Have Financial Transactions Between Physicians and Hospital Systems Changed Over the Past 30 Years? Part Two: 2021 and Beyond

Value-Based Reimbursement 

Evidence in 2021 reveals that most value-based payments — both in Medicare and in the overall healthcare system — are still limited to pay for performance, upside-only shared savings, and care management fees paid to a patient-centered medical home (PCMH). When people in the healthcare sector talk about the future of payment, most accept the premise that value-based payment and risk-sharing will grow in prevalence. However, they tend to believe that growth in risk-sharing will be less dramatic than for pay for performance. Currently, hospitals and healthcare systems across the country are “slow-walking” toward value-based care (VBC) because they need to fill beds, and the potential rewards from shared savings or risk contracts are not enough to make up the difference if they reduce their admissions.[1]

The VBC reimbursement model has not been without its complications, however. In places and organizations in which it is adopted, it means the model must be adapted alongside current fee-for-service (FFS) models, making the process even more complicated. Additionally, FFS models will not go quietly, and many physicians will undoubtedly be concerned about how VBC affects their revenue stream. FFS models may not be completely on their way out of the healthcare industry, but VBC models are definitely pushing their way in. The process will not be smooth, and it will take a lot of time and energy to make the switch.[2]

Self-Funded Efficiency Programs

Simultaneously with the development of government initiatives, commercial accountable care organization (ACO) products (often via clinically integrated networks (CINs)) entered the marketplace. Slowly, these formerly opposing institutions have come together to form high-value network arrangements to demonstrate sufficient success. Examples of self-funded healthcare efficiency programs include:

• Employer-owned health plans. Employer-owned health insurance is a voluntary benefit provided by some companies to their employees. Employers realize several benefits from providing health insurance to employees: (1) lower premiums, (2) tax incentives, (3) improved hiring and recruiting, (4) employee loyalty and retention, (5) employee job satisfaction, (6) healthier and more productive employees, (7) fostering a healthy company culture, (8) pre-tax benefits, and (9) placement of health coverage within reach of employees.[3]
• Hospital efficiency programs (HEPs). Commercial payors are shifting their payment schemes to reward quality care that results in overall cost reductions. Employers are entering into value-based contracts that improve their bottom line while positively impacting the level of care provided to patients. This commitment to becoming more efficient is driving all key stakeholders to change the status quo and enter innovative “value-based” models for care delivery. One innovative model gaining traction is a HEP. A HEP is an accelerated solution to eliminate financial waste, improve quality, and drive innovative best practices into the delivery of care. HEPs can be created in a variety of ways, but they all have similar fundamental physician leadership. Examples of HEPs are employment, CIN, and individual contracts.[4]
• Clinical co-management agreements (CCMAs). CCMAs are a moderate form of alignment representing an arrangement between hospitals’ service lines and their medical staff members, whether they are employed or contracted. Physicians become actively engaged in setting and managing the clinical direction of a particular service line.[5]
• Gainsharing agreements. The Department of Health and Human Services (HHS)’ Office of Inspector General (OIG) defines gainsharing as an arrangement by which hospitals and other healthcare organizations promote standardization and more efficient use of expensive supplies to cut costs; a percentage of the resulting cost savings is then distributed among the physicians who helped generate those savings. The OIG had previously expressed significant concerns about the risks posed by gainsharing in a July 1999 special advisory bulletin.[6] By 2001, the OIG softened its position through an advisory opinion permitting a limited gainsharing arrangement under the Civil Monetary Penalties Law and the Anti-Kickback Statute. The OIG’s most recent advisory opinions indicate that properly structured arrangements under which cost savings are shared can serve legitimate business and medical purposes.[7]

Fee-For-Value Models

Many payors over the past few years, especially governmental payors, have been rolling out fee-for-value (FFV) reimbursement models, incentivizing and rewarding high quality and cost efficiency from providers. These models are in various forms, from shared savings programs to bundled payments. Further promotion of these models will likely continue. These include:

• Care model process redesign. Care model process redesign is a systematic approach to optimizing value-based outcomes in any well-defined care process. It is not a static event. Instead, it is a dynamic methodology that allows providers to fine-tune their commonly used care processes over time using an iterative, data-driven process improvement model. Healthcare/system redesign involves making systematic changes to primary care practices and health systems to improve the quality, efficiency, and effectiveness of patient care. Chronic diseases such as heart disease, stroke, cancer, and diabetes are among the most common, expensive, and preventable health problems Americans experience. According to the Institute of Medicine, evidence has shown that half of these Americans are not receiving good care for chronic diseases. The current structure of America's healthcare system makes it difficult for patients to access affordable, effective care.[8]
• Population health. Population health is an approach to health that aims to improve the health of an entire population consisting of health outcomes, patterns of health determinants, and policies and interventions. The Centers for Disease Control and Prevention views population health as an interdisciplinary, customizable approach that allows health departments to connect practice to policy for change to happen locally. This approach utilizes non-traditional partnerships among different sectors of the community – public health, industry, academia, healthcare, local government entities, etc. – to achieve positive health outcomes. Population health “brings significant health concerns into focus and addresses ways that resources can be allocated to overcome the problems that drive poor health conditions in the population.”[9]
• CINs. CINs are networks of providers that share information via electronic health record (EHR) systems to improve the quality of patient care, reduce costs, and demonstrate value in the healthcare marketplace. Typically physician led, CINs can be composed of employed and/or independent physicians and can also include partnerships with healthcare systems. Leadership within a CIN will establish clear goals and objectives, as well as participation guidelines for members to meet the demands of the ever-changing healthcare landscape.[10] CINs are further discussed below.
• Super CINs. A super CIN often serves as the platform upon which physicians can build an ACO. The CIN provides a legal framework around which physicians can set goals for standardization, efficiency, and coordination, which is the objective of an ACO. CINs and ACOs complement each other. With proper technical support, these organizations can improve the quality of care, lower costs for patients, and get better payment rates from insurers. CINs are evolving quickly across the country in response to changing reimbursement trends and the move to value-based payments. In most markets, single healthcare systems have formed independent CINs in an effort to more formally align independent and employed physicians in the region. Certain markets are starting to see the development of super CINs, also known as population health alliances. 

