Legal (Fraud and Abuse) Barriers To Care Transformation and How to Address Them ("Wayne's World")

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.

Related Resources

For decades, the AHA's Ameriplan Report served as a blueprint for a number of proposals on national health insurance and health care reform.
AHA Center for Health Innovation Market Scan
Leaders need to think strategically about the pandemic’s impact on health care in the near and long term and plan for a future defined by resilience and…
Special Bulletin
The Department of Health and Human Services (HHS) on Nov. 20 released two final rules that will modernize and make important changes to physician self-referral…
Other Resources
About Project TRANSFORM Prisma health-Upstate, University of South Carolina School of Medicine-Greenville and Clemson University School of Nursing have…
The AHA urges an expeditious review and release of the Physician Self-Referral and Anti-Kickback Statute final regulations that were submitted by the Centers…
AHA, together with five other organizations, urges Attorney General Barr to announce that the Department of Justice will exercise prosecutorial discretion and…