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SEPTEMBER 2015
Special Feature: Sovereign Health Cancer Care Adventist Health System to Pay $118.7 Million Settlement over Stark, False Claims Allegations Horizon Announces ‘Innovative’ Partnership with Major Health Care Players House Republicans’ ACA Lawsuit Moves Forward
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KENNETH BLANK, MD
DOV GORSHEIN, MD
ALAN SHAIMAN, MD
GOPAL DESAI, MD
NADRA MOULAYES, DO
Radiation Oncologist
Radiation Oncologist
Radiation Oncologist
Radiation Oncologist
Breast Surgeon
OUR TOP DOCTORS CLOSE TO HOME... STEPHAN DORKHOM, DO
STEVE ELIAS, MD, FACS
HOMAM BADRI, DPM
RICHARD MAGGIO, MD, FACS
BRENDAN SULLIVAN, MD, FACC
Medical Oncologist
Vascular Surgeon, Vein Specialist
Podiatrist
Urologist
Cardiologist
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A fully integrated multi-specialty community healthcare system providing clinical excellence and convenient care to
NORTH JERSEY & NEW YORK RESIDENTS Built from the ground up right here in the Garden State, Sovereign Health System has called New Jersey home for more than 20 years. After two decades of steady growth, Sovereign Health System continues to expand its physician ranks, cutting-edge services, and conveniently located facilities to better serve the people of New Jersey and New York. Sovereign knows it’s important to have that one-on-one connection with your nurse and doctor. That’s why at Sovereign you are treated like family -- and why our latest patient-satisfaction rating is 95%. Sovereign provides you with multi-specialty care, ongoing support, and comprehensive services in one fully integrated community healthcare system. In short, we offer peace of mind . . . close to home.
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New Brunswick– Saint Peter’s University Hospital
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A fully integrated multi-specialty community healthcare system...CLOSE TO HOME
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C O N T E N T S
Special Feature
Sovereign Health Cancer Care
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8 Adventist Health System to Pay $118.7 Million Settlement Over Stark, False Claims Allegations 10 Horizon Announces ‘Innovative’ Partnership with Major Health Care Players 12 House Republicans’ ACA Lawsuit Moves Forward 13 AdvaMed CEO Ubl to Lead PhRMA 15 New Medical Billing Code System’s Deadline Arrives 16 Prime Finalizes Takeover of Saint Clare’s Health System 16 Westminster-Based AxisPoint Health Appoints CEO
Affiliated Practice
Special Feature
Sovereign Health
Cancer Care Bringing Cutting Edge, Compassionate Cancer Care Closer to Home
By Iris Goldberg When CEO and Chairman of Sovereign Health System, John H. Hajjar, MD, FACS, MBA set upon his mission to create a physician-owned and led healthcare system with community-based centers of excellence to deliver highquality, cost-effective care, cancer patients were certainly high on his list of priorities. Within his urology practice, Dr. Hajjar saw many with prostate, bladder, kidney or testicular malignancies that were in need of comprehensive care from a cancer specialist. Often, this required New Jersey patients to travel to academic medical centers far from home, sometimes in different states such as New York or Pennsylvania. In fact, today, many patients with all types of cancer who reside in New Jersey continue to seek cancer treatment elsewhere. With four cancer care centers of excellence located in Hackensack, Jersey City, Wayne and most recently, in New Brunswick, Sovereign Health is providing patients the highest level of cancer treatment within their own communities. Utilizing state-of-the-art technology and recruiting impressively trained oncology experts who have published extensively in leading peer reviewed journals, Sovereign can offer cancer patients top tier care and treatment. The newest member of Sovereign Health’s oncology team is Stephan J. Dorkhom, DO, who treats cancer patients at the $14 million, 32,000 square foot facility just opened on campus at St. Joseph’s Wayne Hospital. The brand new St. Joseph’s Cancer Center will operate in partnership with Sovereign Health to bring comprehensive, advanced cancer treatment to residents of Wayne and surrounding counties and communities. “From the time I was eight years old when my paternal grandmother, whom I loved very, very much, died from metastatic pancreatic cancer, I have wanted to become an oncologist, find a cure for cancer and save other kids from the traumatic experience I suffered as a young child,” Dr. Dorkhom candidly shares. While his early dream of a cancer cure remains elusive, Dr. Dorkhom has remained true to his original goal, receiving his training at some of the most prestigious institutions in
4 AFFILIATED PRACTICE
Stephan J. Dorkhom, DO
the country in order to develop the expertise to provide positive outcomes for cancer patients. Graduating from Colgate University with honors in molecular biology, Dr. Dorkhom was invited to work at the National Institute of Health (NIH), where he was involved in innovative research to isolate a new cancer gene, with the findings published in the medical literature. Postponing medical school for a year, Dr. Dorkhom seized an opportunity to work in the pharmaceutical field, translating his academic experience into the development of new cancer-fighting drugs. Although this was extremely gratifying, he elected to move on with his medical training and has achieved board-certification in Internal Medicine as well as Hematology/Oncology.
