Piecemeal Healthcare Mergers Fly Under Radar

 Reprinted from the NY Times April 9th 2016 – written by Reed Abelson

Federal officials are expected to argue in court starting Monday that a large hospital merger in the Chicago area could hurt consumers and should be stopped. It would be the latest in a series of efforts by regulators to push back against a wave of consolidation among major health care providers.

But a frenzy of smaller transactions is also profoundly changing the landscape, many of which face little regulatory resistance. The deals are often for a couple of doctors here, or a hospital there, making them too small to attract much attention. But as those deals add up, they are creating groups that in some cases dominate local or regional markets. And they are raising questions about whether the gaze of antitrust officials is directed in the right place.

“There’s a lot of consolidation going on at a lot of levels,” said Leemore S. Dafny, a former federal official who is a health economist at Northwestern University. She added, “I don’t think the antitrust laws are set up to stop it.” Doctors and hospitals are making the calculation that bigger is definitely better. Consolidation, they say, helps them better coordinate care and manage patients, making care more effective and less expensive.

Skeptics, however, say that the small combinations can eventually translate into higher costs. By gaining market share, they say, hospitals are able to charge more for their care and gain more influence about where patients are sent for lucrative services. Regulators, meanwhile, are left with limited information about the smaller deals, including answers about whether they diminish competition, leading to higher prices and lower-quality care.

 Dr. Farzad Mostashari, a former health official in the Obama administration, describes what is taking place as “creeping consolidation” — being done at a pace that keeps it away from prying eyes. “If you move slowly enough, maybe nobody will notice,” he said.

Many of the smaller deals go unreported, leaving any tally of them incomplete. But at least 940 health care service transactions took place last year, up from about 480 in 2010, according to Irving Levin Associates, a research firm. This mix of deals, which involved groups like physician practices, hospitals and nursing homes, totaled some $175 billion.

Because of the consolidation, patients are more likely to be getting care from providers with formal ties to one another. The doctor who is employed by a hospital, for example, may send a patient for a CT scan at a facility owned by the same hospital. Patients may be discouraged from going to a provider outside a given network, either by their insurer or their doctor.

The combinations taking place include smaller hospital mergers, like one in Arizona in March, when two hospitals merged. The same month, Baptist Health, a small hospital group in Kentucky, said it planned to reach into Indiana to add another hospital. Neither of those deals has generated significant attention.

The difference in regulatory attention is particularly stark in Illinois.

The hospital deal in Chicago, between Advocate Health and NorthShore University HealthSystem, brings together two large systems, including hospitals and doctors’ groups. It was announced in 2014 and involves more than 6,000 doctors. Advocate and NorthShore say they will promise not to raise their prices above inflation. They also say they plan to introduce a health plan that will be cheaper than comparable policies offered by the insurers in the market.

But the deal is being opposed by the Federal Trade Commission in a case expected to start Monday at the United States District Court for Northern Illinois.

New WCPT report advocates for PT involvement in disaster management

Physical therapists should be considered central to disaster management, and an intrinsic part of planning for and responding to events such as earthquakes and floods. That is the message of a major new WCPT publication. 

The report points to the need for high quality rehabilitation after disasters. But it also emphasises that the role of physical therapists is not limited to direct provision of rehabilitation. It embraces preparedness and recovery and can include assessment, coordination, psycho-social support and advocacy. The in-depth report emerged from discussions between WCPT and physical therapists involved in humanitarian responses, who identified a need to advocate for rehabilitation professional involvement in all phases of disaster management.

It was informed by a project advisory group including representatives from the International Committee of the Red Cross (ICRC), Mèdicins Sans Frontières, CBM International and WCPT member organisations in Japan and the Philippines. “It is an impressive document, very timely, and will be a great resource for physical therapists, in particular those involved in the disaster continuum as well as student education,” said WCPT Vice President Margot Skinner, who was a member of the project advisory group. This month marks the fifth anniversary of a massive earthquake and tsunami in Japan.