The formation of super CINs/population health alliances is motivated by the perceived need to reach larger populations and to form more comprehensive delivery networks, in many cases fueled by increased competition within the marketplace. The main goals of most super CIN/alliance structures are to expand network offerings and services through direct-to-employer products and to effectively pool resources to build robust population health infrastructures. Super CINs are the product of multiple CINs under a single superstructure. Super CINs/alliances allow smaller systems, hospitals, and physician organizations to leverage infrastructure costs, management and governance oversight, care management protocols, and population health management capabilities, and take on population financial risk while still retaining their independence.[11]  

VBC also involves care programs for targeted populations, such as Medicare Advantage, chronic care management, or remote patient monitoring. Healthcare professionals demarcate patient populations in a variety of ways depending on what they are trying to evaluate or accomplish. Individuals can also be grouped into a patient population based on their health characteristics, such as asthma,  pregnancy, diabetes, congestive heart failure, coronary artery disease, chronic obstructive pulmonary disorder, high-risk obstetrics, and, more recently, mental health and obesity.[12]  

Consumerism in Healthcare

Consumerism in healthcare is generally understood to mean “people proactively using trustworthy, relevant information and appropriate technology to make better-informed decisions about their healthcare options in the broadest sense, both within and outside the clinical setting.”[13]

Recent periods have seen an increase in consumerism under the pressures of the Patient Protection and Affordable Care Act (PPACA) for every American to purchase health insurance. According to the National Research Corporation (NRC Health), the definition of healthcare consumerism is “transforming an employer’s health benefit plan into one that puts economic purchasing power — and decision-making — in the hands of participants. It is about supplying the information and decision support tools they need, along with financial incentives, rewards, and other benefits that encourage personal involvement in altering health and healthcare purchasing behaviors.”[14]

Although PPACA’s intent is for every American to have health insurance coverage, the cost and pressures of that program weigh heavily on consumers and providers. Consumers must purchase coverage through individual-market health insurance plans. Providers have increased patient loads of patients who may be dropped from their plans due to missing their premium payments, leaving the providers to pick up the cost of providing the services. The effect is a growth in consumerism and an increased workload and costs to healthcare providers. The increase in copayments, deductibles, and out-of-pocket expenses to the patient is driving patients to shop for the best prices as well as to demand to know what they are paying and what services are being provided. Although consumers may choose to take the advice of their physicians, hospitals, or other advisors over lower costs, the rise in retail marketing and published pricing is proof that consumers want more information about the cost of care.[15]

The passage of PPACA may have accelerated healthcare consumerism, but as was recently pointed out, “Consumerism has been making inroads into the healthcare industry for at least a decade, with patients increasingly acting like consumers who have a choice in their healthcare options, trying to make the best decisions for quality and cost just as they do with any other commodity.”[16]

Price Transparency

Price transparency is a rising issue among patients who must pay for a greater part of their healthcare through higher premiums, deductibles, and out-of-pocket expenses.  In response, on January 1, 2021, a new rule from the Centers for Medicare & Medicaid Services (CMS) went into effect requiring hospitals to publish the prices they negotiate with insurers for various medical procedures. Previously, those prices had been undisclosed. This rule will inject transparency into the U.S. healthcare system — and thereby result in lower costs and better-quality care for consumers.[17]

Another aspect of price transparency is the elimination of unexpected bills. Surprise bills occur when patients are billed at highly inflated prices from out-of-network providers they did not select in advance. On July 1, 2021, HHS announced the “Rule to Protect Consumers from Surprise Medical Bills.” The announcement states that no patient should forgo care for fear of surprise billing. Health insurance should offer patients peace of mind that they won't be saddled with unexpected costs. Provisions include banning of surprise billing for emergency services without requirements for prior authorization; banning of out-of-network cost-sharing for emergency and non-emergency services; banning of out-of-network charges for ancillary care (such as an anesthesiologist or assistant surgeon) at an in-network facility in all circumstances; and banning of other out-of-network charges without advance notice. Healthcare providers and facilities must provide patients with a plain-language consumer notice explaining that patient consent is required to receive care on an out-of-network basis before that provider can bill at the higher out-of-network rate.[18]

Market Consolidation

Independent physicians cite COVID-19 concerns due to losses in revenue and shortages of cash on hand. Those physicians who are looking for partners listed financial support as the primary driver. Consulting firm McKinsey & Co. reports that 54 percent of large independent practice doctors and 30 percent of small independent practice physicians said the pandemic “has shown the benefits of working for a large practice outweigh the benefits of working in a smaller practice.”[19]

Consolidation in healthcare includes mergers, acquisitions, affiliation agreements, and facility closures. Combining former competitors in a market has the potential to reduce competition, affect the quantity of care, and increase prices. Most healthcare consolidation occurs through mergers and acquisitions involving two companies that provide similar ranges of healthcare services.

Independent provider organizations and health systems alike feel the economic stresses of healthcare changes (COVID-19 influenced). Most are electing to become bigger and stronger through consolidation or partnership. Internal changes are also imperative as clinical and financial operations must drive high-quality, low-cost care.

The reasons for market consolidation trends have changed over the years. Largely as a response to the growth of managed care, the 1990s experienced an episode of “merger mania,” in which both hospitals and physician practices were rolled up into hospital systems. By the early 2000s, hospital merger and acquisition activity had slowed, and as noted in Part One of this article, many acquired physician practices were divested.

Another wave of healthcare consolidation began around 2010, primarily motivated by PPACA and changing financial models.[20] PPACA created reimbursement incentives to move patient care from an inpatient to an outpatient setting, motivating hospital systems to acquire physician practices to capitalize on increased outpatient revenues and secure referrals for hospital-based services. PPACA eliminated many of the essential competitive checks remaining in the American healthcare system.[21] Because the law relies so heavily on unfunded regulatory mandates to finance the benefit structure, it is obliged to strengthen the power of incumbent providers to prevent targeted competition from eliminating their profit centers. The provisions of the law attempt to do so by:

• Closing off alternatives to paying for healthcare by requiring individuals to purchase comprehensive insurance;
• Reducing the ability of insurers to compete with innovations in benefit design by requiring standardized benefit packages;
• Increasing the discriminatory subsidies that protect dominant hospitals from competition;
• Limiting patient choices by using Medicare payment policies to drive doctors and other medical professionals into a small number of integrated hospital systems.

Mergers and Acquisitions

As of the first quarter of 2021, hospital merger and acquisition (M&A) activity was significantly down, despite larger-than-average transaction sizes, according to a report from Kaufman Hall. The trend continued in the second quarter of 2021. The total number of deals through the second quarter of 2021 is 27.[22] Deals announced may be hinting at a new tendency for hospitals and health systems whereby leaders seek to enter larger transactions with a trend toward regionalization. Since the pandemic was declared, hospital M&As have reached an average size of seller by revenue to over $800 million by the second quarter of 2020, which is currently the highest average size recorded in the last decade. A recent report states that “For health systems, a focus on regionalization facilitates the sharing of resources within a defined geography, a capability that proved particularly valuable during the heights of the COVID-19 pandemic. A robust regional market presence positions health systems to partner with health plans and local employers by offering the necessary scale for population-health-focused initiatives and cross-market access for employees at work and at home.”[xxiii] The community also benefits. COVID-19 is expected to have a lasting impact on hospital M&A activity.

