Author: Martin Merritt

On Dec. 3, CMS issued a final rule giving the agency greater power to deny or revoke enrollment to providers, by scrutinizing employees and owners of providers, who may have a less than stellar history with the Medicare program. The government is also considering greater reliance on the IRS to assist with delinquent recoupment collections.

Among the highlights:

· Adding the ability to deny the enrollment of providers, suppliers, and owners affiliated with an entity that has unpaid Medicare debt. CMS says this will help prevent individuals and entities from being able to incur substantial debt to Medicare, leave the Medicare program, and then re-enroll as a new business to avoid repayment of the outstanding Medicare debt. CMS will only enroll otherwise eligible individuals or entities if they repay the debt or enter into a repayment plan.

· Adding the ability to deny the enrollment or revoke the billing privileges of a provider or supplier if a managing employee has been convicted of certain felony offenses. This provision ensures that CMS can block or remove bad actors from the Medicare program to protect beneficiaries and safeguard the Medicare trust funds.

· Permitting CMS to revoke billing privileges of providers and suppliers that have a pattern or practice of billing for services that do not meet Medicare requirements. This is intended to address providers and suppliers that regularly submit improper claims in such a way that it poses a risk to the Medicare program.

Meanwhile, The Hill reported recently that, “Twenty-five Republicans are asking the Supreme Court to take up another case against Obamacare, this time challenging a controversial medical board that the party has labeled ‘a death panel.'” The dust-up, this time, involves something called the Independent Payment Advisory Board (IPAB), which is charged with cutting Medicare spending if it exceeds a certain level.

Why are these two stories related? The new CMS rules and the IPAB issue perfectly describe the Medicare and Medicaid problem. Spend too much, then make the only rules anyone can actually agree on: Those which punish physicians and providers.

The idea behind IPAB is that we can’t afford to keep spending as if there were no tomorrow, but we can’t trust elected officials to ever say, “No, we can’t afford it.” IPAB was designed to make these hard “end-of-life vs. how much it costs” choices; makes perfect sense, even if the solution isn’t perfect.

Common fiscal sense, however, goes out the window, when politics are factored into the equation. The result is a government which spends way too much and won’ t make hard choices about cutting spending.

Instead, we continue to create a system in which it is possible for physicians and providers to rack up huge amounts in “Medicare debt,” and then must enter an agreement to work it off, or they cannot find work at all.

Maybe this new rule will only be targeted at the really bad apples; I am not so sure. I am starting to hear echoes of Tennessee Ernie Ford’s Dust Bowl song, “Sixteen Tons,” about company stores, and company debt, which can never be worked off.

Read Article on Physicians Practice

The midterm elections are over, Congress is controlled by conservative Republicans, and five key governor’s races went to candidates who vowed never to expand Medicaid in their states. This brings me to a November 3 New York Times article which posed an interesting question: Suppose the Supreme Court had not struck down the Affordable Care Act’s provision forcing states to expand Medicaid? How would the healthcare uninsured landscape differ?

In order to recap, the Affordable Care Act recognized that as a system, health insurance works best if there is universal coverage. It does not matter whether universal coverage is obtained voluntarily or through something akin to blackmail.

Medicaid is a federal program created in 1965 along with Medicare. Unlike Medicare, Medicaid is partially funded by the U.S. government, but is administered by the individual states, free to set their own eligibility requirements. The amount of federal money provided to each state depends upon a number of factors. States must pay for the remainder of Medicaid costs. The reform law forced individuals and businesses to purchase health insurance, and attempted to coerce states into expanding Medicaid. Many refused. Thanks to a Supreme Court opinion holding that states cannot be penalized for exercising a right to choose not to expand, Medicaid expansion never got off the ground in holdout states.

Congress recognized some of the poorer states lack the budget to pay for Medicaid expansion, thus Congress included a “carrot.” Under the law, the federal government promised to pay all the costs of these “newly eligible” …. but not forever. Trouble was, the law also carried a “stick.” The states were given a “choice” under severe penalty for choosing unwisely: Either expand Medicaid, or lose federal Medicaid funding altogether. The U.S. Supreme Court struck this provision down, as unconstitutionally coercive. The world’s originator of national healthcare, Germany’s Otto Von Bismarck, was probably correct in his observation in the late 1800’s, “Laws are like sausages, best that you don’t watch either being made.” At any rate, a major pillar of the Affordable Care Act, coerced Medicaid expansion was dead.