To view “Prostate Cancer: Importance of Getting Screened” click here
During his residency training at Columbia University College of Physicians and Surgeons, Dr. Dorkham was House Staff at Memorial Sloan Kettering where he worked with some of the leading cancer specialists worldwide and authored a paper on hepatocellular carcinoma. Then he pursued fellowship training in Hematology/Oncology at the renowned MD Anderson Cancer Center in Houston. While there he was first author on a book chapter on “Advances in the Treatment of Chronic Myelogenous Leukemia.” (CML) Dr. Dorkhom has also had first author presentations at both the American Society of Hematology (ASH) and the American Society of Oncology (ASCO). Dr. Dorkhom’s publications and presentations are available online.
Before joining Sovereign, Dr. Dorkhom spent some time in Lubbock, Texas where he treated patients with all tumor subtypes in oncology and both benign and malignant hematology. While there he attained somewhat of a celebrity status, appearing in a number of television segments. (See links at right.) Now that Dr. Dorkhom has joined the Sovereign Health Cancer Care team, he is determined to further the core values established by Dr. Hajjar as these are definitely aligned with his own beliefs. “One of the things we are focused on here is striving to deliver compassionate care,” Dr. Dorkhom emphasizes. “We treat the whole patient – mind, body and spirit. Our goal here is to focus on the patient, spend a lot of time answering questions thoroughly and trying to give our patients hope,” he adds. In terms of working in a community-based cancer center, Dr. Dorkhom could not be more delighted. “Cancer patients don’t want to travel. They’re sick and not feeling well so they want to get top of the line care close to home,” he shares. So what I am able to do is bring the training I received at the two best cancer centers in the country right here to the patients who live in this and surrounding communities,” Dr. Dorkhom proudly states.
To view Dr. Dorkhom’s segment on testicular cancer click here
Going forward, Sovereign Health plans to fill its newest cancer center with more oncologists like Dr. Dorkhom and his colleagues in Wayne, who are expertly trained and extremely motivated to provide compassionate care at the highest level to cancer patients within the community. With Sovereign Health’s cancer facilities throughout the state, New Jersey’s cancer prognosis is an optimistic one. SEPTEMBER 2015
5
If you are a physician and are interested in joining the Sovereign Health Medical Group, please contact : Paul Angresano, VP, New Business Development at 201-855-8376 / pangresano@sovms.com
Sovereign Health
Sovereign Health
SurgiCare
Development & management company for ambulatory surgery centers (ASC). Same-day procedures performed in a convenient, caring setting. SURGEM, LLC., has new facilities in select markets in New Jersey, New York and Florida with additional facilities coming soon. Our 13 centers are conveniently located, staffed with highy skilled, caring physicians and nurses, equipped with the latest technology, and designed to provide an optional patient experience in a spotless facility and comfortable setting. We treat you the way we would want ourselves or our family members to be treated, and that approach is reflected in everything we do - and in our consistently high patient-satisfaction ratings. Carlstadt 630 Broad St 201-355-1700
Mahwah 400 Franklin Turnpike 201-766-1550
Englewood Cliffs 630 East Palisade Ave 201-503-1522
Oradell 555 Kinderkamack Rd 201-265-8173
Fair Lawn 15-01 Broadway 201-703-8487
Ridgewood 1124 East Ridgewood Ave 201-493-2310