Consolidation through ACOs

As noted above, PPACA also encouraged the formation of ACOs in the Medicare program, which brings groups of doctors, hospitals, and other healthcare providers together voluntarily to provide coordinated high-quality care to their Medicare patients.[24]  Compensation mechanisms for ACOs require that the ACO bear risk for patient or population outcomes instead of receiving fees for service. Providers have financial incentives to consolidate into entities capable of providing integrated care. These financial incentives drive the movement toward both horizontal and vertical consolidation among healthcare providers and change the market structure to deliver healthcare services.

FTC Consolidation Scrutiny

The Federal Trade Commission (FTC) takes a very narrow view of competition and the efficiencies credited, and is not eager to give mergers the green light. In past years, the FTC has been highly successful in blocking hospital and other healthcare provider mergers when the agency believes the transactions are anticompetitive. Meanwhile, healthcare providers, especially community and independent hospitals, face a difficult time keeping up with the needs of their communities, reinvesting in their care system, attracting physicians and nurses, and producing the cost of capital to make investments. Unable to survive, many have disappeared, eliminating access to healthcare to populations in their areas. Thus, as a throwback to the 1990s, several states have resorted to issuing certificates of public advantage (COPAs). Though COPAs vary from state to state, the FTC defines them generally as regulatory regimes adopted by state governments to displace competition among healthcare providers and immunize mergers and other deals from antitrust scrutiny. After actions by several states, the FTC is watching the effects of mergers and divestitures of hospitals and their effect on the price and quality of healthcare services as well as on access to care and employee wages.[25]

In a January 14, 2021 press release, the FTC announced that it has issued orders to six health insurance companies[26] to provide information that will allow the agency to study the effects of physician group and healthcare facility consolidation that occurred from 2015 through 2020. The objective is to provide detailed information about how physician practice mergers and healthcare facility mergers affect competition. The results will also aid policy makers by providing important evidence documenting how mergers and acquisitions of physician groups and healthcare facilities affect the proper functioning of healthcare markets.[27]  

The Biden administration announced on July 9, 2021 that he would call on the Department of Justice and FTC "to enforce the antitrust laws vigorously" in healthcare and other key industries. The White House said it's urging antitrust regulators to recognize that "the law allows them to challenge prior bad mergers that past Administrations did not previously challenge." The executive order instructs antitrust regulators to “review and revise” their merger guidelines to ensure that patients are not harmed by a potential tie-up.[28]

IPAs Repositioning to CINs

As healthcare moves toward value-based reimbursement, many independent physician associations (IPAs) are repositioning as CINs. An IPA is a business entity organized and owned by a network of independent physician practices and often hospitals to reduce overhead or pursue business ventures such as contracts with employers, ACOs, or managed care organizations. There are substantial opportunities for innovation in delivery system modeling and benefit design in creating physician networks. Specifically, the creation of practice networks involving PCMHs may accelerate important and necessary changes in healthcare delivery.[29]

The FTC defines a CIN as an “active and ongoing program to evaluate and modify the practice patterns by the network’s physicians and create a high degree of interdependence and cooperation among the physicians to control costs and ensure quality patient care.” The FTC generally considers a program or organization to be clinically integrated if it does the following:

• Establishes mechanisms to monitor and control utilization of healthcare services that are designed to control costs and ensure quality of care;
• Selectively chooses CIN physicians who are likely to further these efficiency objectives;
• Utilizes investment of significant capital, both monetary and human, in the necessary infrastructure and capability to realize the claimed efficiencies.

The three primary types of CINS are:

1. Hospital organizations. The most prevalent type of CIN is typically a joint venture between a health system and its medical staff, supported by health information exchanges.

2. Health systems (hospital- or payor-owned). These types of CINs operate like an ACO, where the health system is the sole corporate member of the subsidiary entity and member physicians sign separate legal agreements to participate.

3. IPAs or “super groups.” These are owned and operated by only physician members and/or partners.

The key to participating in a CIN is ensuring that the members can work together to improve care, control costs, share data, and invest in care coordination and health information technology to ensure that population data can be tracked and utilized, and target metrics met.[30]

There are several differences  between IPAs and CINs:

IPA:

• Loosely formed alliances among physicians
• Primarily focused on independent private practicing physicians
• The main purpose for forming an IPA is for payor contracting
• With the recent changes in reimbursement from FFS to value-based, IPAs that are not clinically integrated can’t effectively negotiate payor contracts

CIN:

• Consists of a group of providers who come together to improve quality and cost efficiency in healthcare delivery
• Provides higher value to the consumer of healthcare services
• Employs best practices, processes improvement methodologies, and measures true cost and outcome metrics via direct methods such as patient surveys and activity-based cost accounting methods
• Facilitates referral optimization by matching patient needs with those providers best capable of meeting those needs
• Contracts for services on behalf of its members
• Usually includes a care management or care coordination infrastructure as well as an information technology infrastructure that serves multiple purposes

IPAs that want to become CINs to participate in VBC arrangements face a daunting list of tasks to transition successfully. Briefly, the list includes:

• Gain cultural buy-in
• Enlist strategic partners
• Create a sound business plan
• Establish an effective CIN governance structure
• Construct a robust IT infrastructure
• Attain capital and operational financing
• Understand contracting
• Implement marketing and business development[31]

A CIN’s clinical integration enables collaboration among independent providers to deliver high-quality care more efficiently. These independent physicians, hospitals, and other providers share responsibility for patient care across the community and share patient information to fulfill that responsibility. CINs have employed health information technology to improve current operations — increased quality and reducing cost and waste — while sustaining independence. They position themselves to negotiate with payors and employers to take advantage of opportunities in a value-based reimbursement market.[32] CINs thus offer legally structured collective rate negotiation yet entity/member independence.

Expansion of ACO Models with Increased Flexibility

The goal of the value movement is to incentivize providers to move away from the traditional FFS model and provide coordinated care for patients to improve quality and reduce cost. ACOs are a key mechanism to achieve this goal because they are offered along a continuum of varying financial risk and reward. They allow participants to progressively assume more risk while successfully managing the quality of care for patients. But, just as importantly, they are clinically integrated to assure better care coordination among the continuum of providers.

Medicare is leading the advancement of accountable care, currently operating several different ACO models, including various Medicare Shared Savings Program (MSSP) tracks, the Next Generation (Next Gen) ACO model, and the Direct Contracting models.[33] Private CINs, often sponsored by health systems, are following Medicare’s lead in setting up and operating similar value-based entities from the private payor insurer’s perspective.