Two years later, the Times wonders, “what might have been,” but for Supreme Court meddling. The article shows two maps which look like Petri dishes showing microbe growth. The map on the right shows the uninsured population if Medicaid expansion was upheld. It appears remarkably free and clear of clusters of “bad things.” The map on the left is rather heavily populated with darker dots representing uninsured.

The bias in the drawing implies that an epidemic of “bad things” could have been be avoided, (and utopia achieved), if Medicaid had been expanded as Congress intended. That’s ridiculous.

Simply placing a large portion of the population into an unfunded, or underfunded government insurance program, which doctors likely will eschew, does not mean the problem of the uninsured population has been solved.

According to a 2014 Merritt Hawkins study, Medicaid pays so poorly compared to Medicare, very few physicians are willing to accept current Medicaid patients.

In many of the states where the expansion would have been forced, the acceptance rate is around three out of 10 doctors. Clinics accepting Medicaid can’t always see new patients quickly. Many further believe Medicaid patients are more likely to sue for malpractice. If a patient can find a doctor, the below-cost reimbursement levels result in clinics which are understaffed, and lack modern equipment.

Medicaid is largely seen as a socialized dystopian mess, requiring physicians to take on too many patients, which means something akin to Soviet bread lines, with no margin for profit.

Now that the elections are over, the more troubling question isn’t so much whether Medicaid will ever be expanded, but instead: Who will take will take care of people who are simply too poor to afford basic healthcare?”

Read Article on Physicians Practice

As a health lawyer working in Dallas, I have some new heroes. Chief among them, Dallas Presbyterian nurses, Nina Pham (pictured below) and Amber Vinson. Lying in a hospital bed in northeast Dallas fighting the deadly Ebola virus, Pham is worried that she’s let us down. No ma’am, we let you down. Nina Pham, Amber Vinson, and the remaining health workers at Presbyterian Hospital were completely unprepared by the CDC to handle a patient infected with Ebola.

Nevertheless, Pham and Vinson bravely did their duty. As Lincoln said at Gettysburg, it seems to me the “last full measure of devotion” these dedicated nurses can give, is to put their lives at risk for the good of a patient. Pham and Vinson deserve the highest praise for their selfless dedication to patient care.

Texas Health Presbyterian Hospital in Dallas is one of the finest hospitals in the nation. If there is a better hospital in Texas, I don’t know about it. If there are better healthcare professionals in the world, I don’t know where to find them. But they were not prepared for an Ebola patient.

AP Photo/ tcu360.com

That didn’t stop nurses and doctors from doing their jobs the best way they knew how.

According to an unconfirmed statement released by National Nurses United (NNU), the largest U.S. nurses’ union.

There were no protocols in place for dealing with the crisis. Once Ebola patient Thomas Eric Duncan, the first person to be diagnosed with Ebola in the U.S., was admitted to the hospital, he was “left in an open area of a Dallas emergency room for hours, and the nurses treating him worked for days without proper protective gear and faced constantly changing protocols.” According to NNU, the nurses’ statement said they had to “interact with Duncan with whatever protective equipment was available,” even as he produced “a lot of contagious fluids.” Duncan’s medical records, which his family shared with The Associated Press, underscore some of those concerns. It appears that nurses were forced to use surgical tape to attempt to seal seams of protective clothing, unaware the greatest risk appears to be the removal of such protective wear. Many days passed before Tyvek suits, triple gloves, triple boots, and respirator caps became available.

After Pham fell ill, followed by Vinson, reports reveal the hospital is now in freefall. Patients are cancelling doctor’s appointments. Parking lots are empty. The CDC are in no better position. Statements issued by the CDC first blamed Pham for getting sick, then blamed Vinson for violating CDC policy in boarding an airplane while symptomatic. I’ll say it, “Please stop it. They didn’t fail us, you did.” It should be clear by now that these women would have done anything to protect the public, if they had only been given proper guidance from the CDC.