Freehold* 901 West Main St., Suite 302 732-303-1616
SJCH Pediatric (Fair Lawn) 14-01 Broadway 201-791-0100
Jersey City 631 Grand St 201-830-2280
Wayne 246 Hamburg Turnpike 973-790-0954
University Center for Ambulatory Surgery (Somerset) 2 Worlds Fair Dr 732-748-1117 Manhattan, NY** 800 2nd Ave (7th Floor) 212-419-1016
Cancer Care The Physicians of Sovereign Health Cancer Care are fellowship trained to treat malignancies of any site
Sovereign Health Cancer Care offers our patients state-of-the-art technology in a compassionate outpatient setting. With VMAT IRMT and cone beam IGRT, radiotherapy is delivered precisely and safely every day. Our oncology experts have published extensively in the nations’ leading peer reviewed journals and have vast experience treating cancers of all sites, including prostate, breast, lung, brain and cancers of the gastrointestinal and gynecologic systems. Hackensack 20 Woodridge Ave 201-880-7580
New Brunswick - Saint Peter’s 215 Easton Ave 732-745-8590
Jersey City 631 Grand St 201-942-3999
Wayne - Saint Joseph’s 234 Hamburg Turnpike 973-310-0300
Boca Raton, FL 1905 Clint Moore Rd 561-544-5501
Sovereign Health Medical Group
*Located in CentraState Medical Center **Administrative services agreement
Sovereign Health Medical Group was created by physicians with the needs of patients and other physicians foremost in mind
Sovereign Health Urgent Care
Get immediate medical care at Sovereign Health Urgent Care When an injury or illness occurs and you are in need of medical attention on an immediate basis, visiting an urgent care clinic is a smart move. Your time is important, and we are dedicated to seeing you as quickly as possible. Our priority is providing excellent patient care in an efficient manner. Fair Lawn 15-01 Broadway 201-794-3600
Glen Rock 85 Harristown Rd 201-479-5450
6 ANew F F Jersey I L I A TPhysician ED PRACTICE
Hewitt 1900 Union Valley Rd 973-728-5930
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Urgent Care Facilities
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Other Specialties
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Neurology
Breast Cancer
Awareness Walk OCTOBER 4 new date
OCTOBER 11 on the St. Joseph’s Wayne Hospital Campus *
Proceeds to benefit Breast Cancer Awareness, Educational Scholarships and Prevention *Original October 4 event postponed to October 11 due to inclement weather
University Imaging 246 Hamburg Turnpike, Wayne, NJ on the campus of St. Joseph’s Hospital Featuring a new expanded Walking Route Check in begins at 8:00 a.m. – Step-off at 9:30 a.m. Includes: Breakfast and Give-a-ways
YOU’RE NOT FACING CANCER ALONE...
Chairman: David Rasa, MD,R.Ph Co-Chairs: Lynn Heydt and Donna Cochrane
WE’LL BE WITH YOU
EVERY STEP OF THE WAY
Walker $10 per person
(includes tee shirt) Suggested donation
Corporate / Team Sponsor $100
At Sovereign Health Cancer Care, our culture is built around one word – empathy. We understand and share the feelings, anxieties and emotions of our patients as our own family. When it comes to breast cancer, Sovereign Health Cancer Care is dedicated to providing you with the best and most compassionate care from our staff and physicians. Our state-of-the-art technology and cutting-edge treatments are designed to diagnose and treat cancer as early as possible. Our convenient locations mean you don’t have to travel far to receive the care you deserve. Simply put, Sovereign Health Cancer Care is devoted to you and your well-being, and to providing you with excellent care, close to home.
(includes signage at event) Team members strive for a minimum of $25 in sponsorship donations. Upon receiving your registration a team kit will be sent to you.