In 2020, because of the drastic financial losses due to the COVID-19 pandemic, CMS outlined actions to demonstrate its commitment to being good partners with providers who commit to VBC. The changes include:

• Delaying the start date for the new Direct Contracting model from January 1 to April 1, 2021. The agency will adjust any quality benchmarks to reflect the new performance period. CMS also will start an application cycle during 2021 for a second cohort to launch on January 1, 2022. Multiple groups have complained that CMS hasn’t given enough details to ACOs on the contours of the model.
• Extending the Next-Gen ACO model through December 2021. The Next-Gen model calls on ACOs to take on more downside risk than in the MSSP. The model sunsets at the end of 2021, and CMS had privately told participants that it wouldn’t be back. For the 2020 performance year, CMS will reduce shared losses for Next-Gen ACOs during the months of the COVID-19 public health emergency (PHE). The agency also canceled a quality audit for 2019 and capped the ACOs’ gross savings upside potential at five percent.
• Extending the Oncology Care model, which centers on VBC payment arrangements in oncology practices for an additional year through June 2022. The agency also gives practices the option to forgo upside and downside risk performance for any periods of time affected by COVID-19. Practices that continue to participate in one- or two-sided risk will have any COVID-19 episodes removed from reconciliation for the performance periods.
• Delaying the start of the serious illness component of the Primary Care First model until April 1, 2021. The Primary Care First only component still started on January 1, 2021.
• Removing the downside risk for the Comprehensive Care for Joint Replacement model for any episodes from January 31, 2021 through the termination of the COVID-19 PHE period. CMS also extended the fifth performance year through March 2021.
• Giving participants in the Bundled Payments for Care Improvement Advanced model an option to eliminate upside or downside risks. Participants that choose to continue with two-sided risk will have COVID-19 episodes of care excluded.
• Extending the Comprehensive End State Renal Disease (ESRD) Care model through March 31, 2021. CMS reduced 2020 downside risk by reducing shared losses by the proportion of months throughout the PHE period. CMS also capped gross savings at five percent and removed the 2020 financial guarantee requirement.
• Removing episodes of care for the treatment of COVID-19 for the Medicare ACO Track 1+ model. The agency also gave participants a voluntary election to extend the agreement for one year through December 2021.
• Delaying the first performance period for the Kidney Care Choices model to April 1, 2021. CMS also created an application cycle during 2021 for a second cohort to launch in January 2022.

CMS has previously given regulatory relief for the MSSP and post-acute care programs, such as the long-term care quality program.[34]

Increased Retail Medicine

The competition is heating up among retailers such as CVS Health, Walgreens, and Walmart, pushing ahead with ambitious plans for in-store clinics and doctors. These options are growing in popularity for people who are hesitant to go to a doctor’s office because of possible exposure to COVID-19. Further, the retail clinics offer one-stop-shopping for help with managing chronic conditions, obtaining medications, and having laboratory tests done. Ease of access is also a major driver as consumers of all generations look for quick and less personal care (e.g., basic care that does not require a specialist). The services offered vary by retailer and may include dental, vision, behavioral care, fitness programs, assistance with insurance issues, and primary medical care. “Colds and sniffles” are extremely popular care for these settings. Price transparency is another feature, with price lists for an office visit, dental exams with X-rays, and therapy sessions for new patients, making healthcare more affordable and accessible for customers. Watch for ambitious measures by larger retailers that far exceed the current generation of retail clinics that offer urgent care for minor acute issues such as strep throat or an ear infection and routine care, such as vaccinations.[35]

Innovative Models for Wellness and Population Health

Another emerging trend that began in the last decade is population health. Population health strategies that improve access to healthcare and address social determinants of health may reduce emergency services. Studies show that positive results are occurring in reducing the rising rates of emergency department (ED) use and inpatient hospitalization in underserved communities that are home to many people with low socioeconomic status. For example, Scott & White partnered with the Dallas Park and Recreation Department to create a level-three primary care clinic integrating wellness and prevention programs in a city recreational center. The clinic, known as the Baylor Scott & White Health and Wellness Center at Juanita J. Craft Recreation Center, offers comprehensive health and wellness services with an emphasis on access to care, health education, nutrition, and physical activity. The Center is a model for population health, community collaboration, and innovation, all aimed at meeting the healthcare needs of the surrounding neighborhood in South Dallas.  The on-site health clinic has five exam rooms and two providers on staff. The physician and nurse practitioner work hand in hand with nutritionists, health educators, social workers, and other health professionals to provide quality care — all conveniently located.

ED and inpatient care use were examined over 12 months after initiation of services at the Center. People who used the Center's services showed a reduction in ED use of 21.4 percent and a reduction in inpatient care use of 36.7 percent, with an average cost decrease of 34.5 percent and 54.4 percent, respectively. These data support the use of population health strategies to reduce the use of emergency services and inpatient care. The Center exemplifies the integration of social determinants of health within a population health strategy.[36]

Recent Alignment Trends

U.S. hospitals will exceed $320 billion in losses in 2020 due to the impact of COVID-19, according to the American Hospital Association. Financial pressures will continue to be prevalent as more providers see a lifeline in partnering with larger organizations to remain competitive in today’s healthcare landscape. Expect to see more large health systems as organizations try to monetize large investments and drive synergies from scale.[37]

While the potential alignment structures seem unlimited, and some structures have been around for a while, recent transactions focus on the following:

• Employment with practice and acquisition
• Professional Services Agreements (PSAs) (with the leasing or purchase of ancillaries)
• Mergers
• Joint Ventures
• CCMAs (as a wraparound or standalone arrangement)
• Private Equity/Private Equity-Like Ventures
• CINs/ACOs

The following focuses on private equity (PE) and PSAs due to their growth in prominence.

Private Equity Intervention

A PE entity is an investment firm using institutional capital to purchase operating entities. The primary goal is to acquire an enterprise with compelling base value and then grow it through add-on acquisitions using additional leveraged capital. Platform or anchor acquisitions are the initial entity purchased by a PE sponsor within a defined region/state, which then entails the add-on acquisitions. Investments in healthcare entities may come directly from a PE firm or, more likely, through PE-sponsored platform companies.[38] In most deals where PE is referred, buyers are led by a platform company, instead of the actual PE firm.

In the sale of aggregated assets,[39] EBITDA[40] is expanded through, among other things, add-on acquisitions and improved efficiencies. The firm sells aggregated assets. The value is returned to investors through a liquidity event plus some ongoing earnings distribution.

PE intervention in healthcare transactions is having a significant impact on the industry. In previous years, PE investors were increasingly interested in deals in the healthcare sector, and the number of transactions grew. Now, the COVID-19 crisis is driving massive growth with the adoption of telehealth and telemedicine services.[41]  Those services are discussed in greater detail below.