Time will tell how bad this situation will become. But to Pham and Vinson and the other dedicated healthcare professionals at Presbyterian, we in Dallas would like to simply say, “Thank you.”

Read Article on Physicians Practice

A managed care tug-of-war has been ongoing for well over two decades between physicians and insurance companies. Managed care networks require physicians to agree by contract to a limited reimbursement schedule, in exchange for placement on the insurer’s approved list of providers. Now, physicians are being advised that they have been terminated from the provider network, which termination often falls into one of three categories: termination without cause; termination for cause; and refusal to renew.

Want more “payer power?” Join us at Practice Rx, Sept. 19 & 20 in Philadelphia for “Payer Negotiation Strategies: Using Your Own Payer Report Card as Leverage” and other sessions to boost your bottom line. Register today.
Termination without cause, simply put, “isn’t.” There is always a reason, and the reason is usually money. Termination without cause is akin to being “banned from the casino” for winning. Carriers take the position that they are not required to contract with physicians, and are free to terminate provider status without stating a reason.

The most costly physicians appear to be those who rely on mid-level employees to perform ancillary laboratory and testing services in house. The total payments to the physician may well appear to be more expensive, when in fact, the cost per patient may be no different or less than an outside referral.

Non-renewal often follows the same pattern. Physicians are singled out because they are the highest earners.

Termination for cause, in which the carrier gives a reason, may involve some alleged misstatement in the credentialing process, or some error in billing and coding. Carriers originally referred many such misstatements to licensing boards, but have discovered it is much easier to simply terminate the provider agreement. Carriers may be required to offer a type of appeal, though the likelihood of success may not be great.

Physicians have been fighting back, according to a recent article by the Texas Medical Association, “A Bitter Pill, Physicians Seek Justice for Network Termination.” The article tracks the history and outcome following UnitedHealthcare’s decision to terminate thousands of physicians from Medicare Advantage plans. In December, a federal appeals court granted the medical associations a preliminary injunction, preventing the payer from kicking physicians out of its Medicare Advantage plans until doctors could arbitrate their cases.

The basis of the lawsuits against carriers often depends upon the type of insurance involved. Medicare and workers’ compensation statutes may dictate procedures which must be followed before termination can occur. Private plans may have fewer statutory restrictions, depending upon the laws of a particular state.

The Texas Medical Association offers a white paper entitled “Physician Steps in Termination of Network Participation,” designed to help physicians appeal insurance network termination and available upon request.

If you have been terminated, or notified you will be terminated, contact a healthcare attorney who is licensed your state.

Read Article on Physicians Practice

Many physicians are familiar with the provisions of Stark Law and the Anti-Kickback Statute, and the requirement that physician contracts be at a price consistent with “fair market value.” This is aimed at preventing hidden kickbacks, in which the physician might be paid too much for services (or charged too little for things the physician must purchase, such as office space or equipment leases).  

Less is understood about the requirement that contracts must also be “commercially reasonable.”

I asked Michael Heil, one of the founders of MD Ranger, about this. MD Ranger is a subscription service providing market benchmark data about hospital-physician agreements, Michael also leads the consulting firm HealthWorks, which provides valuation services to both physicians and hospitals for hospital-physician agreements.

Martin Merritt: How is “commercial reasonableness” defined?

Michael Heil: In CMS regulations an agreement is “considered commercially reasonable in the absence of referrals if the arrangement would make commercial sense if entered into by a reasonable entity of similar type and size and a reasonable physician (or family member or group practice) of similar scope and specialty, even if there were no potential DHS referrals.”

MM: That definition sounds quite subjective. Are there more objective standards?

MH: No, not really. The only additional sources are IRS guidelines that list a few factors for consideration (such as duties and responsibilities of the physician and economic conditions in the marketplace). Some additional clues can be found in a few court rulings where findings were made against hospitals when the issue was whether anything should be paid at all.

MM: Can you give an example of how commercial reasonableness is different from fair market value?

