Joe Wolfe, Attorney, Hall Render Killian Heath & Lyman PC, speaks with Bruce Toppin, Chief Legal Officer, North Mississippi Health Services, and Jamie McIntyre, Director, HealthCare Appraisers, Inc., about co-management arrangements and how Advisory Opinion (AO) 12-22 influenced the approach to co-management. They discuss the impetus for AO 12-22 and its outcome, common questions or misconceptions about co-management, and how co-management has evolved. Bruce’s health system requested AO-12-22, which was released by OIG in December 2012, and he shares his health system’s experiences. From AHLA’s Fraud and Abuse Practice Group.
To learn more about AHLA and the educational resources available to the health law community, visit americanhealthlaw.org.
Joe Wolfe, Attorney, Hall Render Killian Heath & Lyman PC, speaks with Bruce Toppin, Chief Legal Officer, North Mississippi Health Services, and Jamie McIntyre, Director, HealthCare Appraisers, Inc., about co-management arrangements and how Advisory Opinion (AO) 12-22 influenced the approach to co-management. They discuss the impetus for AO 12-22 and its outcome, common questions or misconceptions about co-management, and how co-management has evolved. Bruce’s health system requested AO-12-22, which was released by OIG in December 2012, and he shares his health system’s experiences. From AHLA’s Fraud and Abuse Practice Group.
To learn more about AHLA and the educational resources available to the health law community, visit americanhealthlaw.org.
<silence> This episode of AHLA speaking of Health law is brought to you by AHLA members and donors like you. For more information, visit American Health law.org.
Speaker 2:Uh , welcome everyone to today's AHLA podcast where we're going to be talking about co-management agreements and the impact of advisory opinion 12 dash 22 , uh, on the industry. Uh , I have with me our guest, Bruce Toin from North Mississippi Health Services and Jamie McIntyre from Healthcare Appraisers. Uh, today's podcast is brought to you by the American Health Law Association's Fraud and Abuse Practice Group. Uh, I currently chair the Practice Group, and our mission is to help our members stay informed about healthcare fraud and abuse and compliance issues. Um, our vice chairs are doing a great job of developing webinars , uh, publication and other types of content to educate our members on important compliance developments and enforcement trends in the healthcare industry. Again, today's topic is co-management , uh, especially co-management in the aftermath of this OIG advisory opinion 12 dash 22. We'll get into that in a moment, but , uh, 12 dash 22 was an advisory opinion issued back in December of 2012 for a cardiology co-management arrangement between Bruce's Healthcare Organization and a local group. Um, this is an advisory opinion that is routinely looked to for structuring co-management agreements, especially as healthcare organizations look for safeguards. Um, some safeguards mentioned in the opinion that I've looked to include cost savings measures based on evidence and clinical outcomes and external valuation regarding fair market value for the fixed and performance based components, and some other safeguards to address historical concerns about stinting on care , uh, increasing referrals to a hospital cherry-picking patients , um, or, or those who are desirable with desirable insurance or accelerating patient discharges. So, lots of takeaways from that advisory opinion. Um, before we get into , uh, a bit more on, on co-management and, and this advisory opinion in particular, I wanted to give Bruce and , and Jamie a , an opportunity to introduce himself . So Bruce , uh, can you tell us about , uh, give us a bit of background on yourself?
Speaker 3:Sure. Uh, I'm the Chief Legal Officer at North Mississippi Health Services. Been here 27 years, if I can , uh, believe that. And , uh, I went to law school in New Orleans at Loyola University , uh, undergrad at SUNY Albany in New York, and grew up in upstate New York. Uh, worked at a law firm in New Orleans, associated a partner, Jones Walker. But I've had a great career here, and hopefully I can survive for three more years.
Speaker 2:Great. Uh , thank . Thanks Bruce. Uh, uh, Jamie , could you give us your background?
Speaker 4:Sure. So , uh, I am Jamie McIntyre. I'm a director in the Boca office at Healthcare Appraisers. Um, also active in AHLA , um, my previous life and my first love , um, was as an operator. So first at an FQHC as a program director , um, and later at a 450 bed tertiary care facility. Um, my education is in the law, but I knew that I, I definitely did not want to practice. Um, so this is kind of perfect because, you know, it gives me continuity with both hospital operations and with the regulatory side. I get to be a very, very part-time participant at a lot of hospitals versus just a full-time , uh, employee at one. So it's great. And also University of South Carolina alum. So go Gamecocks .