PE firms focus upon practices that fulfill specific specialty niches or serve as anchors to grow and develop a presence within a defined geographical region. The following are the most commonly acquired medical groups from 2013 to 2016:

• Anesthesiology practices (19.4 percent)
   
• Multispecialty practices (19.4 percent)
   
• Emergency medicine (12.1 percent)
   
• Family practice (11.0 percent)
   
• Dermatology (9.9 percent)

The period from 2015 to 2016 showed an increase in the number of acquired cardiology, ophthalmology, radiology, and obstetrics/gynecology practices. Further growth in acquisitions in 2017 and 2018 showed growth, particularly in ophthalmology, dermatology, urology, orthopedics, and gastroenterology. A report of the acquired practices during 2017 and 2018 shows anesthesiologists represented 33.1 percent of all physicians; emergency medicine specialists, 15.8 percent; family practitioners, nine percent; and dermatologists. 5.8 percent.

That profile of practices with several sites and many doctors matches PE firms’ typical investment strategy of acquiring platform practices with large community footprints and then growing value by recruiting additional physicians, acquiring smaller groups, and expanding market reach.[42]

The goal is to promote critical mass to better manage costs, purchases, and payor reimbursement. PE allows physicians to retain some of their ownership (likely realizing some up-front value, as well).  This varies by deal and is largely dependent upon state healthcare regulatory laws, licensure laws, and corporate practice of medicine laws.  Also, this realization promotes a subsequent sale that may ignite more value and pay-out to the physicians. However, the up-front payment results in a physician compensation “haircut” in post-transaction compensation to the participating physicians.

In contrast to valuations performed before the pandemic, pricing is severely affected by current market volatility as the pandemic continues in 2021. Whether that trend will continue and what the deal environment will look like moving forward is undecided. Will valuations and pricing continue to be affected? 2021 and beyond will tell the story of current and future PE healthcare investing. PE investments are not for all physicians, but they may have an appeal to older physicians who may be looking for a good way to redeem their practice equity value at retirement.

Private Equity Models for Hospital/Physician Transactions

Hospitals are presenting PE-like arrangements to align physicians and hospitals. This concept makes sense because, until now, hospitals have been forced just to stand by and watch as PE firms enter their local markets, write large checks for practices, and then implement significant changes that have broader implications (and in some cases adverse effects) on that local healthcare market. Also, this model has a unique component for how a valuation can be derived that could increase the appeal for physicians to choose to partner in this structure with the hospital over a PE firm.[43]

PSAs

PSAs are an option physicians and hospitals prefer over full employment. Often considered as employment “lite,” these affiliations represent a significant partnership without encompassing standard employment. PSAs offer flexibility in structure, opportunities to increase and enhance the bottom line for both the hospital and the practice, stability in the relationship with the hospital, and bonus opportunities for exceptional performance. Additionally, PSAs offer opportunities to expand services together without being fully aligned through employment by the hospital or through a clinical integration model and a more effortless segue to full employment for physicians and staff.

A PSA transaction does not involve the sale of the practice, per se. The hospital does not purchase the physician’s practice. If agreed by both parties, the tangible assets may be sold or leased to the hospital through the PSA.

A practice may sell (or retain) ancillaries separately at fair market value. PSA rates are based on the group rate per work relative value unit (wRVU).[xliv] A PSA is similar to going to a single-payor contract where the PSA rate with the hospital ultimately becomes the sole source of revenue.  The practice may retain risk and overhead obligations. PSAs are often used by surgical specialists or proceduralists where reimbursement and ancillary reimbursement have declined. Multiple PSAs can exist simultaneously.

The following are the most common PSA models: traditional, global, carve-out, practice management arrangement, and hybrid models.

Traditional PSA

The hospital contracts with physicians for professional services, often reimbursed through a rate per wRVU. The hospital assumes ownership of the practice’s administrative structure by, among other things, employing all support staff, performing the billing and collection functions, and owning the accounts receivable. This arrangement is the most similar to employment, as the hospital takes over practice structure and management.

Global Payment PSA

The hospital contracts with the practice to provide professional services in exchange for a global rate per wRVU, which encompasses all physician compensation and benefits.  The practice also receives reimbursement for its fixed and variable overhead costs. The two parties work together through a joint management committee to adhere to annual budgets and oversee the overall relationship. However, the practice retains control of its practice entity and staff. Therefore, this model is most like the private practice model as the entire practice structure and its management remain fully independent. The practice entity is retained and contracts with the hospital; the administrative management and staff are not employed by the hospital, but the physicians are employed.

Carve-Out

Provider groups can opt to “carve-out” certain services, locations, specialties, subspecialties, or practice physicians to fall under the purview of a PSA. For example, a health system could contract with a private gastroenterology practice to provide endoscopies only, or a subset of providers could serve one community hospital while another subset could serve a competing hospital. The practice could set up a PSA only for a subset of the professional services or providers. All related administrative costs would be carved out as well and reimbursed by the respective partner organization.

Practice Management Arrangement

The hospital employs the physicians, thus making it markedly different from the traditional and global payment PSA models. The practice entity stays intact and contracts with the hospital for management services. The partner organization does not employ administrative management staff members of the practice. The practice remains existent and provides these services via a management contract (a corollary yet separate agreement from the PSA itself) and receives a corresponding fee set at fair market value.

Hybrid Arrangements

Countless variations of the models above are possible, allowing the prospective partners to mix and match the desired qualities of each within their specific PSA. For example, the hospital could employ or contract with physicians, and the practice entity could spin off into a jointly owned management services organization.

What’s Next for PSAs?

As innovation and responsiveness continue to be a key focus for all transactions, PSAs have continued to rise in popularity, given their ability to be structured in a wide range of models and meet various needs. Further, they can be significantly modified to meet any given situation’s nuances, creating the ability for “win-win” relationships. As noted previously, employment remains the dominant method of alignment. However, parties are increasingly open to PSAs with physicians often seeking to retain certain levels of independence and autonomy.

PSAs are viewed differently as to their level of integration. Most health systems view them as near full integration, while practices and physicians consider them complete affiliation. Realistically there is no right or wrong answer. However, other than an ability to unwind and return to private practice (mostly relevant to global payment PSAs), PSAs fall within the “full” integration category.

Finally, a PSA can be easily used in conjunction with virtually all other moderate and limited integration structures, establishing a strong foundation for continuous improvement of the continuum of care and service level in a community.[44]

The Rise of Virtual Medicine and Telemedicine

One of the most significant innovations over the past 30 years is in technology. The EHR, mobile health, telemedicine/telehealth, portal technology, self-service kiosks, remote patient monitoring tools, sensors and wearable technology, wireless communications, real-time locating services, and pharmacogenomics/genome sequencing, among others, have changed the practice of medicine.[46]  During the COVID-19 global pandemic, telemedicine helped to preserve personal protective equipment during a worldwide shortage, protect healthcare workers from being infected, monitor patients’ chronic conditions without putting them at risk by attending medical settings, and allow the efficient use of ED exam rooms.[47] The COVID-19 outbreak highlighted the advantages that telemedicine offers and has pushed many health systems to implement telemedicine services more widely across these institutions. Without the prompt from the pandemic, many health institutions would have continued to avoid the widespread implementation of telemedicine due to the high cost of investment in technology and the lack of parity in reimbursement by payors. They may never have realized all the benefits telemedicine has to offer.