Health Partner $300
(includes sign recognition and listing on websites)
Step out, call
973.956.3304 or visit
www.bit.ly/stjosephscancerwalk2015 Health Partners Sponsored by the Sisters of Charity of Saint Elizabeth
Please join the Sovereign family in supporting those with breast cancer on October 11, 2015 at the Breast Cancer Awareness Walk at St. Joseph’s. >>
FELLOWSHIP TRAINED PHYSICIANS DEDICATED TO YOUR CARE
NADRA MOULAYES, DO Breast Surgeon
DOV GORSHEIN, MD Radiation Oncologist
STEPHAN DORKHOM, DO Medical Oncologist
Sovereign Health Cancer Care - St. Joseph’s Cancer Center 234 Hamburg Turnpike, 973-310-0300
www.sovereignhealthsystem.com SOVEREIGN MEDICAL SERVICES, INC.: 85 HARRISTOWN RD, GLEN ROCK NJ, 07452 | 201-834-1100
Adventist Health System to pay $118.7 million settlement over Stark, False Claims allegations By Lisa Schencker |
Adventist Health System will pay the government $118.7 million to settle allegations it offered doctors excessive compensation for referrals—a settlement amount that nearly doubles a record set just last week. In 2012, three whistle-blowers brought the case against the Florida-based system, which includes 44 hospital campuses in 10 states. They alleged that Adventist paid doctors for referrals in Florida, North Carolina, Tennessee and Texas in violation of the Stark law, which in turn, led to tainted claims to the government in violation of the False Claims Act. The whistle-blowers said the system also paid for the leases of a BMW and Mustang for a surgeon and paid $710,000 in bonuses and salaries to a dermatologist who worked three days a week. Adventist noted in a statement Monday that the settlement "fully resolves issues AHS voluntarily disclosed to the United States government in early 2013 involving its implementation of certain physician employment compensation models and highly technical physician billing and coding issues." Adventist said in the statement its own review did not identify any negative impacts on quality, safety or cost of patient care. Since that self disclosure, Adventist noted that it's implemented a centralized process to set physician compensation, among other things. "Adventist Health System regrets these oversights, and while some of its hospitals had no violations, the organization has improved monitoring and business practices system-wide as a result of lessons learned from this experience so that it can continue to uphold the highest standards of compliance with regulations," according to the statement. Adventist is one of the largest systems in the nation, with an operating revenue of nearly $8.4 billion in 2014, according to the Modern Healthcare systems financial database. The settlement is the largest ever reached without litigation under the Stark law, said Peter Chatfield, a partner with Phillips and Cohen in Washington, D.C., a law firm which represented the whistle-blowers in the case. It's an amount that shatters the previous record set a week ago. On Sept. 15, the U.S. Justice Department announced that the North Broward Hospital District would pay $69.5 million to settle allegations that it paid doctors far more than fair market value based, in part, on their referrals. A week before, Columbus (Ga.) Regional Healthcare System agreed to pay the government $35 million to settle allegations it violated the Stark law and False Claims Act. Neither North Broward nor Columbus Regional admitted to any liability as part of those settlements. “I think what this is showing is that Stark is being looked at very seriously by the government, and it's not just on a fair market value basis but also on the basis that if physicians are being paid for referrals, whether outpatient or inpatient, and that's not appropriate,” Chatfield said. Stark cases are increasingly being brought to court under the False Claims Act, which carries triple damages. False Claims Act cases usually settle because of those potentially huge damages. Chatfield said the number of Stark cases being brought under the False Claims Act may be increasing as whistle-blowers become more aware of such settlements, as they are entitled to a percentage of whatever money the government is able to recover. The amount the whistle-blowers will get from this case has not yet been determined, Chatfield said. The whistle-blowers in this case all formerly worked at Adventist's Park Ridge Health in Hendersonville, N.C., and included Michael Payne, a risk manager; Melissa Church, executive director of physician services; and Gloria Pryor, a compliance officer for physician offices. The federal government had also joined the case, which was sealed until now. As part of the settlement agreement, which covers this lawsuit and a separate but similar whistle-blower suit filed in 2013, Adventist will pay $115 million to the federal government, $3.48 million to Florida, $198,453 to North Carolina, $66,897 to Tennessee and $4,711 to Texas. Much of the settlement amount is based on allegations involving Florida Hospital Medical Group, an Adventist-owned physician practice in Florida. The whistle-blowers became aware of alleged violations while working at Park Ridge in North Carolina. As part of the lawsuit, they alleged that Adventist, as corporate policy, told its hospitals to purchase physician practices and group practices or employ nearby physicians so it could control all patient referrals in those areas. Adventist also settled a number of other allegations, including that it:
8 AFFILIATED PRACTICE
• Upcoded Medicare claims for patients in nursing and assisted-living facilities • Submitted claims for services by doctors without proper credentials to work at the hospitals where they were filling in for regular doctors • Unbundled services and submitted them as separate claims to get larger reimbursements from the government • Submitted claims for services that weren't documented in patients' medical records The Stark law has been widely criticized for its complexity. But earlier this year, the CMS proposed regulatory changes that experts say seem aimed at easing the law's technical burdens and reducing the numbers of self-disclosures coming to the CMS under the law. This year, a federal appeals court upheld a $237 million verdict against Tuomey Healthcare System in Sumter, S.C., in a Stark case that alleged violations of the False Claims Act, but that case involved litigation.
