled into one composite score.  Certain quality aspects may be considered more important than others such as health outcomes over efficiency and therefore a weighted score can be applied in such case to calculate the overall score.   A well rounded provider that is efficient, commands high satisfaction rates, and produces good health outcomes ought to be the focus of defining a “high performer”.  A crucial piece to the performance level must also include the relative risk and size of the provider’s patient panel.  For example, the disease burden may be higher for a very busy practice in a low-income rural area with access barriers to coordinated services compared to a thriving high income community.  As such the “raw score” should include a relative risk and panel size modifier in the equation to account for different demographics that way it “equalizes” the playing field among providers in various regions and prevent gaming of the system.


Avoiding a loss is better than gaining a win

Loss aversion is another behavioral term that refers to the tendency for people to strongly prefer avoiding losses than acquiring gains.  Studies suggest that losses are psychologically more powerful as gains.   One particular study in the education sector that evaluated teachers showed improved performance when paid in advance and asked to return the money if students did not improve sufficiently compared with when they were given year-end performance bonuses.  Such an incentive can be placed on a health care team which also includes the patient.  This gives both the provider and patient adequate “skin in the game” to work together to achieve the reward for their excellence.  Examples of loss of aversion would include eliminating co-pays one year in advance for patients while providing bonuses for health teams where they must pay back if goals are not met.


Reforming the framework of incentive design in population health management ought to be a key focus by health care delivery systems.  A shift in value based payments among health plans that leverage behavioral economics into incentive plans has significant potential in optimizing health care.


Posted by jasonalexander Feb 27, 2016

Good luck to all of our members as they prepare for the Board of Governors Exam.  If you're looking to discuss test strategies and share study materials, please check out Board of Governors Exam Study Group.

A Crib Sheet for Non-Lawyers Regarding Medicare Fraud: Qui Tam Action, False Claims Act, Anti-Kickback, and Stark Law


Qui Tam


In ancient English law, generally known in American law as common law, a "writ of qui tam" is a writ that allows a private citizen, who assists a prosecution on behalf of the government.  In doing so, the citizen can be eligible to receive all or part of a monetary penalty if one is imposed. Qui tam is an abbreviation of the phrase qui tam pro domino rege quam pro se ipso in hac parte sequitur, meaning, "[he] who sues in this matter for the king as well as for himself." 


The False Claims Act


The False Claims Act, 31 U.S.C. § 3729 et seq., originally passed by Congress on March 2, 1863, constituted an effort by the government to respond to frauds perpetrated on the government by nefarious contractors. Arguably, the Act was instituted because of bad mules. During the Civil War, unscrupulous contractors sold the Union Army, among other things, decrepit horses and mules, faulty rifles and ammunition, and rancid rations and provisions.  Importantly, a reward was offered (the qui tam provision), permitting citizens to sue on behalf of the government and be paid a percentage of the recovery.  This later evolved into “whistleblower” protections and benefits established to incentivize people with specific knowledge of frauds against the government to come forward and make them known.  Therefore, the Act is a legal tool used to counteract fraudulent billings submitted to the Federal Government and have typically involved health care, military, or other government spending programs.


Nearly every part of the healthcare industry provides opportunities for unscrupulous persons and entities to defraud Medicare. Under the False Claims Act, any claim for Medicare payment that is tainted by any illegal activity or noncompliance with established regulations could potentially be considered Medicare fraud.


Some examples of actions that usually constitute fraud include:

  • Billing Medicare for any good or service that is not medically necessary
  • Billing Medicare in a way that does not accurately represent the goods or services provided, such as up-coding or billing for services not rendered
  • Noncompliance with FDA regulations for suppliers of pharmaceuticals, and devices
  • Improper or noncompliant documentation of medical necessity and other information
  • Violations of the Anti-Kickback Statute (see below)
  • Stark violations (see below)


While not all inaccurate Medicare billing necessarily involves intentional fraud, healthcare providers and manufacturers of drugs and medical equipment must strictly adhere to applicable regulations to avoid potential False Claims Act violations.


Anti-Kickback Statute


The Anti-Kickback Statute, 42 U.S.C. §§ 1320a-7b, is designed to ensure that healthcare providers such as physicians and hospitals make decisions based on the needs of their patients without influence from those who stand to profit from influencing their decisions.


The Statute prohibits the offering and accepting of any reward, payment, or incentive intended to encourage the recommendation, use, or purchase of any good or service that could be covered under a government health program such as Medicare or Medicaid. This includes not only direct bribes, but also in-kind rewards such as:


  • Free vacations
  • Gifts
  • Paid contracts
  • Other indirect forms of remuneration


Caveat: Manufacturers of pharmaceuticals, medical devices, and medical equipment have a vested interest in increasing the use of their respective products. Therefore, the targets of kickback schemes are often directed at physicians because they have the ability to recommend and prescribe drugs and other products directly to patients. For example, a manufacturer or marketer of a particular antidepressant might offer illegal incentives to a physician to prescribe that drug over other similar medications or treatments.  Check with your organization’s General Counsel for guidance before accepting any “freebee” regardless of how small.


