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.