This content is for members only. Currently redirecting you to log in …
Regarding Board Report 13 (Previously ’22 BR 10): House of Delegates Composition, I think that the Tenenbaum Law Group report that these Board of Trustee recommendations are based off should be released to all PAMED members. It does not make sense to vote on a policy based on information and data that members cannot access.
Regarding Board Report 13 (Previously ‘22 BR 10): House of Delegates Composition
I think that in a show of transparency, the Tenenbaum Law Group report that these Board of Trustee recommendations are based off should be released to all PAMED members.
In 2023, students/residents made up 31.1% of membership but received only 13.9% of the county delegates, while physicians who made up 68.9% of membership received 86.1% of the delegates. Comparing 2023 to 2022, students/residents lost 4,380 members and lost 43 county delegates, while physicians lost 2,282 members and gained 3 delegates. To put it another way, in 2022 the delegates per member for students/residents was almost half that of physicians. In 2023, that number dropped to almost one-third. As written, these resoled clauses will further disenfranchise medical students, residents, and fellows. The House of Delegates (HOD) should fairly represent those who they aim to serve—its members. As long as that includes medical students, they should be fairly represented.
Regarding Board Report 5: Resolution 22-405: Against Direct Contracting Entities I was told that the reason for the reversal of the February Board of Trustees decision to approve this resolution was due to the following:
"One member produced a productive argument for the direct contacting entities equating them to an FQHC. The resolution asks PAMED to request a stop to the program. I believe it was also mentioned that the resolution may have prohibited certain members or groups from engaging with direct contact entities.”
I wanted to share some additional information as I feel this resolution should be adopted as written: adoption of Board Report 5:
1. Direct Contracting Entities, henceforth referred to as ACO REACH, should not be equated to a Federally Qualified Health Center (FQHC). That someone would do so demonstrates how little they understand the issue. A FQHC is a physical entity that is a safety net provider that primarily provides services typically furnished in an outpatient clinic. FQHCs include community health centers, migrant health centers, health care for the homeless health centers, public housing primary care centers, and health center program “lookalikes.” ACO REACH is an insurance middleman between Medicare and physicians. They have zero physical presence and instead act similar to an accountable care organization (ACO).
The major difference between the traditional ACO's formed under the Affordable Care Act are the loopholes built into the program that allow profiteering, which has attracted private equity groups who make up the majority of ACO REACH participants. Attached is a letter from another physician group to HHS highlighting some of the ACO REACH participants with a history of health care fraud. One of the major selling points the ACO REACH program touts is that physicians will have at least 75% control of the board. However, The door is left open to accommodating a lower threshold for ACO REACH organizations that submit proposals detailing the current governing body and ways Participant Providers will be involved in governance. In the Request for Applications from CMS is states (https://innovation.cms.gov/media/document/aco-reach-rfa):
"The ACO may seek an exception from the 75 percent control requirement by submitting a proposal to CMS describing the current composition of the ACO’s governing body and how the ACO will involve Participant Providers in innovative ways in ACO governance. Any exception to the 75 percent control requirement will be at the sole discretion of CMS."
There are two main issues with this:
1) What would be equivalent to being on the board with voting rights? Given CMS's track record of oversight on this program, I imagine that they will side with whatever the ACO REACH organization says is "innovative". For example, they said that DCE's would need to apply and meet the requirements of ACO REACH, and instead they grandfathered them in. They also said, "participants must have a strong compliance record" and instead a number of DCE's/ACO REACH participants have a history of health care fraud or other malfeasance. In Pennsylvania this includes, but is not limited to:
Parent company: Centene (primarily Medicare Advantage and Medicaid managed care insurer) DCEs: 1) Complete Health Accountable Care, LLC (AL, FL); 2) Accountable Care Coalition of Direct Contracting, LLC (AR, CA, CT, DE, FL, GA, HI, IA, IL, IN, KS, MA, ME, MI, MS, NC, NH, NJ, NY, OH, PA, RI, SC, TX,VA, WA); 3) Accountable Care Coalition of Southeast Texas, Inc. (TX) ● Overcharged the VA by nearly $100 million: In 2021, Centene subsidiary Health Net agreed to repay the Dept. of Veterans Affairs $97 million for inflated and duplicate claims it billed the agency while acting as a third-party administrator securing private care for veterans. ● Overcharged state Medicaid plans by hundreds of millions: Centene has faced a string of investigations stemming from its pharmacy benefit manager subsidiary repeatedly overcharging Medicaid for prescription drugs. The settlements include $165 million in Texas, $88 million in Ohio, $56 million in Illinois, $55 million in Mississippi, $27 million in Kansas, $21 million in New Hampshire, $19 million in Washington, $15 million in Arkansas, and $14 million in New Mexico, with reports of an ongoing investigation in California as of October 2022.