“For Japanese physical therapists who have experienced earthquakes and other disasters, the report is well organised and has structured information reflecting on their own activity and describing activities and practice in other disasters,” said Kazuto Handa, President of the Japanese Physical Therapy Association. WCPT’s Professional Policy Consultant Catherine Sykes co-authored the report with Pete Skelton, a London-based physiotherapist and Rehabilitation Project Manager with Handicap International who has worked as part of emergency responses in Nepal, Gaza, Iraq, the Philippines, Libya, Jordan and Haiti.  “Disasters are a growing global problem,” said Pete Skelton, “and while there is often a huge amount of goodwill from physical therapists around the world after a disaster has struck, it can be difficult to know how best to help. When properly prepared, physical therapists can play a vital role in disaster response, but sometimes well intended volunteers can undermine existing locally led emergency work.”

“This guide provides essential information to those interested in national or international disaster response, introducing key international guidance and evidence. Critically, it is also designed to help physical therapists plan and prepare for disasters before they occur, and to support those who are re-building after a disaster has hit.” The Nepal Physiotherapy Association (NEPTA), which played a major role in organising physiotherapy response following the major earthquake in April 2015, was one of the organisations providing case studies for the report. Others included Handicap International, ICRC and CBM. “The vital responsibilities for the physiotherapist during the early days of the adverse situation were: triaging injuries, safe transfers, proper positioning of patients, early mobilisation including bed activities, supply and user training of mobility aids,” said Nishchal Shakya, the NEPTA President.

“We have now realised that this was an opportunity for physiotherapists to prove their value as an integral part in the health system.” The report, The Role of Physical Therapists in Disaster Management, is available for download from the WCPT website.

After the Gig, the IRS – What Independent Contractors Need to Know about Tax Time

 Reprinted from the NYTimes – March 5th Tara S. Bernard.   Read the article for good tax tips, then join our upcoming live webinar April 7th – IC vs. Employee – What You Need to Know 7:30-9:00 EST

Since losing her job in advertising during the financial crisis, Dina Scherer has spent her days helping women cultivate their own personal styles — finding flattering color palettes, editing closets and taking customers on shopping excursions. As a one-woman enterprise, she can be considered a card-carrying member of the so-called gig economy, receiving about half her client leads through Thumbtack, an online marketplace that connects consumers with an array of service providers, whether wedding photographers, music teachers, plumbers or organic cleaning services.

But there’s a reason the gig economy is also known as the 1099 economy, with the number a reference to the tax form issued to independent contractors: Workers in such arrangements are not employees of any company, and the onus is on them to run what are essentially their own businesses, even if the business is simply renting a room through Airbnb or providing rides through Lyft or Uber.  All independent contractors are responsible for handling their own taxes, keeping track of their potentially deductible expenses and familiarizing themselves with the requisite tax forms, all in time to send the forms to the federal government by April 15. (This year, it’s April 18.) “It was intimidating” at first, said Mrs. Scherer, who runs her image and styling agency, Modnitsa Atelier, out of a WeWork shared office space in downtown Manhattan. Now, though, she has her income and expense tracking system down to a science, and consults an accountant come tax season.

There has been a lot of debate about how online platforms have changed the nature of work. In some cases, on-demand companies have been harshly criticized for making employerlike demands on workers but denying them basic benefits and protections. In January, Lyft, the ride-hailing company, settled a lawsuit brought in 2013 by drivers in California who sought to be recognized as full-time employees. Though Lyft agreed to pay $12.25 million, its drivers remained classified as contractors. But the gig economy goes well beyond providing rides on demand. For entrepreneurs, online marketplaces like TaskRabbit, Thumbtack or Etsy have become another avenue to generate leads for their own businesses. Then, there’s the chance for everyone to become a hotelier.

“While more Americans are turning to this kind of gig economy, they do face new and more complicated tax requirements,” said Kathy Pickering, executive director of the Tax Institute at H&R Block.

Where to begin? Here are several requirements the self-employed need to think about, particularly during tax season:

Reporting income Independent contractors who haven’t set up any formal business structure (or who have, as a single-member limited liability company) should report their income through the traditional tax return, Form 1040. They will also typically use a Schedule C, which lists income and expenses, or perhaps a Schedule E, when collecting real estate income.

