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“我们是否应该在我们正在开发的独立ASC合资企业中为我们雇佣的外科云顶集团40011官网提供所有权职位?” Health system executives have asked us this question for decades. 答案并不总是显而易见的. 一些人甚至错误地认为,给受雇云顶集团40011官网提供投资机会是非法的. 但随着越来越多的云顶集团40011官网认识到需要建立更强大的门诊手术能力, 越来越多的外科云顶集团40011官网受雇于云顶集团40011官网或根据专业云顶集团协议(psa), 探索这个选项是必要的.
Many health systems try to apply a standard policy to all arrangements. 例子包括:
- Prohibiting employed physicians from ownership in an ASC.
- 允许在被云顶集团40011官网雇用之前拥有ASC的云顶集团40011官网继续作为所有者, but not offering ownership to other employed physicians.
- 根据ASC的运营协议,允许任何有资格作为投资者的受雇云顶集团40011官网拥有所有权.
But applying a standard policy to a complex situation is 很少成功. Rather, health system executives should allow themselves 灵活地为受雇的外科云顶集团40011官网提供ASC的所有权地位 what is in health system’s best interest. Many strategic, 金融, operational, and legal factors should be considered.
战略上的考虑 Often Support Offering Ownership to Employed 云顶集团40011官网
Forward-looking health systems have been investing heavily in shifting cases to ASCs—in some cases strategically reducing inpatient revenue to better position themselves for the future. 对于许多这样的系统, including both independent and employed physicians in the ownership of their ASCs has become central to their ambulatory surgery strategy.
Table 1 presents common strategic considerations impacting the decision whether to offer ASC ownership to employed physicians.
![医院雇用的门诊外科合资企业的云顶集团40011官网所有者](/user_area/uploads/Hospital-Employed-Physician-Owners-in-Ambulatory-Surgery-Joint-Ventures_Table-1.png)
财务方面的考虑可能会阻碍向受雇云顶集团40011官网提供所有权
Surgeons sit near the end of the continuum of care for a surgical episode, 这使得计算他们对云顶集团40011官网的总体财政贡献更容易. 大多数外科云顶集团40011官网的经济贡献可以通过外科云顶集团40011官网诊所的收入和损失的总和来计算, 辅助云顶集团(影像), PT, 等.), ambulatory surgery, and hospital surgeries/admissions. Health system executives are often surprised to learn the degree to which the 金融 performance across these various services fluctuates among surgeons of different specialties and subspecialties.
The average annual investment among hospitals that employ surgeons to ensure access and community benefit is approximately $320,每个供应商000美元.[1] But the investment varies substantially across specialties and subspecialties. 图1显示了针对各种外科专科的临床手术,每家医疗云顶集团提供者每年净投资的中位数.[2]
![医院雇用的门诊外科合资企业的云顶集团40011官网所有者](/user_area/uploads/Hospital-Employed-Physician-Owners-in-Ambulatory-Surgery-Joint-Ventures-Figure-1.png)
与此形成鲜明对比的是, hospitals frequently show a profit from surgeries and other ancillary services related to surgeries—many of which are commonly maintained within an independent surgical group’s practice. 但是,正如诊所手术的投资在不同的专业和外科云顶集团40011官网之间存在很大差异一样, so can income from surgeries and ancillary services. 影响单个云顶集团40011官网手术和辅助收益的因素包括云顶集团40011官网的业务量, mix of inpatient versus outpatient surgeries, 付款人混合, 成本效率, 等. 也, substantial variance occurs not only between specialties but also within a specialty and among physicians of the same subspecialty.
Figure 2 presents findings from an analysis of the 金融 contribution of the employed orthopedic surgeons at a health system by place of service, with ancillary services included as hospital income. 在这个云顶集团40011官网中, the annual average contribution for every orthopedic subspecialty is a loss at the clinic and a profit at the ASC and hospital. But the magnitude of the losses and profits varies substantially. 诊所的损失远远低于从业骨科云顶集团40011官网的行业平均水平, 从最低80美元起,000 for general orthopedics to a high of approximately $380,000元脊椎. Hand-and-wrist and foot-and-ankle surgeons generate the greatest ASC profits, 但他们的最低医院利润导致手和手腕的整体损失,边际利润为5美元,脚和脚踝的费用是5000美元. Joint replacement and spine clearly provide the highest overall 金融 contribution to the health system but for this particular organization generate minimal ASC income.[3]
Based on this analysis, this health system could ill afford to offer ASC ownership to all its employed orthopedic surgeons. 这样做会减少 the income the system receives from the ASC and relies on to make up for the 诊所的损失.
