Value Based Care

With the shift to Value Based Care (VBC) models across the healthcare industry, Benesch Healthcare+ has increasingly represented clients in the assessment, implementation of and participation in value-based enterprises. Examples of value-based enterprises we have encountered and counseled clients regarding include:

• Accountable Care Organizations (ACOs)
• Specialty Managed Care Organizations
• Management Service Organizations (MSOs)
• Provider Sponsored Health Plans
• Independent Physician Association (IPAs)

Within these value-based enterprises, we have negotiated various aspects of the organization, administration, management, structuring, and participation including:

• Clinically Integrated Networks
• Co-Management Arrangements
• Quality Incentive Payments
• Payments/Allocations for Shared Savings/Shared Risk Programs
• Bundled and/or Capitated Payment Arrangements

Further, we have counseled numerous healthcare providers on the transition to VBC and represent many entities engaged in VBC programs on regulatory, tax, real estate, and intellectual property matters related to the integrated partnership of provider stakeholders engaged in VBC arrangements with governmental and private commercial payors. Our experience spans the gamut of provider types including post-acute, acute-care, physician providers, and specialty care such as renal care.

Our attorneys regularly advise executives, operators, and investors in VBC and population management organizations on regulatory and critical business and policy issues facing companies in this space. We are adept at providing guidance on best practices in structuring a value-based enterprise and negotiating value-based contracts from both a regulatory and a contractual perspective. Our representation includes structuring and organization, agreement review, economic analyses, data use and sharing.  As VBC arrangements may implicate the Anti-Kickback Statute, physician self-referral laws and other associated risks, we routinely provide guidance to clients on compliance with safe harbors and exceptions promulgated to facilitate care coordination and risk sharing.

Representative Experience:

• Represent an Arizona based crisis care behavioral health client in the assessment of a value-based enterprise including the structure of the operating entities and potential compensation streams for participants. Work included analysis of the safe harbors to the Anti-Kickback Statute and exceptions to the Stark Law for value-based enterprises.
• Represented an Ohio-based home health care agency in its participation in a Medicare Shared Savings Program ACO including negotiation of the participation agreement.
• Represented a joint ventured long term care hospital in its participation in a private ACO operated by a large regional health system in Wisconsin. Negotiated key terms including responsible population and economic rights.
• Represented an Ohio-based special needs plan in the development of risk sharing compensation structures and securing approval of same with the Ohio Department of Insurance.
• Represented multiple physician clients across the country in the assessment of participation of the Medicare ACO Reach program. Representation included assistance with interpretation of program requirements and timely completion and submission of participation applications.
• Represented a large Ohio-based regional health system in the assessment of rights and obligations in its administration of an ACO associated with its captive health plan including payments to physician participants.
• Provided strategic advice to clients considering or participating in demonstration programs sponsored by the Center for Medicare & Medicaid Innovation, including the Kidney Care Choices (KCC) Model and ACO Realizing Equity, Access, and Community Health (ACO REACH) Model (formerly Global and Professional Direct Contracting (GPDC) Model.
• Performed health regulatory due diligence on a provider organization specializing in care for chronically ill patients subject to risk sharing agreements with a private equity backed VBC platform.
• Advised multiple physician practices in connection with risk adjustment audits, investigations, and compliance matters with respect to their participation in Medicare Advantage plans.
• Negotiated and drafted numerous value-based and risk contracts between payors and health providers, ACOs and other value-based c entities.
• Negotiated and drafted numerous strategic partnerships for healthcare providers entering into risk sharing arrangements with private equity backed value-based care conveners.