Value-Based Care

Since the 2010 enactment of the Affordable Care Act (ACA), the traditional Medicare reimbursement model has been evolving – slowly but steadily – from fee-for-service to a more value-based approach. Rule changes to the Medicare Shared Savings Program (MSSP) confirm the ongoing emphasis that the Centers for Medicare & Medicaid Services (CMS) places on value-based care (VBC) and accountable care organizations (ACOs). Recent high-profile mergers and acquisitions (M&A), joint ventures and private equity investments involving value-based care providers also indicate that this segment of the healthcare industry has gained new traction.

Holland & Knight's Value-Based Care Team combines our deep understanding of healthcare law with a strong commitment to driving positive outcomes for our clients. We help healthcare providers focus on patient care at every stage of their transition to value-based care.

Alternative Payment Models

Under value-based payment models, providers' payment depends on their management of the overall health outcomes and the total costs of each patient's care. These alternative payment models (APMs) can be extraordinarily complex, and they pose new opportunities and risks for providers.

We assist hospitals, integrated health systems, physicians, payers, post-acute care providers and other licensed healthcare provider entities to evaluate and develop strategies for success under value-based care and risk-sharing models. Our healthcare lawyers help clients across the nation understand the advantages and disadvantages of participating in innovative public sector, commercial and direct-to-employer (or self-insured) VBC models.

Advising on All Aspects of Value-Based Care

Value-based care clients benefit from the size and scope of Holland & Knight's Healthcare & Life Sciences practice, the largest in the United States. Our experienced healthcare attorneys have keen insight into the range of approaches being developed by government and commercial payers and providers around the country. Our lawyers have worked with payers and providers to develop episode-of-care and other bundled payment arrangements, quality performance bonus programs and various shared-risk programs. We also have helped providers effectively organize and contract for voluntary and mandatory Center for Medicare and Medicaid Innovation (CMMI) Bundled Payments for Care Improvement (BPCI) model programs for acute and post-acute care.

Our work for these clients includes advising ACOs on participation in the MSSP, working with hospital systems on bundling arrangements, and assisting ACOs and hospital systems in entering into shared savings and other value-based payment arrangements with self-insured employers, commercial insurers, Medicare Advantage plans and Medicaid managed care organizations (MCOs). In addition to assisting healthcare clients in negotiating arrangements with applicable payers, we have extensive experience in developing provider networks, including participation agreements and allocation methodologies under which physicians and other providers share in savings and other incentive payments.

Achieving success in the transition requires an effective and creative shift in care delivery to a more accountable and outcome-based model of reimbursement. Holland & Knight's healthcare experience includes extensive work with private equity firms and venture capitalists investing in value-based care providers. Additionally, our healthcare client roster includes a growing number of technology companies focused on developing innovative products that enable the use of value-based care.

Strategic Partnerships and Collaborations

Partnerships are at the core of value-based care, and we are nationally recognized for our work in representing clients in transactions, innovative partnerships and strategic collaborations within the healthcare industry. Our value-based care attorneys work with clients to navigate joint ventures, the formation and operation of ACOs, and other innovative arrangements to help drive care coordination, improve patient outcomes and achieve financial success.

Regulatory Compliance

Navigating the regulatory landscape is crucial to successfully implementing value-based care. Our attorneys are well versed in federal and state regulations, including the Medicare Access and CHIP Reauthorization Act (MACRA), the Merit Based Incentive Payments System (MIPS), APMs and the Stark Law, to name a few. We proactively identify compliance risks, develop tailored compliance programs, and provide ongoing guidance to help you meet regulatory requirements while maximizing reimbursement opportunities.

Reimbursement and Managed Care Contracting

As more providers and payers consider value-based care models and risk-sharing agreements, the complexity of payer contracts has increased, making the need for experienced healthcare counsel more critical. Holland & Knight's Value-Based Care Team assists with ACOs and CMS Innovation Center models, bundled payment arrangements, shared savings/shared risk arrangements. Our experience includes representing clients in contract negotiations between plans and providers, plans and their customers, and plans and their vendors. Our lawyers provide counsel on information and data sharing agreements between VBC participants that can significantly impact the success of value-based care models. Our experience includes negotiating value-based contracts that support population health management activities and other goals.

Antitrust

Strategic collaborations can create opportunities for value-based care initiatives, but they can also invite antitrust scrutiny and potential enforcement. While providers, payers and others in the healthcare industry look for ways to further partner and coordinate care across entities and state lines, federal and state enforcement of antitrust and other competition laws is increasing. Greater scale often involves provider consolidation, whether through a merger, acquisition or joint venture. The Federal Trade Commission (FTC) and U.S. Department of Justice (DOJ), as well as state attorneys general, have issued statements expressing concern that such consolidation could reduce competition and harm consumers through higher prices or lower quality care. Our antitrust attorneys are regularly engaged in the creation of VBC arrangements in order to navigate these challenges and to respond to government agencies when necessary.

Data Security and Patient Privacy

The ability to share patient information among healthcare providers participating in a value-based care arrangement is critical, which means safeguarding personal health information is paramount. Holland & Knight's HIPAA and Healthcare Privacy Team includes experienced healthcare regulatory compliance, cybersecurity and technology lawyers who develop and implement effective compliance programs for value-based care providers and other healthcare provider and payer organizations that we can harmonize with state privacy laws.