People running multiple businesses — say, selling photo prints on Etsy while driving for Uber — would need to keep track of all income and expenses separately, using dedicated Schedule C’s for each. There may be state and local tax forms as well. Generally speaking, payments received directly from customers need to be tracked and reported when filing the tax return. But contractors working through a platform like Uber or Lyft, for instance, may be issued a 1099-MISC (which is required when income generated exceeds $600; it is also reported to the I.R.S.). They may also be issued a 1099-K, which tracks income paid through credit- and debit-card payment networks. That all needs to be reported as well.

“One of the most common errors that gets made is people forget or miss reporting all of their income,” Ms. Pickering said. Independent contractors, she said, should track all income on their own, since some may be reported via 1099s and other portions may not. Many on-demand companies send annual earnings reports, too.

Self-employment taxes Employees generally split payroll taxes — which cover Social Security and Medicare and are automatically deducted from paychecks — with their employers.

But independent contractors who generate more than $400 in net profit are responsible for the entire amount, known as self-employment taxes. “No one shares that with you,” said Greg Rosica, a contributing author to the EY Tax Guide 2016.

Expenses and deductions The added taxes may feel burdensome, but self-employment income opens the doors to a host of new deductions, as long as expenses are germane to the business.

“If you are doing things like Uber or a rides program, you can take your gas, your carwash, your vehicle licenses,” Ms. Pickering said. “That may not be obvious for someone getting into this for the first time.”

But there are also several broad categories of expenses that can apply to different businesses. People working out of their homes, for instance, can take the home office deduction, as long as the space is used “regularly and exclusively” for business purposes. If that’s the case, you can deduct $5 a square foot of dedicated office space, up to a maximum of $1,500. Alternatively, a more complicated calculation, based on actual expenses, could yield a greater home office deduction.

Phone lines and computers may also be deductible, separate from the home office expense, but if the time is split between personal and business use, that needs to be documented. “The I.R.S. won’t take your guess,” said Mark Luscombe, principal tax analyst at Wolters Kluwer. “These things should be contemporaneous. They don’t look kindly on you if you create records at the time of the audit.”

Transportation expenses — say, to meet customers — may also be deductible and can be accounted for in a couple of ways: When driving, you can either take the standard mileage deduction or actual expenses to operate the vehicle (lease payments, insurance, gas, oil) based on the ratio of business to personal use. Track both, then take the larger deduction.

Individuals who use their vehicles more than half the time for business may be eligible to deduct up to $25,000 of the cost, as long the vehicle meets certain specifications. “That is a great one for Uber and Lyft drivers, but it also goes for anyone with their own business,” said Lisa Greene-Lewis, a certified public accountant at TurboTax.

Health Insurance As part of the Affordable Care Act, individuals are required to have health insurance, unless they qualify for one of the exemptions. Self-employed people can deduct their health care premiums, as long as they buy the insurance through their business, while contributions to tax-advantaged retirement accounts, like traditional I.R.A.s and SEP I.R.A.s — may also be deductible.

Estimated tax payments Many self-employed people may need to make quarterly estimated tax payments during the tax year if they expect to owe more than $1,000 in federal taxes.

Rental income People who rent part or all of their homes for generally no more than 14 days — say, for just a few lucrative holiday weekends — aren’t required to report the income (and can’t deduct any expenses). But anyone who is renting a space for a longer stretch must generally report that income, along with expenses, on either a Schedule C or Schedule E of the tax return.

There’s quite a bit that can be deducted, items as varied as advertising and cleaning bills, property insurance, repairs and fees paid to agencies like Airbnb.

How much you can claim depends on how many days your home was rented, versus the time it was used personally. If, say, a beach cottage was available for rent all year, even thought it wasn’t rented the entire time, all allowable expenses are deductible. But if it was rented for 85 days and you used it for 15 days, you can typically deduct 85 percent of expenses, according to EY, which wrote a guide on rental property income for Airbnb.

If you’re renting one room in an apartment, one of two methods can be used to calculate how to divide up the expenses: Base the percentage either on the number of rooms in your home or on square footage.

State income taxes and perhaps even local taxes may be owed as well, so be sure to check with those authorities.

Tools Airbnb, Lyft, Uber and others are working with tax and software firms to provide educational materials for their contractors, as well as discounts and tools.