MH: A hospital considered paying for orthopedic spine surgery call at a rate that was well within fair market value. But it was already paying for restricted neurosurgery coverage. The neurosurgeons were fully credentialed for spine surgery. Based on commercial reasonableness requirements, the hospital shouldn’t contract with the orthopedic spine physicians at all: A reasonable entity would not pay for the same coverage twice in the absence of referrals.

MM: Are there any examples from case law?

MH: In Kaczmarzyyk v. SCCI Hospital Ventures, 2004, the court found an excessive number of medical directors in violation of the commercial reasonableness requirement. To help with assessments like this, MD Ranger provides data on the total number of medical directors for hospitals of various types and sizes.

MM: MD Ranger has developed a checklist to make the process more objective.

MH: We are happy to share it. As you said, the regulatory standard is quite subjective, but here are criteria that physicians and hospital administrators should consider that help make it more objective

Read Article on Physicians Practice

In the new healthcare transactions book, “Doctor Deals,” Nicholas A. Newsad and Kyle Tormoehlen of Healthcare Transaction advisors provide insight into one of the more recent types of arrangements by which hospitals seek to win patronage of physicians: the development of a “co-management” arrangement.

I recently spoke with Newsad for a primer on these arrangements.

Martin Merritt: What is a physician co-management arrangement and why are we hearing so much about them?

Nicholas A. Newsad: These are contractual arrangements whereby hospitals are engaging groups of independent and employed physicians to manage the quality aspects of one or more hospital service lines, such as cardiovascular services or orthopedics.

Co-management is very effective due to its versatility. These arrangements are extremely adaptable to a wide variety of hospital service lines, as well as the specific goals of different groups of physicians.

HHS’ Office of the Inspector General (OIG) reviewed a cardiology co-management agreement and issued OIG Advisory Opinion No. 12-22 on January 7, 2013.  This has promoted the use of co-management agreements.

MM: How are co-management arrangements structured?

NN: Generally, they are being structured as contractual agreements between a hospital and a separate management company. The management company may be wholly owned by physicians, or the management company may be co-owned by physicians and the hospital itself.

The duties of the co-management company include base duties, for which compensation is fixed, as well as incentive performance targets, for which compensation is tied to results. We usually see at least 30 percent of the total co-management fees attributed to incentive compensation and the achievement of performance targets.

The management services are provided by the physician owners of the management company. For example, for an orthopedic co-management arrangement, we would expect there to be a physician manager for each subspecialty, including ortho-spine, sports medicine, hand surgery, foot and ankle surgery, rehabilitation, and hip and knee replacement.

MM:  Can you explain what works about these agreements in the real world?

NN: Co-management is an effective way to empower physicians with the means to improve hospital operations. If there are willing parties to such an arrangement, then it is merely a matter of developing consensus on the objectives, structure, and the terms of the agreement.

A grassroots approach to developing these arrangements starts with face-to-face meetings with each physician that practices within the service area. Group consensus is most effectively developed by soliciting input from each and every prospective physician participant.

We have observed that the development of the co-management contract can be expedited when independent counsel is engaged. While using hospital’s counsel may save the parties money, it can cause conflicts because counsel is not only drafting the agreement, but they are also representing the hospital. Engaging independent counsel removes this conflict.

Lastly, we’ve found that the terms of the co-management agreement should be negotiated by a small group of physicians that are empowered to speak for the entire specialty group. If the larger group of physicians doesn’t select their representatives on the initial steering committee, then the negotiated agreement terms may be rejected by the larger group.

MM: What else should physicians know about co-management agreements?

NN: Co-management is extremely adaptable to specific hospital service lines, goals, and unique situations. The performance targets can focus on clinical, operational, or strategic goals.

We have observed nearly 70 different performance metricslevied on providers through Medicare’s accountable care organizations, the Hospital Readmission Reduction Program, the Hospital Value-Based Purchasing Program, and the Bundled Payment for Care Improvement Initiative. Payers United, Wellpoint, and Aetna are also following suit.

Co-management arrangements are an ideal mechanism for aligning the interests of physicians and hospitals in this new environment of value-based reimbursement.

Read Article on Physicians Practice

A number of doctors are being asked to either invest in, or sign personal services contracts with, ancillary services providers including compounding pharmacies, home healthcare agencies, and skilled nursing centers.  While these arrangements can have self-referral and anti-kickback statute implications, there are also several “non-health law” considerations.  