Operational Considerations Encourage Flexibility
The decision to include or exclude employed physicians from ASC ownership can significantly impact the success and operations of the ASC due to the following:
- 数量和付款人组合: Owners are more mindful of case types that present opportunity for increasing value and have a favorable impact on 金融 performance. 运作良好的会计核算中心向其合作伙伴提供案例成本核算方面的教育, which informs the partners of case types that are advantageous in the ASC and provides insights on case types that may be cost prohibitive or present with concerns.
- 或效率: Owners help make sure ORs are used efficiently, 小组时间得到充分利用, 而且案件会准时开始. They actively participate in optimizing and improving key performance indicators and are motivated to support implementation of change that will impact the overall operating performance of the center. 附带的好处是, 当医院支持受雇云顶集团40011官网参与ASC合资企业时, the employed physician becomes more cognizant of cost and efficiency, which can help improve processes and efficiency in the hospital ORs as well.
- 费用管理: Owners participate in the evaluation of high-cost implants, 药物, 而医疗用品则更容易在标准化上达成共识. They work collaboratively when purchasing instrumentation and capital equipment to ensure the ASC has what it needs to provide safe, 高质量的护理和更有可能发现机会,以减少病例成本.
- 所有权和治理份额: Independent physician owners of an ASC may view employed physicians as part of the health system and seek to limit the combined health system and employed physician share of ownership and governance. 这 could have significant tax and 金融 reporting implications to the health system if the limitation results in the health system having a minority share in ownership and governance. The health system should seek to ensure the ASC is structured to further the health system’s charitable purposes and mission consistent with IRS rulings and case law.
- 付款人承包: Payer contracting is critical to the overall success of an ASC, and a hospital has the ability to improve an ASC’s contracts. 医院可以通过提供增加在asc执行的病例百分比来进一步改善合同. 鼓励受雇云顶集团40011官网在ASC工作是实现这一目标的极好手段. It is often advantageous for the hospital to control payer contracting, and if the hospital has ASC provisions in existing payer contracts, 这些条款可能规定了必须与合资企业结构一起考虑的标准. 例如, the hospital’s ownership position 典型的ly must be the majority to control payer contracting and/or add an ASC as an affiliate to a hospital contract.
Legal Considerations Present No Obstacles to Employed Physician Ownership[4]
ASCs are not considered a designated health service under the Stark law, 因此, 在很大程度上, Stark不适用于asc. 与此形成鲜明对比的是, the Medicare Anti-Kickback Statute does apply to ASCs. 联邦法规建立了一系列保护某些ASC结构的安全港.
然而,重要的是要了解医疗保险反回扣法规是如何运作的. 而安全港则为任何符合其所有条件的企业提供绝对的保护, an ASC is never required to meet a safe harbor. 符合安全港的好处是,在安全港内的安排不会被政府起诉. 然而,正因为如此,安全港被设计得非常狭窄.
When an arrangement does not qualify for a safe harbor, its legality is determined solely by the participant’s intent. The Anti-Kickback Statute prohibits offering, 支付, 征求, 或者接受任何报酬,如果报酬的一个原因是影响联邦医疗保健计划下的转诊. To analyze compliance with the Anti-Kickback Statute, one asks a very basic question: Is anyone 支付, 或者寻求报酬, 为推荐?
While it is worth knowing the elements of a safe harbor, there is no reason to obsess about perfectly meeting every element. 一般来说, 允许受雇的外科云顶集团40011官网投资于他们将积极使用的ASC的风险非常低.