In the near term, with the widespread adoption of telemedicine, patients’ reliance on nearby hospitals and physician groups will become less relevant in the consultation process. Easy-to-adopt, plug-and-play solutions will level the playing field for all doctors, including small practices, and will not require large technology infrastructures. Reimbursement for telemedicine instituted during the pandemic will likely become permanent in at least some ways. On July 13, 2021, CMS released an advance copy of the calendar year 2022 Medicare Physician Fee Schedule (PFS) proposed payment rule, which was published on July 23, 2021. While the proposed rule introduces some new virtual care services (including remote therapeutic monitoring), CMS rejected all requests to permanently add new telehealth services next year. Last year, CMS created a set of “Category 3” codes to designate telehealth services covered temporarily during the COVID-19 PHE, but for which CMS has not yet developed evidence sufficient to meet the requirements for permanent coverage. Practitioners have been asked to collect clinical data to help CMS determine whether these codes should be added on a permanent basis.

Currently, coverage of Category 3 codes lasts through the end of the calendar year in which the PHE ends, but CMS has proposed extending that expiration date to December 31, 2023. This move is intended to allow more time to compile data on Category 3 codes and utilization levels of these services during the PHE, and give stakeholders more opportunity to develop support for the permanent addition of these services to the Medicare telehealth services list.[48]

In an Interim Final Rule published on March 31, 2021, CMS authorized physicians to bill for telehealth visits as if they were office visits in response to the COVID-19 PHE. Since then, many hospitals have pointed out that there was no mechanism for a hospital to bill an originating facility fee for a telehealth service performed by a physician from a hospital outpatient department or other provider-based clinic.  Consequently, these services were reimbursed less when performed from a hospital site, as compared to a physician office site (The UB92 hospital outpatient billing form does not provide for billing of a telehealth originating site facility fee because the patient is not physically present at the hospital). This issue was raised repeatedly by providers during the CMS “Office Hours” teleconferences, during which CMS acknowledged the inconsistency and promised to release additional guidance.[49]

The CARES Act, the Coronavirus relief bill passed by Congress and signed by President Trump in March 2020 expanded Medicare coverage for telehealth. The $2 trillion Coronavirus relief package includes several telehealth provisions, including more relaxed guidelines for Medicare coverage and new allowances for connected health at federally qualified health centers, rural health clinics, and hospices. Round two of the CARES Act provides $249 million to support physicians by providing reimbursement of services necessary for telehealth. Additional funds will be made available to reimburse physicians for telecommunications services, information services, and connected devices essential to enable telehealth during COVID-19.[50] The changes triggered by the CARES Act were intended to last only until the PHE was considered over.[51]

Telehealth was a viable service before the pandemic, but it was reimbursed at lower rates than in-office visits. There were geographical restrictions that placed strict parameters on where a patient could access virtual healthcare services – as well as where a clinician could treat them. It was, in a word, limited. Now, with many of those restrictions lifted at least temporarily, hospitals, insurers, and patients are starting to see some of the downstream effects, and all parties are wondering how virtual care will look, and what it will be like, when the pandemic is finally in the rearview mirror. 

While unfortunate that it took a pandemic event to heighten awareness, telemedicine is here to stay and will continue to comprise a greater percentage of total care. Already the industry is seeing utilization change as a result, and payment parity is on both payors' and providers' minds. Regrettably, some private payors are considering rolling back the payment arrangements made to physicians during the early months of the pandemic due to the payors’ extensive financial losses.[lii]

There is broad recognition that telehealth services have helped ensure access to necessary care during the COVID-19 pandemic. As the pandemic continues, additional reforms are necessary to ensure that telehealth services become an integrated part of VBC. However, attention must be paid to Section 1834(m) of the Social Security Act, which, without further action by Congress, will lead to most Medicare beneficiaries losing access to telehealth services at the end of the PHE. The expansion of and advances in telehealth services during the pandemic provide important benefits to Medicare beneficiaries that the elimination of restrictions on coverage in Section 1834(m) would allow to continue once the pandemic subsides.[53]

Conclusion

“Change is the only constant in life,” said Heraclitus, the Greek philosopher, in contrast to King Solomon’s wisdom. Heraclitus was a pioneer of wisdom who lived 500 years before Jesus Christ and 400 years later than Solomon. His thoughts fed into the writings of Aristotle and Plato.

The changes in healthcare over 30 years are monumental and ongoing. As the healthcare industry continues to move toward VBC, more robust relationships between physicians and hospitals will be critical. The focus has shifted from employment to various transaction models that are far from the simple structures of the 1980s and 1990s and even the first and second decades of the new century. Although all such arrangements varied in success, they laid the groundwork for today’s arrangements, perhaps affirming that there is nothing [entirely] new under the sun. Today’s structures are increasingly complicated, as they offer better options to physicians who historically avoided alignment. Legal and regulatory requirements abound, and their consideration must accompany all aspects of every transaction, even more than ever.

APPENDIX A

Healthcare Market Paradigm Shifts

The past 30 years have seen an overall change in basic assumptions from a traditional healthcare delivery model to an accountable care era of healthcare delivery. An aspect of the new era encompasses VBC, which focuses on value rather than volume. Here are some examples of the differences:

