The Legal Challenges of Multi-Provider Alternative Payment Models: Minimizing the Risks of the Volume-to-Value Transition

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This is a complimentary program sponsored by Manatt, Phelps & Phillips LLP.

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Alternatives to fee-for-service (FFS) have proliferated in recent years as government, insurers and employers seek to increase value in the health care system.  Since the passage of the Affordable Care Act (ACA), both federal and state policies have promoted the adoption of alternative payment models (APMs), providing financial incentives for groups of providers to improve care quality while containing costs.  According to a recent study, there were 744 Accountable Care Organizations (ACOs) operating as of March 2015, giving evidence to the growing momentum behind the transition from volume to value.

All U.S. payers – including Medicare, Medicaid and private insurers – are increasingly moving to value-based contracting with health care providers.  Hospitals and physicians must establish integrated networks to engage in alternative payment arrangements, whether with government health care agencies or private payers.  These hospital-physician integration efforts, however, raise unique regulatory compliance challenges that differ substantially from those faced in the traditional FFS environment.

In this program, Manatt provides insights into the growth of APMs, sharing examples of new models across Medicare, Medicaid and the private sector.  The program takes an in-depth look at how both government and private payers are implementing APMs and the regulations that are raising the incentives to drive provider participation.  It then explores the fraud and abuse and antitrust issues and implications around value-based contracting arrangements between hospitals and physicians, the options available to protect these arrangements, and the structuring and compliance strategies for minimizing risks.

Educational Objectives:
• Understand the types of payment models and their growth across Medicare, state Medicaid programs and the private sector.
• Find out how states are building APMs into Medicaid payment methodologies and how private payers are adopting APMs.
• Learn how the Medicare and CHIP Reauthorization Act (MACRA) of 2015 will increase incentives for provider participation in APMs.
• Examine how the Stark Law, Anti-Kickback Statute (AKS) and the Gainsharing Civil Monetary Penalty Law are implicated by value-based contracting arrangements between hospitals and physicians.
• Discover which exceptions, safe harbors and waivers can potentially protect these arrangements.
• Explore how collaborations between hospitals and physicians implicate antitrust laws.
• Discuss structuring and compliance strategies for mitigating legal risks.

Who would benefit most from attending this program?
In-house and outside counsel and executive leadership at provider organizations, including hospitals, health systems, academic medical centers and physician organizations.

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Robert Belfort, Partner, Health Care Practice, Manatt, Phelps & Phillips, LLP

Mr. Robert Belfort is a partner in the health care practice of Manatt, Phelps & Phillips, LLP and has over 20 years of experience representing health care organizations on regulatory compliance and transactional matters.  Mr. Belfort has extensive experience advising a wide variety of health care clients, including hospitals, medical groups, health insurer, managed care organizations, accountable care organizations, mental health providers, pharmacy chains, information technology vendors and health care industry trade associations.

Mr. Belfort’s practice focuses on the following areas: Managed Care and Accountable Care; HIPAA/Privacy; and Fraud and Abuse. He counsels health insurers and other managed care organizations on compliance with Affordable Care Act standards, Medicaid managed care requirements, Medicare Part C and Part D rules, HIPAA portability and nondiscrimination mandates, and state insurance licensing and market conduct laws. He also advises both insurers and providers on establishing accountable care organizations and other value-based contracting arrangements.Within HIPAA and privacy, Mr. Belfort assists clients in managing health information within the parameters established by HIPAA and state confidentiality laws. He conducts internal gap analyses, drafts privacy policies and advises on the development of other privacy safeguards and also helps clients respond to complaints and privacy breaches.  He also works with regional health information organizations and other multistakeholder entities to develop patient consent and other data-sharing policies and practices.  Within fraud and abuse, he advises clients on structuring transactions and conducting day-to-day business operations to ensure compliance with the Anti-Kickback Statute, the Stark law, Medicare and Medicaid participation and billing requirements, professional licensing rules, and corporate practice of medicine and fee-splitting restrictions.  He also performs risk assessments, develops compliance programs, conducts internal investigations and represents clients in government investigations and audits.

Mr. Belfort is admitted to practice in New York.  He earned his J.D., Order of the Coif, from New York University School of Law and his B.A., magna cum laude, from Oberlin College.