QuickBooks Self-Employed, an accounting program and app, recently introduced a new automatic mileage-tracking feature. And Xero Tax Touch is an app that helps on-demand workers keep track of their incomes and expenses on the go. The information can be transferred to a Schedule C at the end of the year.

Mrs. Scherer, however, uses an old-fashioned spreadsheet, which helps her categorize expenses. It’s all easy to track, since she uses a dedicated credit card and checking account.

But her advice to new contractors? “If you are really fresh and don’t know anything, track everything,” she said. “You’d be surprised what’s deductible.”

Consider this a public service announcement if you work with United Healthcare

November 20 2015:  united healthcare very badFor the last few works I have been consulting with therapists and patients on audits related to United Healthcare. I am sharing this information in the hope that it might save therapists and patients  from going through some of the egregious issues I have seen first hand.

For patients who are insured by United Healthcare- You May Be Entitled to a Refund!!   In accordance with an agreement reached with the Attorney General’s Office, if you were a  patient who received care from an out of network provider who was inaccurately listed by UHC as in network, you can get a refund if you paid the provider more than the copayment or co insurance you were required to pay under your benefit plan, plus 12% interest!!
This applies to all dates of services from January 1 2006 though October 30, 2015.  If you have any questions about this, or how to send in your claims for review, you can contact United HC  directly at 877-276-7342 or you can contact the OAG directly at 800-428-9071 ( in NYS), or 518-776-2480 (out of NYState) or go to  www.ag.ny.gov/bureau/health-care-bureau

Therapists who are in or out of network with United HC – WATCH OUT FOR audits and the “Recovery Services” team of Optum who are aggressively trying to classify therapy services either as medically unnecessary, or retroactively denying payment, and demanding refunds because documentations summited in audits ” did not support” payment or meet their standards.  Here is a link to their policy and procedures on documentation– follow it very very carefully, and I recommend writing all notes  in full sentences, not using any abbreviations and embedding specific time spent on each part of treatment for all timed CPT codes. In my 35 years in the field, I have never seen a more aggressive attempt to classify services that were rendered in the good faith that they would be paid for as “overpayments” with refunds demanded or taken from future payments.

Hospital Branding Goes Retail

Reprint from July 2015 – CRAINs NY BUSINESS

Hospitals in New York routinely spend heavily on advertising.  Mount Sinai Health System for example, just ran full page ads in local newspapers as part of an expensive multimedia marketing blitz. The Hospital for Special Surgery also has a healthy ad budget but it is trying another way to raise brand awareness. The orthopedic power house rolled out its new online store and clothing line linked to its Back in the Game campaign and online patient forum. More than 800 patients have posted their recovery stories on the hospital’s website. With the click of a button, each one can be shared with the #backinthegamehashtag- and patients can now buy athletic apparel featuring the slogan.

“A brand can pivot from standing for what you do to standing for what you mean”, said an HSS spokesperson. It’s something mature brands frequently do in other categories, but rarely if ever done in the hospital industry, he added.
The store is not meant to be a major source of revenue.  Still, plans call for going beyond T-shirts and hoodies to selling apparel related to such activities as cycling and gardening,



Okay Occupational Therapists – The NY Times Gave us a Gift- the Real Question is How are We Best Going to Use and Re-gift it????

Elizabeth Harris’ February 18th article on Occupational Therapy’s sharp increase was a great post holiday season, get the first quarter of 2015 off to a great start, marketing dream come true.  But, it is not enough to simply share the article on your website, or Facebook page. This well written and pretty spot on  article  offers many platforms upon which to market your OT services, or  introduce a new segment of what you may want to offer in the future. So instead of just posting the article, I decided to offer some suggestions on how you may want to use the article as a platform, or springboard in your practice.

As discussed, the demand for OT services in the school systems in NY, Chicago, and probably other major cities is up sharply because  more special needs students are  entering the system, there is a “new” approach to educating these students, and there are increased academic demands on all young children.