Footnotes

1. Terry, K., Slow Walking to Value-Based Care: Why Fee for Service Still Rules, The Health Care Blog (2020), https://thehealthcareblog.com/blog/2020/08/26/slow-walking-to-value-based-care-why-fee-for-service-still-rules/.  On November 20, 2020, the U.S. Department of Health and Human Services (HHS) finalized reforms to the federal Anti-Kickback Statute and the Stark Law to reduce regulatory barriers to care coordination and accelerate the transformation of the healthcare system to promote payment for value and the delivery of coordinated care. The changes took effect on January 19, 2021 (except for a Stark law provision affecting group practice profit shares which becomes effective January 1, 2022). The final rules facilitate a range of arrangements to improve the coordination and management of patient care and the engagement of patients in their treatment if all applicable regulatory conditions are met. (Source: Haynes & Boone. Stark and AKS Final Rules Effective January 19, 2021, https://www.haynesboone.com/news/alerts/health-law-vitals-january-2021.)
2. DECO, Understanding Fee-for-Service and Value-Based Care, https://www.decorm.com/understanding-fee-for-service-and-value-based-care/.
3. Himber, V.,  9 Reasons to Offer Small Business Health Insurance  (Jan. 11, 2021), https://www.ehealthinsurance.com/resources/small-business/9-reasons-to-offer-small-business-health-insurance.
4. Strilesky, M., et al., Hospital Efficiency Programs—an innovative model to help providers achieve risk capability as they prepare for risk-based payments (2015), https://www.dhg.com/Portals/0/ResourceMedia/publications/DHGHC_RiskCapable_Whitepaper.pdf.
5. Greeter, A., Harrison, T., & Ropski, L., Physician Empowerment in the Hospital: An Overview of Clinical Co-Management Agreements (2016), https://cokergroup.com/wp-content/uploads/2019/02/Physician_Empowerment_in_the_Hospital_-_An_Overview_of_CCMA_November_2016.pdf.
6. Office of the Inspector General, Special Advisory Bulletin, Gainsharing Arrangements and CMPs for Hospital Payments to Physicians to Reduce or Limit Services to Beneficiaries (1999), https://www.oig.hhs.gov/fraud/docs/alertsandbulletins/gainsh.htm.
7. Grandusky, R. & Kronenberg, K., Hospital-Physician Gainsharing, Back to Basics, Navigant Consulting, https://www.jonesday.com/files/Publication/66fdb136-0fa7-4b89-8ff6-003f06b27574/Presentation/PublicationAttachment/476ab65d-2da8-469b-8ca0-047cf8aa6dbd/March%20Back%20to%20Basics.pdfThe  OIG-Approved Gainsharing Safeguards are: 1) Programs will be transparent, with clearly identified cost-saving actions and resulting savings that allow for public scrutiny and individual physician accountability. 2) the physicians will offer credible medical support for the position that the cost-saving recommendations would not adversely affect patient care. 3) Payments will be based on all procedures, regardless of payor, and savings that result from procedures related to federal healthcare programs are subject to a cap. 4) Procedures to which the cost-saving program applies will not be performed disproportionately on federal healthcare program beneficiaries or a generally healthier mix of patients. 5) Each cost-saving mechanism will be tracked separately to preclude shifting cost savings. 6) Objective historical and clinical measures will be used as benchmarks to protect against inappropriate service reductions. 7) After the arrangement is implemented, individual physicians will have discretionary judgment to select cardiac (or other) devices to use for specific patients. 8) The program is of a limited, one-year duration. (It is unclear as to whether the OIG will approve multiyear programs. In a footnote to the advisory opinions, the OIG indicated that “any renewal or extension of the Proposed Arrangement should incorporate updated base year costs.”). 9) The hospital and the physician groups involved in the gainsharing program will provide written disclosures of their participation in the cost-saving measures about arrangements for patients whose care may be affected. 10) Financial incentives will be limited to a reasonable duration and monetary amount. 11) Participating physician groups will distribute their profits on a per capita basis, thus restricting the incentive for individual physicians to generate disproportionate cost savings through these programs.
8. Health Care/System Redesign, Agency for Healthcare Research and Quality,  https://www.ahrq.gov/ncepcr/tools/redesign/index.html.
9. What is Population Health? Centers for Disease Control and Prevention, https://www.cdc.gov/pophealthtraining/whatis.html.
10. Bires, S., McMurray, M., & Coffin, J., Clinically integrated networks: Guidelines and common barriers for establishment, Medical Economics (2019), https://www.medicaleconomics.com/view/clinically-integrated-networks-guidelines-and-common-barriers-establishment.
11. Wardrop, T. & Corneliuson, S., Super clinically integrated networks: 8 components to consider, Managed Care Executive (2015), https://www.managedhealthcareexecutive.com/view/super-clinically-integrated-networks-8-components-consider.
12. Shahzad, M., Upshur, R., Donnelly, P., et al., A population-based approach to integrated healthcare delivery: a scoping review of clinical care and public health collaboration, BMC Public Health 19, 708 (2019), https://bmcpublichealth.biomedcentral.com/articles/10.1186/s12889-019-7002-z.
13. “The ‘New’ Health Care Consumerism," Health Affairs Blog (Mar. 5, 2019),  https://www.healthaffairs.org/do/10.1377/hblog20190304.69786/full/. 
14. What is Consumerism in Healthcare, NRC Health (2016), https://nrchealth.com/what-is-consumerism-in-healthcare/.
15. Cordina, J. & Greenberg, S., Consumer decision making in healthcare: The role of information transparency, McKinsey & Company (July 13, 2020), https://www.mckinsey.com/industries/healthcare-systems-and-services/our-insights/consumer-decision-making-in-healthcare-the-role-of-information-transparency.
16. Walker, B., Whatever the Fate of the ACA, Here's Why Healthcare Consumerism is Here to Stay, Patient Bond Blog (Aug. 3, 2017), https://insights.patientbond.com/blog/healthcare-consumerism-here-to-stay-aca-or-no.
17. Pipes, S., Price Transparency: A Gift to Americans in the New Year, Forbes (Jan. 4, 2021), https://www.forbes.com/sites/sallypipes/2021/01/04/price-transparency-a-gift-to-americans-in-the-new-year/?sh=6683ec665b9d.
18. HHS Announces Rule to Protect Consumers from Surprise Medical Bills, Press Release (July 1, 2021), https://www.hhs.gov/about/news/2021/07/01/hhs-announces-rule-to-protect-consumers-from-surprise-medical-bills.html.
19. Reed, T., Wave of consolidation may be coming as independent physicians report COVID-19 concerns: McKinsey, Fierce Healthcare (2020), https://www.fiercehealthcare.com/practices/wave-consolidation-may-be-coming-as-independent-physicians-report-covid-concerns-mckinsey.
20. The Impact of Hospital Consolidation on Medical Costs, NCCI Insights (July 11, 2018),  https://www.ncci.com/Articles/Pages/II_Insights_QEB_Impact-of-Hospital-Consolidation-on-Medical-Costs.aspx.