There are certain statutory exceptions that allow legal “safe harbor” for legitimate financial arrangements between manufacturers and purchasers, including equipment leases, space rental, and other contracts. However, all of the terms and conditions of these arrangements must be clearly documented and prices must be at fair market value for the good or service provided. If the arrangement is not clearly documented or the terms are not followed, it may constitute an illegal kickback and thus violate the Statute.


Stark Law


Stark violations are a type of Medicare fraud because they represent cases in which a physician’s financial incentive to refer patients may compromise his or her professional judgment on whether the particular treatment is necessary. This means that claims submitted based on those referrals are medically suspect and therefore fraudulent.


The purpose of the Stark Statute is to reduce the questionable overutilization of medical services encouraged by certain financial arrangements between service providers and referring physicians. To achieve this purpose, the Stark Statute prohibits hospitals or other medical service providers from billing Medicare for items or services provided based on a referral from a physician with whom the provider has a financial relationship. Originally passed in 1989 to cover laboratory services, the Stark Statute has since been amended to cover nearly every type of medical service, therapy, or medical item.


There are exceptions for physicians under bona fide employment contracts with the provider as well as other particular transactions. However, for any financial relationship to be compliant with Stark, it must be well documented, involve fair market value compensation for services rendered, and not be based on the number of referrals the physician makes.


Finally, it should be noted, as stated above under the False Claim Act, that violation of either Anti-Kickback and/or Stark Law automatically "buys" the Defendant a False Claim Act case as well.  The provisions embedded in these laws carry compounding violations and what may be initially thought of as a minor infraction has the potential to grow into substantial federal law violations.  As such, leaders should continue to encourage dialogue with staff as well as ongoing reliance on the organization's General Counsel for guidance in these potentially perilous waters to limit the risk of being named in a qui tam action for fraud.

Overview of HHS/CMS Proposed Rules for Reimbursement CY 2016 for Hospital Outpatient and Ambulatory Surgical Centers

42 CFR 410, 412, 416, and 419 found here


On July 8, 2015, HHS published in the Federal Register its proposed changes for 2016 hospital and Ambulatory Surgery Center (ASC) CMS reimbursement.  The proposal contains detailed analyses ultimately leading to the reduction of reimbursements for hospital and ASC outpatient services in 2016 by $43M while increasing quality-reporting requirements. 


On August 31, 2015, HHS/CMS closed their open call for submission of comments on proposed changes to the ways CMS reimburses for hospital and Ambulatory Surgical Center (ASC) services from the previous year 2015. The law requires the Secretary of HHS to review these regulations not less than once per year.


Under the proposed CY 2016 rules, CMS estimates it will reduce total payments, including cost sharing with the 3,800 facilities paid under the Hospital Outpatient Prospective Payment System (OPPS), by $43M compared to CY 2015 reimbursements.  This reduction includes general acute care hospitals, children’s hospitals, cancer hospitals, and community mental health centers, but does not consider CMS’ estimates of changes in enrollment, utilization, and case mix.


Further, the proposed CY 2016 rule changes the amounts and factors used to determine payment rates for Medicare services paid under OPPS and ASC systems.  The proposed rule also enhances requirements of hospital outpatient quality reporting.


In calculating the $43M reduction, CMS created a baseline model using CY 2015 relative payment weights, [hospital] inpatient prospective payments, and the final 2015 conversion factor.  The proposed total payments, and the extent to which the proposed rule would redistribute money during implementation, will depend on changes in volume, practice patterns, and service mix of services billed by various hospital groups. CMS concedes it cannot predict these values.  Overall, CMS estimates the proposed rule will decrease Medicare payments by 0.2 percent.  The estimated decrease in total payments is largely determined by the increase applied to the proposed conversion factor needed to address OPPS payment inflation rates.


CMS proposes to recalibrate relative payment weights based on Ambulatory Payment Classification (APC) claims and cost report data for hospital outpatient services (using the most recent available data) used to construct a group-weight database.  In its calculation, CMS used 151 million finalized claims for hospital outpatient services delivered on or after January 1, 2014 and before January 1, 2015.


The 2016 rules include proposed changes to APCs encompassing new CPT codes, new technologies, devices, drugs, biologicals, and radiopharmaceuticals while differentiating programs with and without pass-through status. Additionally, OPPS payments for outpatients and partial hospitalization services are considered.  CMS 2016 rules also identify changes to procedures that would qualify exclusively as inpatient services.


In considering revised requirements for hospital outpatient quality reporting, CMS has adopted measures focused on high impact and improve quality and efficiency as reflected in National and CMS quality strategies.  Here, the ultimate goal is to align clinical quality measures with various quality reporting programs with an emphasis on adopting measures using electronic means to collect clinical care delivery data. 