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SEPTEMBER 2015
9
Horizon Announces ‘Innovative’ Partnership with Major Health Care Players By Anjalee Khemlani Rewarding doctors for sending patients home faster and healthier is not a part of the traditional health care system, but a new alliance in the state — featuring many of the biggest names in the industry — hopes to change that. Horizon Blue Cross Blue Shield of New Jersey announced Thursday a new program geared toward decreasing out-of-pocket costs for its members, and holding health care providers accountable for quality care. The state’s largest insurance provider says it is partnering with six of the biggest New Jersey health care systems and the largest medical group to create the OMNIA Health Alliance, which will promote value-based service, an increasingly popular trend nationwide. The company is calling the program a first-of-its-kind, “extremely innovative collaboration,” one that will financially benefit both policyholders and employers. Horizon officials said it is too early put a dollar figure on any potential savings on premiums, but said they will be “substantial” when the plan rolls out in October. However, someone familiar with the details of the plan, who was not authorized to speak on the potential savings, said the partners had access to the following data from 2014. In that year, the person said, Horizon BCBSNJ members treated at a patient-centered practice, as compared with traditional practices, experienced better quality care measures, including a: • 6 percent higher rate in improved diabetes control; • 7 percent higher rate in cholesterol management for diabetic patients; • 8 percent higher rate in colorectal cancer screenings; and a • 3 percent higher rate in breast cancer screenings. Additionally, the person said, Horizon BCBSNJ members treated at a patient-centered practice, as compared with traditional practices, experienced lower costs, including an: • 8 percent lower rate in hospital admissions; • 5 percent lower rate in emergency room visits; and a • 9 percent lower total cost of care. This plan, Horizon officials said, includes national, mid-level, labor, small and individual markets, as well as being on the national health care exchange, but does not include Medicare or Medicaid. Horizon CEO Robert Marino added that the overall effect of this new plan would be “lower premiums, lower cost sharing and value created through wellness and better population management.” Here’s how it will work: Expanding on Horizon’s patient-centered medical home program, this partnership incentivizes health providers to send patients home, rather than adding services piecemeal during a visit. The idea is not new, as a national trend of transparency in health care has been developing similar solutions in the past few years, but it is the biggest push ever seen in New Jersey. Here’s how Horizon Blue Cross Blue Shield feels the OMNIA Health Alliance will impact various groups: Health care providers: bigger pay for improved quality of care, reduced costs of duplicate or excess services Businesses: lower premiums on policies for their employees Policyholders: lower out-of-pocket costs Horizon: shift in health care financing, lower cost of health care Joel Cantor, director of the Center for State Health Policy, said the program could be a game-changer. “This is a very bold shift for them and is something that could be influential in shaping the New Jersey health care delivery system,” he said. The new OMNIA Health Alliance includes Atlantic Health System, Barnabas Health, Hackensack University Health Network, Hunterdon Healthcare, Inspira Health Network, Robert Wood Johnson Health System and Summit Medical Group.