When demand for a service or commodity  is up, historically, supply is down. When supply is down – the value of the supply that exists becomes more valuable.  Thus, this is a great time to offer your services in general, and when possible, to make sure you are being paid enough.  If you are not in a contract with a locked in fee, and have not received a raise in a while, now is the time to ask for one.  Underserved areas desperately seeking OTs may be amenable to offering perks for your commitment to them – think about what you might want in addition to salary.

There are several  undertones in the  article- Remember, everyone can benefit from OT, but not everyone needs it.

The increased demand is fueled in part by those students receiving OT who may not really need it – this creates a secondary opportunity to be the OT who  can first  help  evaluate and weed out those receiving inappropriate  or unnecessary services,  and then  offer  alternatives to individual services like targeted small groups, or  structured home programs. Many times, inexperienced OTs are working  in the school system, and do not have the expertise needed to be able to fully differentiate who needs OT or not.  This is a great time for the well seasoned therapist  to step up to the plate, and show why their input is crucial in this situation. A school system paying more for your expertise in this area  will wind up saving more in the end by not having to fund unnecessary OT services.

OT as a means to catch up or a means to get ahead

The article discusses that as the academic expectations for young children increase, some children are not up to snuff developmentally to meet the challenge. What was not mentioned in the article  but what many of us know to be true is that  as  3 and 4 -year-olds in  classrooms are exposed to  pre academic demands, many more distracted kids will  catch a  teacher’s attention.  What is behavior versus sensory issues in children should come to the forefront. There is no better professional than a well versed  OT to address this and offer  consulting services to help differentiate between the two.  What a great time to have OTs  observe in the classroom and make recommendations generally for the classroom, and specifically for particular students. Consultations can be offered at the start of a school year and then periodically on an as needed basis.

Parents are tapping into occupational therapy services to enhance the performance of their children, with or without special needs.  As healthcare in general  transitions from a service model of sickness to wellness, prevention, and enhancement this is an opportunity  for those OTs who may opt to work, not with special needs children but with any group of  children who want to enrich their skills. This article cries out for OTs to  set up readiness programs.  Whether it is readiness for  pre school, readiness for inclusion classrooms, or  readiness  for private school admission interviews and tests, the ball is clearly in the OTs court.

So do more than just passively post this article, USE it as an active vehicle to help promote your particular skill set and services.





NYC and Surrounding Areas Largest Health Insurers

Crain’s New York Business released its ranking of NYC’s largest health insurers, ranked by the number of enrolled NYC members.  Practice owners always a multifactor decision on which, if any, insurance plans to become participating providers with – what the pay rate is, what the turnaround time for payment is, the complexity of getting authorizations etc., and their degree of penetration in the marketplace where you practice.

Below is a list of the top 10, ranked from largest to smallest  in the 5 boroughs of NY, Nassau, Suffolk, Westchester, and northern NJ counties, compiled from Crain’s as well as some commentary on their growth.
1) Empire BC/BS -4M + members, 14, 000 participating primary care physicians
2) United Healthcare- 3.6M+ members, 85,000+ participating primary care physicians
3) Aetna – 1.9M+ members, 17,000+participating primary care physicians
4) HealthFirst – 1M+ members, 18,000+ participating primary care physicians
5) GHI – 983,000 members, 14,000+participating primary care physicians
6) HIP – 708,000 members, 11,418 participating primary care physicians
7)Cigna Healthcare 700,000 members, 3,700 participating primary care physicians
8)Fidelis Care New York – 580,000 members, 8,600 participating primary care physicians
9)Health Plus Amerigroup – 475,000 members, 10,403 participating primary care physicians
10)MetroPlus Health Plan – 467,000 members, 3,900 participating primary care physicians
Please note that the parent or controlling company of Aetna and Fidelis, the parent company of Empire BCBS and Health Plus Amerigroup, and GHI and HIP  are the same.  Healthfirst recently acquired Neighborhood Health Partners. In NYC specifically, Fidelis increased its city membership by 17.2% and  Aetna has increased its NYC market share by 8.6%







From Physician to Patient – A Salute to Dr. Thomas Graboys – MD and Parkinson’s Memoirist

We lost another wonderful physician this month- Dr. Thomas Graboys, died January 5th, 2015  after a 12 year struggle with Parkinson’s disease and Lewy body dementia. Notwithstanding his accomplishments as a clinical professor at Brighams and Women’s Hospital in Boston and Harvard Medical School and president emeritus of the Lown Cardiavasulcar Research Foundation, it is his autobiography, Life in the Balance: A Physician’s Memoir of Life, Love, and Loss with Parkinson’s Disease and Dementia that may lay the foundation of his legacy.