I asked Robert Feiger, JD, LLM, a tax and business formation lawyer, to share some of the basic legal implications of these arrangements.

Martin Merritt: What are some of the “non-health law” legal implications that doctors need to be aware of when offered a chance to invest, or work for, an ancillary service provider?

Robert Feiger: First of all, most investment offers are offers to become a passive participant in the profits and losses of a pass-through entity, such as a limited liability company, subchapter S corporation, or limited partnership.  Typically doctors are informed by the people forming these entities that their investments are safe because they meet the Medicare and Medicaid small business “safe harbor,” by keeping the percentage of physician investors below the 40 percent threshold. 

The principals of such businesses may not be entirely forthcoming with investors and doctors need to be aware.  While doctors are typically shielded from personal liability from passive investments in pass-through entities, when a doctor makes a referral to a company in which he also has invested, he has done something “active.” Thus, the limited liability he would otherwise enjoy from such a passive investment would not be available if the “active” referral violates Stark Law or the Anti-Kickback Statute.

MM:  Are there other ways the law distinguishes “activities” in these doctor-service provider relationships?

RF: Another typical problem is one of treatment of a doctor as an “employee” verse an “independent contractor.”  The IRS has a 20 point checklist of factors to balance for determining whether a person is an independent contractor or an employee.  The primary question is one of “control”  (whether a company hiring a doctor maintains enough control over the work for the doctor to be considered an  employee).  Though these rules are intended only as a guide and the IRS says the importance of each factor depends on the individual circumstances, they should be helpful in determining whether a company wields enough control to show an employer-employee relationship with a doctor. 

MM: In health law, the difference between a bona fide employee and a “personal services contractor” can be of crucial significance in compliance with Stark Law and the Anti-Kickback Statute. Is the distinction also important in tax and business law?

RF: Incorrectly designating an “employee” as an “independent contractor” could have state and federal tax consequences, workers’ compensation insurance consequences, and tort law liability implications.  Withholding for bona fide employees is different than independent contractors.  Many employers find the tax burden is lower for independent contractors. However, this designation is subject to “reclassification,” either by the IRS or a state taxing authority. 

MM: Sometimes, doctors are approached about investing in an ancillary services company, and then become a medical director or consultant.  Does this change in roles carry any legal significance?

RF:  Generally speaking, tort reform laws vary from state to state, but doctors must be aware that changes in roles can mean changes in exposure to liability.  We previously discussed that a doctor’s status from passive “investor to “referring doctor” can have legal implications. So too, when a doctor who may be a passive investor becomes either a W-2 or 1099 independent contractor of a company, his status changes to an “active” participant.  Tort liability may not attach to a passive investment, but liability may attach to harm caused from negligence in actively carrying out certain functions.  It is always best to consult an attorney before entering into any such business arrangement, whether it is passive or active.

Robert Feiger is a law partner in Dallas-based law firm Friedman & Feiger.  The foregoing is for informational purposes only and does not constitute legal advice.

Read Article on Physicians Practice

I asked Karin Zaner, a director with the Dallas law firm Kane Russell Coleman & Logan PC, to share her tips for how physicians can best deal with the hospital peer review process.

Martin Merritt: Peer review can be one of the most traumatic experiences for a physician. What tips can you share with physicians to guide them through the process?

Karin Zaner: My experience in medical peer review began in 1999, when my firm represented Dr. Lawrence Poliner in his federal court lawsuit against Presbyterian Hospital of Dallas and obtained a $366 million verdict, which was the ninth largest jury verdict in the country in 2004. This verdict was later reversed by the 5th Circuit due to federal peer review immunity — a real life lesson showing the clear lack of legal accountability in peer review. I now advise my physician clients on a wide variety of health law matters, including determining the best strategy to protect a physician’s record when a peer review occurs. When a physician faces peer review (whether due to standard of care or an allegation of disruption), that physician must respond quickly and with credibility. Here are my 10 tips.