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The size of these groups assure the program will have impact. Last year, these organizations combined to serve a total of 4.8 million patients. In addition to the OMNIA partners, eight hospital systems, or a total of 12 hospitals, will be a part of Horizon’s Tier 1 plan: Cape Regional Medical Center, Cooper University Health System, Englewood Hospital, Meridian Health, Shore Medical Canter, St. Joseph’s and Princeton HealthCare System. Horizon, meanwhile, has 3.8 million covered lives, by far the largest number in the state. Because of this, partnering made sense, Hackensack University Medical Center Chief Financial Officer Robert Glenning said. Rather than waiting for legislative action, Glenning said, “We saw this as a concrete action we could take with a large health plan in-state to really look to move to better patient experience, reducing per capita cost of health care.” A joint governing body will be created with senior-level members of each partner, as well as Horizon, in order to ensure accountability, as well as allow refinement as needed. In addition, a third-party system will be used to collect patient responses, which will help in determining the success and quality of care. But with the shift comes a large risk for both Horizon and the health care systems, Cantor said. It could be a major success or fail miserably. “In the longer run, Horizon is making a bet that health systems will learn how to do this well, but not well enough to not need Horizon anymore,” Cantor said. Many industry leaders feel some dramatic change needs to take place. The current system of health care, they say, rewards providers financially for added fees, and there is no benefit to ensuring a patient gets well quickly. Because of that, they say the current system of piecemeal fees is not sustainable, and changes have to be made to a value-based system in order to curb rising health care costs for all involved parties. This partnership, however, only benefits Horizon members, leaving other insurance networks out of the loop. David Knowlton, president of the NJ Health Care Quality Institute, said that could be an issue. “The other shoe is yet to drop,” he said. “This is going to be fascinating to watch because of the implications. “They are so big that they can drive people in given markets out of business.” SEPTEMBER 2015
11
House Republicans’ ACA Lawsuit Moves Forward By Lisa Schencker
Just months after the Affordable Care Act survived a serious legal threat at the Supreme Court, a federal judge gave a boost Wednesday to what could be yet another a major court challenge to the healthcare law. U.S. District Judge Rosemary Collyer decided House Republicans have standing to sue over their allegation that the administration is illegally spending money that Congress never appropriated for the law's cost-sharing provisions. Those provisions include reduced deductibles, copays and coinsurance for many beneficiaries depending on income. The House had to prove it was injured by the administration's actions in order to gain standing. Collyer, who was nominated by President George W. Bush, wrote that if that allegation regarding is appropriations is true, “the House has been injured in a concrete and particular way that is traceable to the secretaries and remediable in court.” “As the House argues, Congress cannot fulfill its constitutional role if it specifically denies funding and the executive simply finds money elsewhere without consequence,” Collyer wrote. “Indeed, the harm alleged in this case is particularly insidious because, if proved, it would eliminate Congress's role via-a-vis the executive.” The judge also wrote, however, that the House does not have standing to sue over a separate allegation in the lawsuit that the administration had no right to delay the law's employer mandate, which requires companies with 50 or more employees to provide coverage. The Obama administration has argued that insurers have a legal right to reimbursement for cost-sharing reductions mandated under the law, citing a part of the statute that says HHS “shall make periodic and timely payments to the issuer equal to the value of the reductions.” The administration also argued that the House shouldn't be granted standing because the fight is essentially a political one. House Speaker John Boehner (R-Ohio) issued a statement praising Collyer's opinion. “The president's unilateral change to Obamacare was unprecedented and outside the powers granted to his office under our Constitution,” Boehner said. The U.S. Justice Department said it plans to appeal the decision. “The law is clear that Congress cannot try to settle garden variety disputes with the Executive Branch in the courts,” said White House Deputy Press Secretary Jen Friedman, in a statement. “This case is just another partisan attack—this one, paid for by the taxpayers—and we believe the courts will ultimately dismiss it.” Now that the case is moving forward, some experts say it could pose a significant threat to the law itself. About 56% of Americans who receive coverage through the ACA's insurance exchanges get cost-sharing reductions, lowering the amounts they pay out-of-pocket for deductibles, coinsurance and copayments, according to the CMS. That equals about 5.6 million people. Without the reductions, “most of the people in the exchanges are not going to want to participate in the exchanges because most exchange participants are receiving cost-sharing subsidies,” said