The 2016 rules do not propose any changes to the selection process of determining quality measures from those used in CY 2015 and go as far as to expressly retain program measures adopted in previous payment determinations.  Nor are any changes proposed to the process (adopted in 2010) for “retirement” or “removal” of program measures based on patient safety considerations – which in essence, is evaluated on a case-by-case basis without consideration of any one specific criteria.  However, proposed quality measures for hospital emergency services, public display of quality measures, and future considerations for out-years (extending through 2019) are considered.  Specific participation and reporting procedures for hospitals and ASCs with respect to form, means, and timing are provided within the proposed rules.


  I summary, the 2016 proposed rule provides descriptions of changes to the amounts and factors used to determine payment rates for Medicare services paid under OPPS and those paid under ASC payment systems based on a conversion factor derived from “big data” while updating quality reporting requirements for hospital and ASC outpatient services with emphasis on electronic reporting methodologies.


For further information regarding Medicare's ASC value Based Purchasing Implementation Plan, See here

CIOs are pulling the heavy sled of reconciling EHR, coding, and compliance enterprise-wide systems and there are lots of people and organizations vying for their attention and investment to help them do it.  Tech is tough! This axiom is likely felt no more acutely than in an industry that is notoriously staffed with professionals that are possibly the farthest away from being accused of being "early adopters."  After all, as one hospital exec once put it to me, "No one wants to be a pioneer -- they end up face down with arrows in their back."  The caveat is valid and worth heeding, however, healthcare is no doubt currently experiencing the most transformative era in our careers.  If there ever was a time for situational bold management leadership decisions needed to align and automate historically analog procedures and operations with ACA/ACO provisions necessary to secure reimbursement and safe clinical service delivery, then when would that time be if not now?


Many technology companies are "tagging" portable medical equipment and DME items for location, scheduled maintenance, and asset visibility purposes with Radio Frequency Identification (RFID) tags and readers.  Use of RFID in hospitals has experienced significant growth in the last ten years and has contributed to alleviation of waste and asset over-purchase as well as use of high risk equipment involved in life support.  Also, RFID has been instrumental in patient safety initiatives.  Mostly used in surgical environments by assisting staff with sponge counts and autoclave-able instruments, among other uses.  Medical applications of RFID have likely paid for itself in avoided staff time spent in recount let alone avoided litigation costs. 


But what ultimately is the likely trajectory of this technology?  Lets briefly consider the possibilities in the way the Wright brothers might of considered the Space Shuttle if they had the chance to see it.


In a study published by Alberto Coustasse, DrPH, MD, MBA; Shane Tomblin, PhD; and Chelsea Slack, MS titled, Impact of Radio-Frequency Identification (RFID) Technologies on the Hospital Supply Chain: A Literature Review, found here, the authors concluded that “Competing strategic HIT technologies for hospitals and federal mandates for EHR adoption have also delayed massive RFID implementation. If barriers to implementation can be overcome, RFID will represent a revolution in HIT.” (emphasis added). 


This matters because beyond the legal compliance issues, the dollars at play are staggering.  The above referenced study cites Nachtmann and Pohl’s survey of hospital organizations where ALL respondents (over 1,300) indicated that about one third of the organization’s operating budget was spent in supply chain functions – equaling an average of nearly $100M per participating facility.  Looking at an average brick and mortar facility’s P&L, the supplies expense element falls second only to staff salaries accounting for an average of twenty-five to thirty cents of every top-line revenue dollar indicating that the fastest way to broaden margins is by lowering operating costs. Like the Wright brothers looking over the space shuttle, they may be overwhelmed by the technology to the degree that its not clear how the machine could ever fly – but remember, the space shuttle, just like the Wright flyer, is at its heart, a glider; albeit a sophisticated one. 


So how sophisticated is RFID getting?  Watch this one-minute video announcing FDA approval of medication embedded with RFID for medications compliance monitoring.  The signal is activated by digestive chemistry to prove compliance.  This FDA green light could have huge implications in patients with dementia and in keeping ambulatory patients in their homes longer with higher medication compliance rates and out of assisted living or skilled nursing facilities or worse acute care facilities.



Other examples include an "RFID powder" that is so small it is virtually undetectable. See the Scientific American article found here for more information.  One interesting note is that most RFID developers are electronics wonks and don't really understand the value of how to apply their inventions in a patient care environment.  For applications, they depend on users, but no surprise, the health care space has been slow to explore and exploit the uses of RFID.  True, the technology is (currently) most cost effective in some applications over others.  But, I can't help but remember Tom Hanks' line from Apollo 13 when attempting to impress a group of lawmakers touring NASA, "Imagine a world where a computer fills a single room."  That has happened in my lifetime to an extent where there is vastly more computing power in my iPhone that was used to bring Apollo 13 home from their fateful moonshot.


From the OR suite to the C suite, RFID technologies are advancing life and resource saving applications. The bottom line is that this technology is too revolutionary and too important to hospital operating costs and patient safety to ignore or write it off as a passing fad. The Wright brothers may not have envisioned the space shuttle when they flew on the shores of Kitty Hawk, but they were positive of the value of harnessing the ability to fly.  They were, after all, pioneers.