Tip 1: Get the bylaws of the organization. Bylaws contain crucial deadlines and due process rights. Insist these be followed.
Tip 2: Hire legal counsel. Whether behind the scenes or on the front lines, getting counsel involved early can limit mistakes and minimize damage.
Tip 3: Respond in writing in a factual tone. Communicating medical facts with corroborating evidence helps the committee understand the case and get your side of the facts into the peer review file.
Tip 4: Maintain credibility. Do everything you can to present the medical facts in an unbiased and reasoned tone. Avoid becoming defensive and do not exaggerate — credibility is key.
Tip 5: Be there for every meeting. Take full advantage of every opportunity to make a personal connection and explain the medical facts to the committee.
Tip 6: Don’t resign or let privileges lapse. If the review is focused on you, to avoid a negative report to the state licensing board or the federal data bank, assume an “investigation” exists and get legal help before you resign or let your privileges lapse.
Tip 7: Understand your legal options. The law in your state may provide options for litigation, but they will be very limited. Consult with counsel to be sure you understand your rights.
Tip 8: Do everything necessary to win at the “fair hearing” stage. Spend your resources on counsel, expert witnesses, and services that will maximize the chance of getting your privileges back at the hospital at the “fair hearing” level.
Tip 9: Look for opportunities for resolution. While preparing for the hearing, be creative and flexible in determining a resolution you can live with.
Tip 10: Practice where you are welcome. Practicing medicine is hard enough. Practicing medicine under a microscope is a recipe for disaster. If it is clear the hospital is not a good fit for you, make your exit with the help of legal counsel.

MM: Do you have any additional thoughts for our readers?

KZ: The best way to succeed in the peer review process is to avoid problems in the first place. Document the medical record well. Respect the healthcare team, which means heading off complaints of disruption. Respect your patients as, even though you meet the standard of care, hospital administration must deal with patient complaints of rudeness. Choose your hospital carefully, and consider maintaining privileges at more than one hospital if your subspecialty requires it. Be active on medical staff committees, which will help you diffuse problems as they surface. Taking care of your patients is not enough — you also have to pay attention to the business and political atmosphere at the hospital. If you cannot resolve conflicts informally, take your practice elsewhere with the help of legal counsel.

Read Article on Physicians Practice

With so many physicians thinking about starting concierge medical practices, I asked financial planner Jason Hull for his thoughts. His firm, Hull Financial Planning, focuses on entrepreneurs and small businesses.  

Martin Merritt: Dropping out of the health insurance rat race is the number one topic at medical practice seminars I attend. What are you seeing from a financial planning viewpoint?

Jason Hull: I’m seeing that this is a growing trend. Physicians want to take back the practice of medicine, avoid the pitfalls of Stark Law, and the uncertainty of post-payment audits.

MM: What tips can you provide our readers who are considering transitioning to concierge practices?

JH:  As much as we entrepreneurs wish it was the “Field of Dreams” scenario where we could build it and they will come, simply opening up an office will not guarantee success.

There are a lot of variables to keep in mind when deciding whether to form a concierge practice, and when deciding what type of concierge practice to form. Here are five of the big ones:

• Convenience. Patients who can see a doctor right away in a location convenient that is to them are more likely to use that doctor. Concierge practices should ensure they provide patients with access to benefits that they can’t get at a normal general practitioner’s office.

• Price. More and more patients are paying attention to the costs of medical care, not just the costs of their health insurance. If they can get the same treatment for less, without a significant increase in inconvenience, they’ll choose the cheaper option. That differentiates the strategies of running a high-end high-touch concierge practice compared to a low-cost a la carte concierge practice.

• Value. If you can give patients a special experience, then they are more likely to stay loyal, and tell their friends. Think about medical tourism. People are paying less for certain elective procedures overseas, and they are getting a spa week in the deal. They are getting both price and value. Consider what you can do to make the patient experience memorable, particularly if you’re offering a high-touch concierge practice.

• Specialization. If you’re the only pain management specialist within a hundred mile radius, then you’ll own the market, at least until another pain management specialist moves nearby. The same applies for either high-end concierge or low-cost concierge services.

• Referrals. If you’re a specialist, then most of your business comes from referrals from general practitioners. Do you have enough referral sources who would refer to your concierge practice? Furthermore, do you have enough pull so that they would refer patients to you rather than the doctor to whom they currently refer patients?

