Legal impediments to implementing value-based purchasing in healthcare.

摘要: I. INTRODUCTION The U.S. healthcare system continually confronts the challenge of controlling costs, improving quality and patient safety, increasing or maintaining access to care. Payors purchasers (both public private) strive develop mechanisms guarantee that they are purchasing highest-value care - seeking ensure amounts paid take into account provide incentives encouraging delivery high-quality, cost-efficient Through "value-based purchasing" ("VBP") strategies, payors transforming from passive claims (as in a traditional fee for service system) active To date, employers, health plans, Centers Medicare Medicaid Services ("CMS") have implemented well over 100 VBP programs.1 However, progress is slower than anticipated. As Institute Medicine ("IOM") others noted, adoption reforms may be hampered by legal barriers arising number state federal laws.2 goal this paper identify potential impediments implementing healthcare. This highlights certain value-based efforts shaping reform financing system. We statutory, regulatory, common law widespread efficient each promising effort. frame discussion, organized tracking "Four Cornerstones" value-driven term was first defined government recognize, reinforce, facilitate implementation core elements developed policy community time. With respect Cornerstone, one more improvement activities initiatives highlighted, described, possible solutions identified. will examine Four Cornerstones Section II provides brief overview principles discussed paper, III an introduction Cornerstones. In IV, we discuss constraints hinder interoperable Health Information Technology ("HIT"), First Cornerstone. V explores measuring publishing information about quality, Second Third Cornerstone making pricing available addressed VI, which discusses antitrust consumer protection-based challenges sharing cost-based provider ranking initiatives. VII using promote high cost effective VIII, specific obstacles associated with data gathered research. II. KEY LEGAL PRINCIPLES A. FRAUD AND ABUSE LAWS 1. Stark Law Ethics Patient Referrals Act (the "Stark Law")3 prohibits physician referrals designated services ("DHS") payments made under program (including inpatient outpatient hospital services) entities his immediate family has financial relationship, unless arrangement qualifies exceptions enumerated statute its regulations. applies investment compensation relationships, whether direct indirect. strict liability, meaning if relationship does not meet element applicable exception, any resulting DHS would constitute per se violation Law. A could result civil penalties, mandated return received improper submitted reimbursement DHS. …