Hi everybody.
We are getting close to the end of the course.
Let's talk about a few bad practices in healthcare,
why they're prohibited and what the result might be.
First, you are going to see antitrust
in the materials this week.
At its most basic,
antitrust is a method of protection for consumers.
Enforcement is mainly to protect consumers' welfare
by carefully watching
and intervening in commercial competition.
As you might know from other chapters,
competition is good in the sense it is meant
to lower consumer prices, foster better quality of care.
However, artificially setting prices
not only hurts consumers,
but it also disrupts that notion of how competition works.
Healthcare antitrust laws were designed in the US
to prevent healthcare monopolies
or unfair business practices
that limit competition in the market.
The goal of antitrust was to promote fair competition
among healthcare providers
and prevent enormous healthcare systems
that control healthcare in an area
which would allow them to have unchallenged higher prices.
They could reduce quality of care
and limit access to healthcare services.
So these antitrust laws apply to various entities
within the healthcare industry,
including hospitals, physician groups, insurance companies,
and pharmaceutical manufacturers.
The goal of these laws is to promote fair competition,
ensure that patients have access
to high quality, affordable healthcare services.
At a minimum, it is really the way
that we prevent one provider of services
to take over a huge region,
and, therefore, no one else can come in the region
and provide competition.
And, therefore, that healthcare entity
basically controls everything.
We try to eliminate that when we see it.
Antitrust violations have significant penalties.
They're important deterrence.
These occur when healthcare providers
or organizations engage in activities like price fixing,
market allocation, or tying arrangements.
Price fixing occurs when healthcare providers agree
to set prices at a certain level
while market allocation occurs
when healthcare providers agree
to divide the market
and not compete with each other in certain areas.
Tying arrangements involve bundling products
or services together, such as requiring patients
to use a specific hospital
if they want to receive a particular treatment.
So you can see how these various arrangements
are, in the same way, preventing competition
and, therefore, allow these healthcare entities
to create their own prices
without competition from a competitor.
Another prohibitive practice is a kickback,
and you'll see the kickback term in both your readings
and in your supplemental readings.
A kickback in healthcare is an illegal practice
where one party offers
or receives something of value in exchange for a referral
or recommendation for healthcare services or products.
Kickbacks can take many forms.
They can be cash payments, gifts, free services,
other incentives.
They might be given by pharmaceutical companies
or medical device manufacturers to physicians, hospitals,
other healthcare providers as a way to encourage them
to prescribe or use their products.
For example, a drug company
could offer a physician a cash payment
for each patient they provide a certain medication to,
or a medical device manufacturer
might offer a hospital free equipment
in exchange for a commitment to purchase
a certain amount of their products.
Kickbacks like these are illegal
under the federal Anti-Kickback Statute,
which prohibits healthcare providers from offering,
soliciting or receiving any form of payment
or other incentives in exchange for referrals
or recommendations for healthcare services or products.
Violations of the Anti-Kickback Statute
can result in pretty hefty criminal charges,
civil penalties,
and exclusion from participating
in federal healthcare programs
like Medicare and Medicaid.
And you can imagine how much of a threat that is
to giant entities, right,
who might get a lot of Medicare and Medicaid dollars.
So another thing you're gonna see this week
is physician self-referral practices
where physicians refer patients to entities
where they have a financial interest
for certain designated health services.
This might invoke the Stark Law,
which seeks to prevent financial conflicts of interest
that could influence a physician's medical decision-making
and lead to the overutilization of healthcare services.
Stark Law includes a range of services
like clinical laboratory, physical therapy,
occupational therapy, radiology.
If a physician refers a patient
for one of these designated health services to any entity
where they have themselves
or family members have a financial interest,
like a physician-owned practice or hospital
where the physician has an ownership stake
can be considered a violation of the Stark Law.
Just like other topics above,
violations of the Stark Law has pretty big penalties, fines,
exclusion from participation
in healthcare programs like Medicare and Medicaid,
and potential civil liability.
It's important for physicians
to carefully review their financial relationships
and any potential conflicts of interest
when making referrals for designated health services.
Usually, these programs are built in
with larger facilities through compliance,
and they check for this.
So we're gonna talk about a couple of things:
antitrust, Self-Referral Law, and the Stark Law.
And so these are confusing.
They can be somewhat overlapping,
and I look forward to seeing your posts
in the discussion forum.