MM: What is the difference between a high-end high-touch concierge practice and a low-cost a la carte concierge practice? 

JH:  Low-cost membership concierge practices tend to provide a la carte basic healthcare services aimed at patients who have high-deductible insurance or no insurance.

High-end membership concierge practices provide on-call specialized services for a smaller number of patients who pay a value-added retainer fee for the availability and convenience.

The revenue and expense models for both are vastly different.

MM: What are some other considerations physicians need to take before opening a concierge practice?

JH: There are four more big considerations. They are: 

1. Are you going to go it alone or with others? If you’re bringing in other doctors, how much of a book of business will they be expected to bring in? How will you share costs and revenues? Will it be a PLLP or PLLC?

2. What are your projected cash flows? You’re going to have to hire staff to handle the other aspects of running the practice. How much will they cost? How many patients do you need to bring in to cover your expenses (including paying yourself and/or your partners)? How long will it take for you to get insurance reimbursements?

3. Where will your patients come from? Can you bring in your current patients without violating non-compete agreements? How will you get the word out about your practice? Will you rely on advertising, location, referrals, or a combination of all of those sources? How long will it take to get a steady stream of patients?

4. Do you have enough cash in the bank to cover a worst-case scenario? My motto as an entrepreneur is to plan for the best and prepare for the worst. What happens if you hire staff, sign a lease, pay for insurance, and only a trickle of patients come in? Will you be able to pay the bills? How long until you will have to cut the cord?

Read Article on Physicians Practice

Dallas, Texas, provides a microcosm of a problem affecting most major metropolitan areas in the United States: uncompensated care.  Dallas County Judge Clay Jenkins, who holds an administrative position over the fourth most uninsured county in America, speaks almost daily with HHS Director Kathleen Sebelius and White House staff about the problems posed by the uninsured in metropolitan areas.

In November 2013, President Obama visited Dallas County to observe first hand, Judge Jenkins’ Affordable Care Act Coalition, a grassroots effort supported by hospitals, concerned citizens and interdenominational religious groups to enroll Americans under the reform law.

I recently sat down with Jenkins to explore how what’s happening in Dallas County has larger implications for medical practices across the nation.

Martin Merritt: How big is the problem of uninsured in Dallas County?

Clay Jenkins: It is a huge problem. If the Dallas-Fort Worth metroplex were one combined county, we wouldn’t be the fourth largest, but the most uninsured county in America. A staggering 672,000 individuals are uninsured in Dallas County, which represents more than 28 percent of our citizens. Of that number, 506,000 qualify for a subsidy, which brings affordable, quality insurance into their grasp.

Texas hospitals provide over $5 billion a year in uncompensated care. Texans pay for this care through local property taxes, increased premium costs, and higher medical costs. Dallas County citizens pay more taxes to cover uncompensated care than for all other county services combined. Our county hospital, Parkland Hospital, provided $685 million in unreimbursed care in FY 2012.

MM: So you developed the ACA Coalition, tell us about it.

CJ: The Dallas County ACA Coalition has been in existence since August 2013, and is successful because of the many different Dallas-area organizations participating. My office’s role in chairing the coalition is to empower our government and private partners in the healthcare, faith, business, and grassroots communities to synergize efforts to comprehensively approach enrolling citizens and their children in the health insurance marketplace.

MM: You say there is no downside for physicians or individuals who need health plans?

CJ: As you know, studies are steadily finding that lack of access to care leads to shorter and less healthy lives. So, anything that increases access to care is a good thing. For physicians, there is a long-term benefit in decreasing the amount of uncompensated care and building a healthier patient population. As to differences in these policies and others, in Texas, the biggest difference to consumers is the network of care, which tends to be narrower for subsidized policies. For providers, the reimbursement rates can be lower with subsidized policies.

MM: How has the White House responded to the coalition’s work?

CJ: The White House is a tremendous partner providing us with extensive resources and information. While we have been a focal point of the White House’s efforts to export our work in Dallas County to other metro areas, we have also been able to pick up best practices and ways to improve our efforts while working with the White House and HHS.

Read Article on Physicians Practice