“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bet8网站备用提供所有权职位?“几十年来,bet8网站备用的高管们一直在问我们这个问题. 答案并不总是显而易见的. 一些人甚至错误地认为,给受雇bet8网站备用提供投资机会是非法的. 但随着越来越多的bet8网站备用认识到需要建立更强大的门诊手术能力, 越来越多的外科bet8网站备用受雇于bet8网站备用或根据专业bet8娱乐协议(psa), 探索这个选项是必要的.
许多bet8网站备用试图将一项标准政策应用于所有安排. 例子包括:
- 禁止受雇bet8网站备用拥有ASC.
- 允许在被bet8网站备用雇用之前拥有ASC的bet8网站备用继续作为所有者, 但不向其他受雇的bet8网站备用提供所有权.
- 根据ASC的运营协议,允许任何有资格作为投资者的受雇bet8网站备用拥有所有权.
但是将标准策略应用于复杂的情况是 很少成功. 相反,bet8网站备用的管理者应该允许自己 灵活地为受雇的外科bet8网站备用提供ASC的所有权地位 什么是bet8网站备用的最大利益. 许多战略,财务,运营, 法律因素也要考虑.
战略考虑通常支持向雇员提供所有权 bet8网站备用
具有前瞻性的bet8网站备用一直在大力投资 将病例转移到ascs -在某些情况下战略性地减少住院患者 收入更好地定位自己的未来. 对于许多这样的系统, 包括独立的和受雇的bet8网站备用在他们的所有权 ASCs已成为其门诊手术策略的核心.
表1给出了常见的战略考虑 影响是否向受雇bet8网站备用提供ASC所有权的决定.
财务方面的考虑可能会阻碍向受雇bet8网站备用提供所有权
外科bet8网站备用在手术过程中处于连续护理的末端, 这使得计算他们对bet8网站备用的总体财政贡献更容易. 大多数外科bet8网站备用的经济贡献可以通过外科bet8网站备用诊所的收入和损失的总和来计算, 辅助bet8娱乐(影像), PT, 等.)、门诊手术和医院手术/住院. 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] 但不同专业和亚专业的投资差异很大. 图1显示了针对各种外科专科的临床手术,每家医疗bet8娱乐提供者每年净投资的中位数.[2]
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bet8网站备用之间存在很大差异一样, 手术和辅助bet8娱乐的收入也会减少. 影响单个bet8网站备用手术和辅助收益的因素包括bet8网站备用的业务量, 住院和门诊手术的混合, 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, 辅助bet8娱乐包括在医院收入中. 在这个bet8网站备用中, the annual average contribution for every orthopedic subspecialty is a loss at the clinic and a profit at the ASC and hospital. 但是,亏损和利润的大小差别很大. 诊所的损失远远低于从业骨科bet8网站备用的行业平均水平, 从最低80美元起,一般矫形手术的费用高达约380美元,000元脊椎. 手腕部和脚踝关节外科bet8网站备用的ASC利润最大, 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]
根据这一分析,这个bet8网站备用负担不起 提供ASC所有权给所有受雇的整形外科bet8网站备用. 这样做会减少 该系统从ASC获得的收入,并依赖于弥补 诊所的损失.
业务考虑鼓励灵活性
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: 业主帮助确保ORs得到有效利用, 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bet8网站备用参与ASC合资企业时, 受雇的bet8网站备用对成本和效率有了更多的认识, 哪些可以帮助改善医院手术室的流程和效率.
- 费用管理: 业主参与高成本植入物的评估, 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: 付款人合同对ASC的整体成功至关重要, 医院有能力改善ASC的合同. 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bet8网站备用在ASC工作是实现这一目标的极好手段. 医院控制付款人合同往往是有利的, 以及医院是否在现有的付款人合同中有ASC条款, 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.
法律上的考虑没有阻碍受雇bet8网站备用的所有权[4]
根据《bet8娱乐》,ASCs不被视为指定的保健bet8娱乐, 因此, 在很大程度上, Stark不适用于asc. 相比之下,医疗保险反回扣法规确实适用于asc. 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, ASC不需要满足安全港要求. 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.
当一个安排不符合安全港的条件时, 其合法性完全取决于参与者的意图. 《bet8娱乐》禁止提供回扣, 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. 分析《bet8娱乐》的遵守情况, 有人会问一个非常基本的问题:有人付钱吗, 或者寻求报酬, 为推荐?
虽然知道安全港的要素是值得的, 没有理由纠结于完美地满足每一个元素. 一般来说, 允许受雇的外科bet8网站备用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, 绝对没有法律要求ASC必须通过三分之一测试.
虽然没有必要应用三分之一测试, 将其作为一种确保所有bet8网站备用投资者(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, 虽然三分之一测试可能不是监管的必要条件, 它可以成为确保中心生存能力的重要工具.
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bet8网站备用提供所有权? 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. 花点时间来评估和权衡战略, 金融, 以及在决定之前的操作影响. 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. 通过降低WRVU率(从而减少/消除诊所损失), 医疗系统可以更容易地证明向外科bet8网站备用提供ASC的股权是合理的.
- 尽管有前面的陈述, 永远不要把bet8网站备用报酬和股权分配混为一谈. 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bet8网站备用来说,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.
- 尽早让法律顾问参与决策过程. 措辞要谨慎,避免让人觉得受雇的bet8网站备用必须参考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, 尽管其他的所有权模式也是可能的.
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年医疗集团绩效调查, 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.
- 3.
本案例研究旨在说明这种差异 在财务影响之间的亚专科和不应考虑 典型的. 例如,许多关节置换和脊柱外科bet8网站备用都有贡献 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. 只要"程序"这个词出现在安全港, 你应该把它读成“ASC门诊程序清单上的程序”.”
出版于2022年7月19日