Michael Cannon, a director of health policy studies for the libertarian Cato Institute and a key influence behind the lawsuit that led to the Supreme Court's King v. Burwell opinion in June. If many healthy people drop out of the exchanges because cost-sharing subsidies disappear, then premiums may rise for those left in the exchanges, he said. It's a concern that's similar to the one many expressed in the debate about King v. Burwell. The challengers in that case argued that the law said insurance premium subsidies should only be available to Americans in states with their own exchanges. The Supreme Court, however, sided with the government in that case in a 6-3 decision that many experts say saved the overall law. Tim Jost, a law professor at Washington and Lee University who supports the ACA, said healthcare could become unaffordable for many Americans if House Republicans prevail in this latest case. “If the insurers are required to provide cost sharing reductions but not reimbursed, that's going to cause very serious financial problems for the insurers, and if they cease to provide cost-sharing reductions, it's going to cause very, very serious problems for a lot of Americans,” Jost said. Then again, Jost said, if the House succeeds in the lawsuit, Congress might just have to appropriate the money for cost-sharing because it's required under the law. There are other reasons, too, that a Republican victory in the case might not shake the foundations of the law as much as a loss for the government in King v. Burwell would have. Richard Kogan and Edwin Park of the left-leaning Center on Budget and Policy Priorities recently wrote that beneficiaries will continue to receive cost-sharing reductions regardless of the case's outcome because they are an entitlement under the ACA. If Congress refused to appropriate money for the reductions, insurers could then seek relief in the U.S. Court of Federal Claims and would likely win, Kogan and Park wrote.
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Meanwhile, Collyer's ruling on standing may get reversed on appeal before the lawsuit is decided. Jost said her decision runs contrary to precedent. “She basically concludes that she's in uncharted waters and can decide for herself what the law should be,” Jost said. Collyer writes in the opinion that the case is unique and asserts that her decision to grant the House standing won't open any “floodgates, as it is inherently limited by the extraordinary facts of which it was born.” Kermit Roosevelt, a University of Pennsylvania constitutional law expert, said it's difficult to predict how the case might unfold given that most similar questions haven't made it past the hurdle of establishing standing. Roosevelt said the case might end up making new law. “There are also interesting political considerations given that the Supreme Court has heard two challenges to Obamacare,” Roosevelt said. “I wonder how much appetite they have for more of them.”
AdvaMed CEO Ubl to lead PhRMA By Adam Rubenfire Stephen Ubl, the lead lobbyist for the medical device industry, has been named president and CEO of the Pharmaceutical Research and Manufacturers of America. Ubl, 46, has led the Advanced Medical Technology Association, or AdvaMed, a medical device trade group, for the past ten years. In his new role, he'll succeed John Castellani, who announced in April that he would retire at the end of 2015. A Washington veteran, Ubl joined AdvaMed in 1998 as executive VP of federal government relations. He left the organization in 2004 to open a healthcare consulting firm and later returned in July 2005 as president and CEO. During his time at AdvaMed, Ubl pushed for a repeal of the Affordable Care Act’s medical device tax, which he says adds about 30% to the industry’s aggregate tax bill. “Other countries look at the medical technology industry as a winner they cultivate,” Ubl said in an interview with Modern Healthcare in October 2014. “In the U.S., regulatory delays as well as the tax climate have pushed many companies offshore.” He also oversaw AdvaMed’s support of the controversial 21st Century Cures Act, which the group says will address inefficiencies in the FDA review process. Opponents, including former FDA commissioner Margaret Hamburg, say the bill, which passed overwhelmingly in the House, could heighten the risk of patients being exposed to inadequately tested products while increasing healthcare spending on high-cost drugs and products of marginal value. Ubl has also drawn attention to the effect that new payment models may have on medical devices. AdvaMed is concerned that risk-based reimbursement models dissuade providers from taking chances on new technologies that are often expensive but have less evidence to back their claims. Prior to working at AdvaMed, Ubl was VP of legislation for the Federation of American Hospitals. He began his career in the nation's capital working for U.S. Sen. Charles Grassley (R-Iowa). Ubl has high hopes for his new role. “This is an exciting time to be joining the biopharmaceutical industry as new medicines are coming to the market that are completely transforming care for patients fighting cancer, heart disease, hepatitis C and other debilitating diseases,” Ubl said. “I look forward to working with PhRMA member companies and the broader healthcare advocacy community to advance public policies that will improve patients’ access to medicines and foster the continued development of new treatments and cures for patients.”