Speaker 2:Great. Uh , thanks Bruce. And, and Jamie , and I'm excited to hear what you have to say about co-management. Um, just, just a bit on co-management, high level and, and maybe give, give the audience some , um, of the legal considerations right outta the gate. You know, what is co-management? And I think there are a lot of different variations of what a co-management arrangement might include and what the scope might be. But in, in my mind, it's typically a hospital or health system that enters into a , a contract with a physician or a group of physicians for their management of a , of an area, a service area. Uh , might be a department within the hospital or might be an area of, of clinical services that the organization , uh, provides , uh, to its , uh, in its service area. Um, it , it may include some type of gain sharing , it might have an administrative component as well , um, from a legal standpoint in, in my mind, and as I look to structure these arrangements, I'm thinking about three laws in particular, one being stark, the other being kickback , and then the third being the Civil Monetary Penalties law. Um, from a stark standpoint, let's say we're structuring , uh, an arrangement with an independent group , uh, we're likely looking to the personal services exception under Stark. And so things like signed it , having the agreement signed, and in writing compensation terms set in advance , uh, also alignment with the big three fair market value commercial reasonableness. And we also can include a physician's referrals of designated health services as a variable , uh, kickback. Um , we're , we're thinking along the same, same lines, probably looking to fit within the personal services and management contract, safe Harbor. Um, and , and again, many of the same requirements. And then the last law, the Civil Monetary Penalties law , um, as , as many of us that work in the space know, we wanna make sure that payments under , uh, an arrangement are not , um, inducing a reduction in medically necessary services , um, somewhat becomes part of the analysis here when we kind of go back to old gain sharing guidance. Um, and, and thinking about co-management, we also, again, wanna make sure we've thought about , uh, that piece as well. So this is intended to be as much just as a backdrop here , um, that we need to be thinking about these kinda laws when we design , uh, co-management , uh, type models. And so with that , um, background, I have a few questions for Bruce and Jamie , and I can't wait to hear their perspectives on this. And first of all, for Bruce , um, and we think about OIG advisory opinion 12 dash 22 , what was the impetus for that? Can you discuss some of the process around requesting it and also give some insight into the ultimate outcome from that, from that advisory opinion?
Speaker 3:Sure. Um , love to it . It, the impetus was , uh, basically rose up from our operational folks. Uh, they were dealing with a local cardiology group. Now , uh, as mentioned in the opinion, there was only one cardiology group, and we are in a rural area, but it's a large hospital, 650 beds. But our cardiology group , uh, while quite large for rural area, was still having problems recruiting because they had a recruit to replace those who may be eventually looking at retirement. Uh, also if for any growth they had to recruit. And they were having a hard time doing that, competing against , uh, larger groups in more urban areas. They also were extremely , uh, well qualified , and their quality was outstanding. But their point was, look, we're doing all this work, and all we do is get clicks for wvu. We don't seem to be benefiting from anything we're doing from the ho for the hospital , uh, standpoint. From the hospital side, the hospital keeps asking the cardiology group about issues of cost , issues of quality, and yet they felt their efforts were not rewarded. Now, from a process standpoint, this was a long process. It started basically, I believe, in , uh, back in 2010. And we, we had to , uh, retain , uh, a firm, Jamie's firm, I believe, and they went ahead and they were outstanding and helping us healthcare , uh, folks were looking at reviewing it and making sure that we had fair market value. That was a start , a real important starting point. Without that starting point, we couldn't move forward. We also utilized a, a law firm out of Boston , uh, that assisted us and had some experience in , in what may be called the co-management space. Uh, they were helpful with that. And then we had a local law firm , um, help Dunbar actually , uh, Danisha Newman , a past president of the AHLA , who really helped guide us through, or guide me through the process of getting the OIG to review this request and get it approved. So that was , uh, that was a long process. You see, we started in 10 internally, and it took us till the end of 2012 to get it done. What was the outcome? The outcome was outstanding. It made the cardiology group very happy. They felt that they had a , uh, stake in the game, so to speak. They had a stake in the outcomes as far as quality. They had a stake in the cost savings, and they understood it. As it relates to, you had mentioned Joe , uh, CMP, I always have to remind that is something that a lot of administrators don't understand. They get, they heard of Stark, they heard of Kickback, but they don't understand CMP and how we can't pay physicians to reduce care. Uh, so , uh, that was an education process. I had a constant re remind our administrators about.
Speaker 2:Thanks, Bruce. Um, and I think my, that , that really helpful perspective, and I appreciate you kind of sharing the timeline too. Um , it helps our audience , uh, you know , better understand , uh, the , uh, the process of requesting an opinion. Um, I think the next question's for both of you , um, you know, how did this op opinion , this OIG advisory opinion 12 dash 22, shape the way you support the development and administration or , or valuation for you of, of co-management agreements from , from both of your perspectives?
Speaker 3:Jamie, go first, please.
