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Introduction

With the Affordable Care Act ("ACA") now upheld by the Supreme Court of the United States, providers, payers, and employers will be faced with the challenge of navigating through the numerous payment and delivery reform changes contained in the law as well as reform initiatives in the commercial insurance market. For decades, private and public purchasers have paid for health products and services based on the quantity provided.

PPACA Impact and Opportunities
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One major component of the ACA is a variety of programs related to accountable care and value-based purchasing. This represents a confluence of ideas that have evolved over the last several decades on better ways to organize, coordinate, and pay for health care services with the intent to produce better quality of care and greater cost efficiency. These ideas and programs will affect all health care providers, health plans, purchasers, employers, and consumers in numerous and significant ways. The public system changes ushered in by the ACA have created a willingness on the part of providers to move beyond the traditional fee-for-service system to a more accountable pay-for-performance model in the context of public and private purchasers.

We recognize that organizations are faced with significant challenges. Our goal is to guide our clients through the complex process of establishing and implementing accountable care organizations ("ACOs") and value-based purchasing initiatives that will provide cost-effective and improved clinical outcomes.

Epstein Becker Green attorneys have nearly 40 years of experience with the precursors of today's ACOs and value-based contracting. Additionally, the national scope of our Health Care and Life Sciences practice provides our attorneys insight into the range of approaches being pursued by payers around the country that are developing accountable care and value-based systems. Epstein Becker Green, along with its affiliate EBG Advisors, which has a full range of medical management and care path knowledge, assists payer, employer and provider clients in addressing the concerns of all parties to accountable care and value-based purchasing contracts.

Scope of Services

Our attorneys can assist in many areas related to accountable care and value-based purchasing, including:

  • Offering insight and addressing considerations around forming an ACO, including ACO payment models, operational tools and strategies, and governance models and value-bases systems
  • Assisting clients in understanding clinical and financial integration around accountable care and value-based purchasing
  • Assisting clients in navigating the structural and regulatory considerations that providers encounter, including the coordination of care and cost management; new compliance implications of increased quality measurement and reporting; and the applicability of the Stark and Anti-Kickback statutes, Civil Monetary Penalty ("CMP") laws, and antitrust laws and enforcement
  • Assisting health care providers and payers in transactional work emanating from accountable care and value-based purchasing
  • Advising clients on the numerous health, employee benefit, and labor laws applicable in the accountable care and value-based context
  • Assisting employers with documenting benefit design
  • Identifying measures appropriate to contracts that target group health plan cost drivers
  • Developing requests for proposals
  • Translating care measures into implementable contractual language
  • Helping identify payment and delivery reform requirements

EBG Successes

  • Epstein Becker Green assisted a large private equity client in establishing a value-based design to reduce the cost of health benefits provided to workers in its portfolio companies.
  • Epstein Becker Green has provided accountable care counsel to 10 of the 27 ACOs that began participating in the Medicare Shared Savings Program ("MSSP") on April 1, 2012, and eight of the 88 ACOs that began participating in the MSSP on July 1, 2012. We are currently providing ACO counsel to nine clients considering entering the MSSP on January 1, 2013.
  • Epstein Becker Green attorneys have written articles on the topic of value-based purchasing and ACOs for reputable publications, including a series with BNA, and regularly blog on the topic.
  • Our attorneys speak frequently on the topic of value-based purchasing and ACOs to various organizations, such as AHLA, HFMA and HCCA.
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