Among the safe harbor requirements impacting the decision of whether to offer employed physicians ownership in an ASC is the so-called “one-third test.“这个测试有两个部分.
- 第一个, 迎接安全的港湾, one-third of each physician investor’s medical practice income must come from the physician’s performance of surgical procedures that appear on Medicare’s ASC outpatient list.
- 第二个, 门诊手术清单上三分之一的手术必须在投资实体进行.[5]
The one-third test often prompts claims that an ASC may not allow investment by a surgeon who doesn’t meet both prongs of the test. Sometimes an ASC will use the test as a tool to force physicians who are not bringing a large share of their cases to the ASC to divest their ownership. While sound business practice and antikickback risk management both make it a good idea to limit investment to surgeons who are very active at an ASC, there is absolutely no legal requirement that an ASC pass the one-third test.
While it is not necessary to apply the one-third test, 将其作为一种确保所有云顶集团40011官网投资者(包括受雇的和独立的)保持活跃的手段是有好处的. 当个人在没有积极帮助经济运行的情况下将资金带出中心时, ASC很快就会变得不稳定. The professionals who are bringing cases to the center may choose to leave if they feel passive owners are profiting from the active investors’ work. 因此, while the one-third test may not be a regulatory necessity, it can be an important tool for ensuring the viability of a center.
保持选择余地
So, 你是否应该在你独立的ASC合资企业中为你雇佣的外科云顶集团40011官网提供所有权? 什么可能会让人觉得正确的战略反应可能没有得到财务影响的支持. Take the time to evaluate and weigh the strategic, 金融, and operational implications before deciding. 记住以下概念:
- 通常可以设计财务安排来支持战略目标. 例如, the 金融 impact to the health system of offering ownership in an ASC to surgeons under an employment or PSA model is driven by the compensation paid per WRVU for professional services and the amount of equity offered in the ASC. By lowering the WRVU rate (and thus reducing/eliminating the 诊所的损失), a health system can more easily justify offering surgeons equity in an ASC.
- Notwithstanding the previous statement, never confuse physician compensation with equity distributions. 从公平市场价值的角度来看,它们之间没有任何关系. A health-system-employed physician’s ownership or lack of ownership in an ASC should have no bearing on the amount or method by which the physician is paid for clinical services provided to the health system.
- 对云顶集团40011官网来说,退出或不续签雇佣协议要比离开自己拥有的企业容易得多. Restrictive covenants of an ASC’s operating agreement and the inability to sell their units at a favorable rate can provide substantial deterrents to physicians from leaving an ASC.
- Involve legal counsel early in the decision process. 措辞要谨慎,避免让人觉得受雇的云顶集团40011官网必须参考ASC. Don’t track referrals made by employed physicians to the ASC and don’t have the employed physician’s compensation be based in any way on the volume or value of referrals to the ASC. It is safest to allow all physicians the same ownership opportunity to avoid the perception that physicians are being offered a level of ownership based on their relative volume of referrals, though other models of ownership are possible.
向ASC添加新案例?
下面是通往成功的10个步骤.
了解更多这 article 最初发表于 贝克尔的ASC评论 2022年7月14日.
脚注
- 1.
基于心电图 2020 Medical Group Performance Survey, 这是基于2019年的数据. 在2021年的调查中,由于大流行,每个提供者对许多专业的投资大幅增加.
- 2.
这 investment is often necessary because, 与独立云顶集团40011官网相比, 医院雇佣的外科云顶集团40011官网经常看到更多的低报销病人, sources of ancillary revenue are stripped from the clinic, and overhead costs are higher at hospital-operated clinics.
- 3.
这 case study is intended to illustrate the variance in the 金融 impact among subspecialties and should not be considered 典型的. 例如, many joint replacement and spine surgeons contribute 极大地提高了ASC的盈利能力.
- 4.
- 5.
安全港的这一要素很容易被误解,因为它只是指“程序”.但安全港对“程序”一词的定义是有限制的, 仅用于出现在医疗保险ASC门诊手术清单上的手术. Whenever the word “procedure” appears in the safe harbor, you should read it as “procedure on the ASC outpatient procedure list.”
出版于2022年7月19日