Lisl J. Dunlop, Partner, Litigation Division, Manatt, Phelps & Phillips, LLP

Ms. Lisl Dunlop is a partner in the firm’s New York office and a member of the Litigation Division.  She advises leading U.S. and multinational companies in an array of industries – in particular in the media, technology and health care sectors – on a broad range of antitrust counseling, antitrust litigation and transactional matters.  Ms. Dunlop advises on antitrust-related aspects of mergers and acquisitions, joint ventures and other combinations, and sales and distribution matters; represents clients in antitrust agency investigation; and has represented major corporations in complex antitrust litigations, including multidistrict treble damages class actions.  Ms. Dunlop has regularly been recognized as a leading antitrust lawyer in Chambers USA, Legal 500, Who’s Who Legal and Global Competition Review.

In addition to over 20 years of experiencing practicing U.S. antitrust law, Ms. Dunlop has significant international experience in both Australia and Europe.  Ms. Dunlop has appeared before U.S. federal and state enforcement agencies, the European Commission, the UK Office of Fair Trading, and the Australian Competition and Consumer Commission, and has coordinated the multijurisdictional defense of transactions throughout the world.  Ms. Dunlop’s experience in competition matters in a broad range of jurisdictions brings added value to clients that conduct business internationally and interact with different legal systems and regulators.

Ms. Dunlop is admitted to practice in New York, the District of Columbia, England and Wales, and Australia.  She earned her LL.M. from Cornell University Law School, her LL.B. from University of Sydney, and her BSc from University of Sydney.

Jocelyn Guyer, Managing Director, Manatt Health

Ms. Jocelyn Guyer is a managing director with Manatt Health, an interdisciplinary policy and business advisory division of Manatt, Phelps & Phillips, LLP.  Ms. Guyer provides policy expertise, strategic advice and technical support to states, foundations, and a broad array of other clients on implementation of the Affordable Care Act, Medicaid and the Children’s Health Insurance Program.  With over 20 years of experience in health policy, she has particularly deep knowledge of eligibility issues and IT systems and has served as an advisor to organizations such as the National Academy for State Health Policy and the American Academy of Pediatrics, and to major foundations.

Prior to joining Manatt Health, Ms. Guyer was a founding member and co-executive director of the Center for Children and Families (CCF), a health policy center at Georgetown University, where she provided strategic advice and expertise to national policymakers and advocates on health policy issues and safety net programs.  She was previously an associate director with the Kaiser Commission on Medicaid and the Uninsured, where she led analyses of emerging issues in health care for vulnerable Americans, including the implications of the Part D Medicare drug benefit for impoverished seniors and people with disabilities.  Prior to Kaiser, Ms. Guyer was a senior health policy analyst on health and welfare at the Center on Budget and Policy priorities, where her responsibilities included designing policy initiatives to expand coverage to low-income parents and working with states to implement family-based coverage expansions.  She also served as a legislative research assistant to the late Senator Daniel Patrick Moynihan.  Throughout her career, Ms. Guyer has been a speaker at national convenings of state officials, provider organizations, advocacy groups and foundations.  She also has presented to members of Congress, as well as to state and local officials on issues such as the future of children’s coverage, transforming Medicaid, and implementation of federal health reform.

Ms. Guyer earned her M.P.A. in Economics and Public Policy from Princeton University, Woodrow Wilson School of Public Policy and International Affairs and her B.A., magna cum laude, from Brown University.

Edith Coakley Stowe, Senior Manager, Manatt Health

Ms. Edith Coakley Stowe is a senior manager with Manatt Health, an interdisciplinary policy and business advisory practice of Manatt, Phelps & Phillips, LLP.  Ms. Stowe guides health systems in designing, developing and implementing innovative delivery models to improve the management and provision of health care.  She focuses on providing project management leadership, clinical process design, quantitative analysis and health reform strategic counseling.  She brings almost a decade of experience working with U.S. federal and local governments and a firsthand understanding of the Affordable Care Act’s (ACA’s) impact on both the market and the states.

Prior to Manatt, Ms. Stowe served as a Health Insurance Specialist at the Center for Medicare and Medicaid Innovation (CMMI) within the Centers for Medicare and Medicaid Services (CMS), where she led the team implementing the Comprehensive Primary Care (CPC) initiative, a payment and care delivery model involving 500 primary care practices in 7 U.S. regions, as well as over 30 health care payers acting in partnership with CMS.  Before CMS, she was a special assistant at the Office of the State Superintendent of Education for the District of Columbia Government, where she was a part of a small team that achieved overdue reforms in the DC educational system for children with disabilities.  She started her career as a Barrister at Outer Temple Chambers in London, UK and later served as an associate for the Judge David Bazelon Center for Mental Health Law in Washington, D.C.

Ms. Stowe earned her M.P.A. from Harvard University, John F. Kennedy School of Government, attended City Law School, City University in London, UK, and earned her B.A. from New College, Oxford University.