SEPTEMBER 2015
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2014 Shared Savings and Pioneer ACO Results Demonstrate Improved Quality, Mixed Financial Results
New medical billing code system’s deadline arrives By Anjalee Khemlani October 1 marks the start of a new billing code system in health care nationwide, and ends the race to meet the conversion deadline. The new ICD 10 coding system, which is created by the World Health Organization, has been around since the late 1990s, but only recently has been pushed as part of the billing system in the U.S. The Center for Medicare and Medicaid Services set the Oct. 1 deadline, after multiple delays over the years, and hospitals and physicians have been slowly implementing the new system. CMS said there would be a one-year grace period, allowing health care facilities to be paid despite errors in using the new codes. The changes from the old system include thousands of additional codes — due to the recognition and discovery of new diseases, as well as differentiating between types, such as type 1 and type 2 diabetes. Independent physicians and small groups have been especially hit hard financially by this new system, according to Larry Downs, CEO of the Medical Society of New Jersey. They have lost tens of thousands of dollars in both time spent away from their practices, attending trainings, as well as the cost of upgrading their electronic systems. The Society joined with the N.J. Hospital Association and ensured members had the resources they needed. Specifically, MSNJ worked with financial institutions to extend small lines of credit if need be to help cover the costs incurred by conversion, as well as to be a safety net in the event payment is delayed from some errors in processing by the new system. Though there has been compliance, there have been complaints, Downs said. The ICD system is used for data collection globally, but in the U.S. it is also used for billing, and has therefore created an extra administrative burden.
SEPTEMBER 2015
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Prime finalizes takeover of Saint Clare’s Health System Prime Healthcare Services has completed its acquisition of New Jersey's Saint Clare's Health System, the for-profit hospital chain announced Thursday. Prime had announced in August that the transaction had closed July 31, but would not be effective until later in the summer or early fall. Now it is official, the company said Thursday in a news release. The deal includes four medical centers — Saint Clare’s Hospital in Boonton, Saint Clare’s Hospital in Denville, Saint Clare’s Hospital in Dover and Saint Clare’s Health Center at Sussex — as well as other facilities in Morris and Sussex counties. “Prime Healthcare looks forward to expanding its presence in the Garden State and partnering with the Saint Clare’s community of dedicated physicians, nurses and employees,” Dr. Prem Reddy, chairman, CEO and president of Prime, said in a prepared statement. “We are committed to providing the best quality care in each and every community we serve, and the addition of Saint Clare’s to the Prime Healthcare family will allow us to continue that tradition.” Prime, which purchased the hospitals from Catholic Health Initiatives, has pledged to hire substantially all employees in the system; invest $30 million in capital improvements over the next five years; maintain charity care at or above current levels; and follow the Catholic ethical and religious directives for health care services.
Westminster-Based AxisPoint Health Appoints CEO Ron Geraty to helm former McKesson division, eyes tens of millions in technology investments By Alicia Wallace
Westminster-based AxisPoint Health, formed this year when McKesson Corp. sold its health care technology and services unit to investors, appointed Dr. Ron Geraty as chief executive. Geraty's experience in the population health and care management area includes serving as the CEO of Alere, a competitor to McKesson's care management division. During Geraty's tenure, Alere grew from $1.2 million in revenue in 2001 to more than $500 million in 2009. "We hope to make this a high-growth company as well," Geraty said of AxisPoint. AxisPoint, which was sold to private equity firm Comvest Partners and Mosaic Health Solutions for an undisclosed sum, has more than 850 employees nationwide, including about 200 in Westminster. The company's services include workflow software for payer organizations, case management and condition management services to help manage costs between patients and providers, and a nurse advice line. With AxisPoint now a standalone entity and no longer a "rounding error" of a giant health care conglomerate, the firm will have a greater sense of focus, Geraty said. He anticipates tens of millions of dollars will be invested in technology and services.
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