A few excerpts:

“My face is often expressionless, though I still look younger than my 63 years.  I am stooped. I shuffle when I walk, and my body trembles. My train of thought regularly runs off the rails.”

“ There is no sugarcoating Parkinson’s.  There is no silver lining here.  There is anger, pain, and frustration at being victimized by a disease that can to some extent be managed but cannot be cured.
Control over my body is a formidable, ongoing struggle of mind over matter.  As the disease progresses, my sense of myself erodes in parallel and I mourn those bits and pieces as I would the loss of a loved one.”

“ I have watched as huge swaths of my abilities have calved like chucks of ice falling from a glacier into the sea. My circle of friends has shrunk, the role I used to play in family life has diminished dramatically, and my medical career is over.”

On the contrary, Dr. Graboys’ career will live on in perpetuity through the lessons he teaches us all in his book.  This should be a must read for all therapists, young and old to remind us how lucky we are if we are healthy, and to fine tune our empathy for our patients.  Dr. Abigail  Zuger, in her review of the book  called it, a “textbook of the graceful and courageous exit”.


Think More Than Twice Before You Waive Co-Payments

One of the most frequent issues I discuss with therapists is the practice of waiving co-pays as a gesture of good will to their patients, and a coping mechanism during times of increased medical  costs. Some  have the best intensions in doing so, while others see it as a “loop hole” to overcharge for services and then accept what the insurance companies pays. The Office of the Inspector General ( OIG) has long taken the position that the routine  waiver of copayments constitutes an illegal kickback, which is a felony.

The routine waiver of copayments also constitutes a violation of the terms of the majority of private insurance company plans. This contractual violation serves as a basis for a recoupment audit, during which insurance companies request proof of collection of copayments for multiple randomly selected patients. If the practice  cannot prove it collected, or exhausted reasonable means of collection, then the carrier may demand a refund for any benefits paid across the board. Routine copay waivers constitute fraud. If a patient is charged $150 and the insurance carrier is billed $100, the patient is supposed to pay $50. If you never attempt to collect the $50, this means the actual charge is $100.  Therefore, the insurance company should only pay 80% of that.

I bring this up in a public forum because of a January 6th NYTImes article –  Justice Department Sues Doctor Paid Richly by Medicare.  Among other things federal officials  accused Dr.  Qamar of paying kickbacks to patients by waiving their portion of the bill, regardless of their ability to pay.

There are provisions for waiving copayments in cases of financial hardship. At a minimum, you should document the financial hardship, and obtain a release from the patient to turn the financial document over to the insurance company, if requested. State laws vary regarding waivers.

The OIG states the following criteria for waiver on the basis of financial hardship:
The waiver must be based on a good faith determination of the patient’s financial need and  not be applied routinely. The government does not specify the financial status that would justify a waiver, so you can develop your own approach, apply it routinely, and document your efforts. For example, if your efforts to collect on a patient’s bill fail, or if it’s obvious that a patient is struggling to pay the amount owed, ask the beneficiary to fill out a form noting their employment status and average household income and expenses. Then make your determination based on the information provided.

The waiver must not be based on the amount of the charges. The decision about whether to waive what a patient owes needs be based on the patient’s ability to pay without regard to what the carrier  may have paid or the total charges for the service.

The waiver cannot not be offered as part of an advertisement or solicitation.


Your Patients ARE ASKING for Price Transparency!!!!

How the High Cost of Medical Care is Affecting Americans    By ELISABETH ROSENTHAL

For many years now I have recommended that therapists consider posting their fees and making what they charge part of an open dialogue with patients. Many still are concerned about doing so, saying it will “scare” away patients etc.  The latest NYTimes poll confirms that patients want that dialogue.  The start of 2015 is a great time to start price transparency in your practice.  The full results of the NYTimes/CBS survey from December 18th 2014 can be read by clicking on the link above.