Legal (Fraud and Abuse) Barriers To Care Transformation and How to Address Them

Hospitals, physicians and other health care providers and professionals are facing significant changes in how they practice and are reimbursed for the care they provide. Instead of payment based on volume (the number of services provided), payment is increasingly tied to value. Public and private payers are using financial incentives to drive behavior to achieve quality outcomes, clinical efficiencies and cost savings – the goals of value-based models. At the same time, the legal framework controlling how, if at all, hospitals and physicians can share the risks and rewards in achieving the goals of these new models has remained static.

This report includes a case study ("Wayne's World") of how these barriers can prevent coordinated care.

barrierstocare-full.pdf

Related Resources

Issue Brief
In this brief discussion we discuss various factors (besides differences in bargaining leverage) that are more likely explanations of the observed differences…
AHA Center for Health Innovation Market Scan
AHA Center for Health Innovation Market Scan
CVS Health is rapidly incorporating Aetna into its business and will open the first in a series of concept stores in February in the Houston market to test its…
Letter
Public
The AHA and the Federation of American Hospitals urge Congress to oppose any legislation that would repeal current law limiting self-referral to physician-…
AHA Center for Health Innovation Market Scan
Humana has selected the first four participating organizations in its hospital-improvement program, which focuses on general acute-care hospitals and ways to…
Guides/Reports
Public
Studies Continued