Speaker 4:Yeah, so, you know, I , I think both of you have touched on this. There's, I think, a lot of insight that you can glean from the reasons that the OIG sites in that opinion as to why they did not pursue sanctions. Um, there's kind of a really nice discussion of each stark anti-kickback and the CMP , um, within that opinion, if you can get, get through it all , um, I think for , uh, for me, it gave me a clearer picture of what it looks like to work within the parameters of those laws and regulations. Um, you know, and , and while you might say that, we still have sort of very little to go on because it is this single opinion that did speak to this single arrangement , uh, I, I do think one thing that I think about every day in practice is that it clarified , um, you know, that good business justifications, a lot of thoughtfulness and commercial reasonableness in the way that these arrangements are stood up and administered is absolutely critical. So , um, you know, i i, I would, would echo Bruce's sentiments that , um, and, and yours, Joe, that, that really thinking about the way that, that those laws may apply and , and even thinking outside of the box can help you put some adequate safeties in place to , to keep the arrangement defensible.
Speaker 2:Thanks, Jamie . Bruce, your thoughts ?
Speaker 3:Uh , I, I agree. And, and , and Jamie brought up a good point. You know, we talk about fair market value in another area of that, that a lot of , uh, operational folks don't consider as commercial reasonableness. And so I ask them , uh, okay, why are we doing this? I mean, what is the reason we're doing it? And I remind them that we just can't do it because we wanna make, keep the physicians happy, which we do in part, but we wanna make sure that there, there is a, a true reason to do this. Are we really going to improve the quality of care? Are we going to go ahead and reduce costs where costs can be reduced without reducing , uh, the care provided to patients? And if they can answer those in the affirmative, then we look at moving forward with potentially other co-management arrangements. In fact, we took some of the components in 1222, and we actually moved them to our employed physician contracts where we have a component about those physicians having to go ahead and meet quality metrics and some of their compensation tied to quality outcomes and also what we call efficiencies. Uh, now some of the efficiencies may be as simple for , uh, for our surgeons, employed surgeons as showing up at 7:00 AM and being ready to do surgery when they have a 7:00 AM surgery, because if they fall behind, everything falls behind and we have to pay our employees overtime , the staff. So , uh, it really helped shape and, and give me questions that I can ask administrators, why are we doing this?
Speaker 4:Yeah. And you know, Bruce, I would say that one of the, for me, one of the underpinnings of, of, of the opinion and the way that these arrangements are operationalized is, is the, the interaction between stakeholders, right? So not every quality person is gonna speak the same language as a finance person is going to speak the same language as a lawyer or an operator. So, you know, under getting a , a thorough understanding and, and good transparency between all of the stakeholders , um, I have found is absolutely critical to good , um, clarification of the objectives of co-management and also to the success of the program. Because if not everybody is on the same page and understanding how this alignment works or what the pitfalls might be , um, you know, you can really run into trouble.
Speaker 2:I agree. Good, good thoughts , uh, from both of you. I also think it's, it's really helpful for the record to have those kind of , that iterative process where, you know, the stakeholders are engaged, they understand the rules , um, you're, you're educating them as to the features of, of co-management, and then also, you know, at the , at , when the outcome measures are developed, that you are actually solving a problem. I think it's critical , uh, to the record , um, as well. Um, so thanks for your insights there. You know, I think the next question here is for Jamie and, and Jamie , uh, knowing you, you, you work on a lot of , um, co-management arrangements now, and, and you , and you, you have historically, and as you think about OIG advisory opinion 12 dash 22 , what were some of the unique features of the arrangement from your perspective?
Speaker 4:So Bruce and his team actually had a lot of unique features , uh, in this arrangement. I think , um, two that stand out to me , um, are the safeties that were built in to the agreement, and also , um, that there were some at the time, I think, what a lot of parties may have deemed to be riskier prospects. So , um, you know, I was very new in, in my job as evaluator at the time, but , um, in looking at this arrangement, one of the things that jumped out at me is , wow, you know, we're gonna incentivize , um, patterns in utilization and, and physician, we're gonna incentivize potentially physician decision making on some , um, some cost related incentives, which I have to say at the time was not in any other arrangement that I had seen. Um, so, so in deploying those, those cost savings types of measures or allowing for, you know, termination upon non maintenance of, of certain of the quality incentives , um, the arrangement formalized , uh, two things. It , it formalized , uh, a process of, of clinical utilization and, and, and patient safety review , um, because there was a cadence of processes written into the contract. And then , um, you know, there, there were, there was a lot of, I think, thoughtfulness around how do we avoid implicating a stinting on care, or how do we protect against , um, any concerns of driving unduly, you know, physician decision making .