21. Pope, C., How the Affordable Care Act Fuels Health Care Market Consolidation, The Heritage Foundation (Aug. 1, 2014), https://www.heritage.org/node/11274/print-display.
22. Singh, A., et al., M&A Quarterly Activity Report: Q2 2021, Kaufman Hall,  https://www.kaufmanhall.com/sites/default/files/2021-07/kh-ma-2021-q2-activity-report_final.pdf
23. Quadax, New Trends in Healthcare Mergers and Acquisitions, Blog Post (May 5, 2021),  https://blog.quadax.com/new-trends-in-healthcare-mergers-and-acquisitions.
24. CMS.gov, What are Accountable Care Organizations (ACOs)?, https://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/ACO.
25. Henderson, J., This Tactic Helps Hospitals Ease Merger Scrutiny, Medpage Today (2021), https://www.medpagetoday.com/special-reports/exclusives/91907.
26. The six health insurance companies receiving orders from the FTC are Aetna Inc., Anthem, Inc, Florida Blue, Cigna Corporation, Health Care Service Corporation, and United Healthcare.
27. Press Release: FTC to Study the Impact of Physician Group and Healthcare Facility Mergers, Federal Trade Commission (Jan. 14, 2021), https://www.ftc.gov/news-events/press-releases/2021/01/ftc-study-impact-physician-group-healthcare-facility-mergers.
28. Liss, S., Hospital mergers to get added scrutiny under Biden order, Healthcare Dive (July 12, 2021), https://www.healthcaredive.com/news/hospital-mergers-to-get-added-scrutiny-under-biden-order/603094/.
29. Independent Physician Associations (IPAs) Definition (2019), AAFP, https://www.aafp.org/about/policies/all/independent-physician-associations.html. 
30. Should I Join an IPA or CIN? Podcast, The Private Medical Practice Academy (May 25, 2021), https://www.thepracticebuildingmd.com/blog/should-i-join-an-ipa-or-cin.
31. Reiboldt, M. & Knight, E.M., Repositioning from IPA to CIN, Coker Group (April 2015),  http://cokergroup.com/wp-content/uploads/2015/08/Repositioning-from-IPN-to-CIN1.pdf. 
32. To Sustain the Value Movement, Make Next Generation ACOs A Permanent Option, Health Affairs Blog (2021), https://www.healthaffairs.org/do/10.1377/hblog20210406.638292/full/. 
33. King, R., CMS offers flexibility for value-based care models affected by COVID-19, Fierce Healthcare (2020), https://www.fiercehealthcare.com/payer/cms-gives-key-flexibility-for-value-based-care-models-affected-by-covid-19.
34. Clinically Integrated Networks and Population Health: Taking the Next Step. Caradigm (2014),  https://www.beckershospitalreview.com/pdfs/white-papers/Caradigm_Clinically%20Integrated%20Networks.pdf.
35. Ladika, S., Healthcare goes retail, Managed Healthcare Executive Volume 30, Issue 9 (Sept. 22, 2020), https://www.managedhealthcareexecutive.com/view/healthcare-goes-retail.
36. Wesson, D., Kitzman, H., Halloran, K.H., & Tecson, K., Innovative Population Health Model Associated with Reduced Emergency Department Use and Inpatient Hospitalizations, Health Aff (Millwood) (2018), https://pubmed.ncbi.nlm.nih.gov/29608367/.
37. Martin, G., Top 10 Emerging Trends in Health Care for 2021: The New Normal, AHA Trustee Services, https://trustees.aha.org/top-10-emerging-trends-health-care-2021-new-normal.
38. A private equity platform company is the initial acquisition made by a private equity firm in a specific industry or investment type. This acquisition will serve as the foundation for a roll-up of other companies acquired in the same industry.
39. Aggregate Assets means the value of the sub-advised assets and the other accounts on the valuation date during the applicable calendar month. The values for the sub-advised assets and other accounts shall be as reported by the applicable custodian and fund administrator. Law Insider, https://www.lawinsider.com/dictionary/aggregate-assets. 
40. EBITDA – Earnings Before Interest, Taxes, Depreciation, and Amortization, https://www.investopedia.com/terms/e/ebitda.asp.
41. Segal, P., et al., Healthcare Private Equity Investing in 2021, The Deal (Dec. 15, 2020), https://www.thedeal.com/events/healthcare-private-equity-investing-in-2021/.
42. Finnegan, J., Private equity firms are acquiring more physician practices. Which specialties are in highest demand? Fierce Healthcare (Feb. 18, 2020), https://www.fiercehealthcare.com/practices/acquisition-physician-practices-by-private-equity-firms-increases-study-finds-which.   
43. Reiboldt, M., Pursuing the Private Equity Model for Hospital-Physician Transaction, White Paper (July 22, 2019), https://cokergroup.com/wp-content/uploads/2019/08/Private-Equity-Model-for-Hospital-Physician-Transactions_07222019.pdf.
44. A metric that can help practices track productivity more closely is the work relative value unit (wRVU). The wRVU measures the amount of completed work (provider time, skill, and effort) instead of the actual dollar amounts associated with the work. Also, the wRVU is a universal measure, which means that a practice can compare the productivity of physicians in different specialties.
45. Reiboldt, M., Greeter, A., & Cowart, T., PSA Progression: What’s Next in the Evolution of Professional Services Agreements? Coker Group (October 2020), https://cokergroup.com/wp-content/uploads/2020/10/PSA-Progression_Whats-Next-in-the-Evolution-of-PSAs.pdf.
46. Seivert, S. & Badowski, M.E., The Rise of Telemedicine: Lessons from a Global Pandemic, EMJ Innov., EMJ Reviews (2021), https://www.emjreviews.com/innovations/article/the-rise-of-telemedicine-lessons-from-a-global-Pandemic/.
47. Mayo Clinic, Neurology and Neurosurgery Telemedicine offers benefits in the COVID-19 era and beyond (2021), https://www.mayoclinic.org/medical-professionals/neurology-neurosurgery/news/telemedicine-offers-benefits-in-the-covid-19-era-and-beyond/mac-20506813.
48. Medicare Proposes New Changes for Telehealth Services in 2022, Foley & Lardner LLP, The National Law Review, Volume XI, Number 204 (2021), https://www.natlawreview.com/article/medicare-proposes-new-changes-telehealth-services-2022.
49. Hospital Billing of Telehealth Visits During COVID-19 Pandemic, Powers, Pyles, Sutter & Verville (May 12, 2020), https://www.powerslaw.com/hospital-billing-of-telehealth-visits-during-covid-19-pandemic/.
50. H.R. 748, One hundred Sixteenth Congress of the United States of America, ”Coronavirus Aid, Relief, and Economic Security Act’’ or the ‘‘CARES Act,’’ https://www.congress.gov/116/bills/hr748/BILLS-116hr748enr.pdf.
51. Mallow, J.A. & Davis, S., Health insurers are starting to roll back coverage for telehealth—even though demand is way up due to COVID-19, The Conversation (Oct. 27, 2020), https://theconversation.com/health-insurers-are-starting-to-roll-back-coverage-for-telehealth-even-though-demand-is-way-up-due-to-covid-19-147648.
52. Many private payors followed Medicare’s suit and paid providers who conducted telehealth visits at the same rate as office visits. Now, that’s all changing due to financial loss by insurance companies. As of October 1, 2020, telehealth visits are not always paid at the same rate as in-person services. Many private insurers are pulling back some of their coverage of telehealth for non-COVID issues.
53. Congress: Act Now To Ensure Telehealth Access For Medicare Beneficiaries, Health Affairs Blog (May 10, 2021), https://www.healthaffairs.org/do/10.1377/hblog20210505.751442/full/.