Value-Based Purchasing and Accountable Care

As models of reimbursement for health care services continue to evolve and grow in complexity, providers, payers, and employers are faced with the challenge of understanding and navigating numerous payment and delivery reforms that impact the commercial and government insurance market.

The fee-for-service paradigm has been shifting to payment for value, based on quality and cost savings. Government-sponsored Medicare and Medicaid programs, as well as commercial managed care plans, have instituted value-based purchasing programs whereby providers may share in both upside medical cost savings and downside losses based on their performance and member population.

Strategies for improving coordination and payment for health care services to produce a higher quality of care with better outcomes, all at an efficient cost structure, abound in both the traditional Medicare fee-for-service and managed care environments. Achieving a successful reimbursement arrangement model requires an effective and creative shift in care delivery to a more accountable and outcomes-based model of reimbursement.

At Epstein Becker Green, we recognize that organizations face significant challenges in this rapidly evolving landscape. Our firm is particularly well-positioned to guide our clients through the complex process of establishing and implementing delivery system reform and value-based purchasing relationships to promote efficiency and innovative reimbursement structures stemming from improved clinical outcomes.

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Epstein Becker Green has 50 years of experience with the precursors to today’s accountable care organizations (ACOs) and value-based contracting and reimbursement risk arrangements. Our attorneys have worked with payers and provider health systems to develop total cost of care, episode-of-care, and other bundled payment arrangements; quality performance bonus programs; and various shared-risk programs. We have worked with providers to effectively organize and contract for voluntary and mandatory Center for Medicare and Medicaid Innovation programs. Additionally, the national scope of our Health Care and Life Sciences practice provides our attorneys with keen insight into the range of approaches being developed by government and commercial payers and providers around the country.

Epstein Becker Green, along with its affiliate EBG Advisors (which provides a full range of medical management and care path consulting services), assists payer, employer, and provider clients in addressing the concerns of all stakeholders in every type of value-based contracting and care delivery environment.

Scope of Services

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

• Forming clinically and financially integrated networks
• Advising on contracting and regulatory matters related to value-based payment, including structuring new delivery systems/networks and provider-sponsored health plans
• Developing participating provider contracts for ACOs, independent practice associations (IPAs), and other integrated entities
• Advising on all types of payment models, such as shared savings, capitation, bundled payments, percent of premium, etc.
• Offering insight into, and addressing considerations around, forming new legal entities (such as ACOs, IPAs, integrated delivery systems, professional corporations, and limited liability companies) and their operational tools and strategies, and governance models
• Assisting clients in participant contracting to achieve clinical and financial integration

• Providing assistance to clients in navigating structural and regulatory considerations, such as, among other things:
  • multistate organizational licensure (such as IPAs and ACOs);
  • multistate utilization review licensure and certification needs;
  • disease management programs;
  • care management and care coordination;
  • the new compliance implications of increased clinical and financial integration models, privacy and security, data sharing and reporting, and antitrust considerations; and
  • the applicability of the Stark Law and the Anti-Kickback Statute, civil monetary penalty laws, corporate practice of medicine doctrines, and antitrust laws

• Assisting health care providers and payers in transactional work associated with value-based purchasing arrangements
• Advising clients on the numerous health, employee benefit, and labor laws applicable in the accountable care and value-based context
• Helping employers document benefit design
• Assisting providers with enforcement actions

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