Parent company: Clover Health (primarily a Medicare Advantage insurer) DCE: Clover Health Partners, LLC (AL, AR, AZ, CO, FL, GA, IL, IN, KS, MO, MS, MT, NJ, NM, NY, OH, OK, PA, RI, SC, TN, TX, VT) ● Fined by CMS for Medicare Advantage marketing: In 2016, CMS fined Clover for using “marketing and advertising materials that contained inaccurate statements” about coverage for out-of-network providers, after a high volume of complaints from patients who were denied coverage by its MA plan. Clover had failed to correct the materials after repeated requests by CMS. ● Department of Justice investigation: As of 2021, Clover was reportedly under investigation by the DOJ for at least 12 issues, including possible kickbacks, marketing practices, and undisclosed third-party deals (Clover responded to the report alleging the existence of the investigation and acknowledged that it had received a request for information from the DOJ, but denied all wrongdoing). We do not know the status of the DOJ’s investigation. ● SEC investigation: In 2021, the Securities and Exchange Commission launched an investigation of Clover due to its failure to disclose the DOJ investigation with shareholders. We do not know the status of the SEC’s investigation.
Parent company: Vively Health (home-based care provider) DCE: Vively Health (AL, AR, AZ, CA, CT, FL, GA, IL, LA, MD, MI, MN, MS, NC, NE, NJ, NM, NV, NY, OH, OK, PA, SC, TN, TX, VA, WA, WI) ● Creating drug wastage for Medicare reimbursement: In 2015, Vively (then called DaVita Healthcare Partners) paid $450 million to settle claims that the company “violated the False Claims Act by knowingly creating unnecessary waste in administering the drugs Zemplar and Venofer to dialysis patients, and then billing the federal government for such avoidable waste.” ● Improper billing of federal health programs for medication: In 2017, DaVita paid $63.7 million to settle claims that the company improperly billed health care programs for “prescription medications that were never shipped; that were shipped, but subsequently returned; and that did not comply with requirements for documentation of proof of delivery, refill requests, or patient consent.” ● Submitting inaccurate information for inflated Medicare payments: In 2018, DaVita subsidiary Healthcare Partners, a Medicare Advantage provider, paid $270 million to settle claims that the company submitted inaccurate information to receive inflated payments from Medicare. The DOJ reported that the company voluntarily disclosed practices, including that it had “disseminated improper medical coding guidance instructing its physicians to use an improper diagnosis code for a particular spinal condition that yielded increased reimbursement from CMS.” The settlement also resolved claims from a whistleblower that Healthcare Partners engaged in “one-way” chart reviews, looking through patient records for diagnoses to add to its coding forms while ignoring inaccurate codes that should’ve been deleted
2) CMS uses a broad definition of ”provider” (https://innovation.cms.gov/media/document/aco-reach-rfa):
Participant Providers may include, but are not limited to:• Physicians or other practitioners in group practice arrangements• Networks of individual practices of physicians or other practitioners• Hospitals employing physicians or other practitioners• Federally Qualified Health Centers (FQHCs)• Rural Health Clinics (RHCs)• Critical Access Hospitals (CAHs)Physicians are just one of many groups listed under "provider". The term is being used a catchall that can encompass hospital administrators, nurses, etc. And like most organizations, the ACO REACH organization holds the power to appoint (or remove) voting board members, ensuring that their corporate interests are the deciding voice.
Also, explicitly against PAMED & AMA policy, the ACO REACH program expands the scope of practice for nurse practitioners (https://innovation.cms.gov/media/document/aco-reach-rfa)
and it will be expanded to include Physician Assistants on 7/1/23 (https://www.jdsupra.com/legalnews/cms-issues-additional-flexibilities-to-7048684/):
Specifically, CMS intends to issue waivers as necessary to test the ACO REACH Model to allow Nurse Practitioners and Physician Assistants:• To certify a REACH Beneficiary’s need for hospice care;• To certify a REACH Beneficiary’s need for diabetic shoes;• To order and supervise cardiac rehabilitation for a REACH Beneficiary;• To establish, review, sign, and date a REACH Beneficiary’s home infusion therapy plan of care; and• To refer a REACH Beneficiary for medical nutrition therapy.
2. This is incorrect. Nowhere in the resolution does prohibit any members or groups from engaging with ACO REACH.
Thank you for the comment! Your comment must be approved first
You've already submitted a review for this item
Thank you! Your review has been submitted successfully
Login to be able to comment
Comment cannot be empty
Rating is required
You typed the code incorrectly. Please try again