Speaker 2:Thanks, Jamie . And, you know, you talk about the safeguards here. I think it was, it maybe in the macro rule or in some of the OIG guidance from around the time that macro was put in place, but the OIG spoke about , uh, the safeguards around gain sharing and mentioned that , um, it would even be unlikely to bring a case against a hospital or physician for a gain sharing ar arrangement arrangement that included some of this , the program safeguards identified in their advisory opinions. And I think that this advisory opinion in particular was referenced as a footnote. So it just shows the significance that the safeguards played not only in 12 dash 22, but , but how the OIG views these safeguards as being Im important. So , um, appreciate that. Uh, Jamie , um, next question is for Bruce. Um, you know, just thinking about 12 dash 22 , did did the process influence any changes in the way that your system approached co-management? Um, a afterwards?
Speaker 3:Uh, it , it , it, it did , uh, you know, we had opportunities and we did enter into a couple of other co-management agreements. In fact, in the physician's lounge , uh, they heard about the success of the cardiology. So all , uh, I shouldn't say all, but most of the private groups approached their service line administrator and , Hey, I wanna, I wanna have a co-management agreement. But we did not enter into co-management agreements with every group because they did not want to go ahead and do the heavy lifting. And the heavy lifting was making sure we had safeguards in place , uh, making sure we had quality metrics that were truly improving the quality of the care we delivered to patients, and we're not what I would call layoffs and something that was so simple. It's like, really, are we really gonna pay for that? Uh, we need to have true improvements in quality. And again, after they reach those incentives , uh, we have to keep moving the bar. You can't keep paying for maintaining as, I think it was in 1222. Uh, so we, we worked with , um, you know, orthopedic groups. And one of the issues on cost of orthopedic groups is many of the orthopedic surgeons come, come out of their residency and fellowships using certain vendors, and they don't wanna change. And pretty soon you're buying from three and four different vendors for implants, and you're not getting any cost savings from that. And, and you one could argue, or the physicians can debate what's better, which one's better than the other. But generally they're all the same at the end of the day, just like a car. I mean, they all have , uh, cars have steering wheels and, and, and four tires, and I guess today EVs, but the gas engine, and they move forward. Now, some move forward in higher style than others, but the implants are basically the same at the end of the day. So to get a co-management agreement where you could work with the phy, the orthopedic surgeons to reduce down from four vendors to two results in cost savings , uh, as I recall , uh, from my economics class in college where I probably was a poor student, 'cause I , it was eight in the morning and I was half asleep. But we had a professor who , uh, didn't speak English well, but he was really brilliant. And he talked about guns or butter. You can invest in guns as a a , a country, you can invest in butter . Well, hospitals can only basically control cost or payments, and insurers aren't paying anymore, or you really have to go to battle with them. And so the, the , the item that health systems and hospitals have to deal with is cost . And so we're looking to reduce cost and improve quality. And that allowed us, 1222 allowed us to approach it from how can we reduce our cost and how can we improve the quality that, that
Speaker 2:Was the going forward mantra of our system. Thanks. Thanks, Bruce. Um, next question's back to Jamie . Um, Jamie , what are, what are some of the common questions or, or maybe misconceptions that you encounter , uh, around co-management arrangements?
Speaker 4:So, you know, not to harp too much on the, the focus of cost, but I, I think cost is a , a concern that's facing every single hospital. Um, and again, you know, back when Bruce and his team stood up this , uh, arrangement that was, that was the subject of the ao , um, it was vastly uncommon to see cost focused type metrics. Um, while it became a little bit more common in the following years , um, after the opinion, I think , um, you know, there was a subsequent softening of the CMP language, which, which, which I think gave a , a , a broader runway for the incorporation of cost related metrics. But now, you know, we've got a decade of, of best practices behind us. We've got , um, 1222, and we've got the softening of the CMP language. So one of the common misconceptions even still is, you know, can I reasonably incorporate cost savings type measures? Um, and you can, you can do it defensively. You can do it in a reasonable way. Um, I've worked with a number of hospitals who, you know, to Bruce's point , uh, there may be no difference in, in clinical outcomes or the safety of a particular supply, but you might be working regularly with a supply that costs two or $300 versus five or $6. Um, and, and unless and until you have alignment with your physician staff on making the decision to use the five or $6 supply, or not automatically setting up certain equipment that is only used in 1% of cases , um, you know, you, you may have a, a real blind spot with respect to those cost savings opportunities. Um, the, the benefit largely to the hospital is that in the context of co-management , um, you know, you cap those savings rather than putting them , uh, for instance, in a gain share where you've got payment on a sliding scale, it does allow for some predictability. Um, two of the other misconceptions I think would, would be that , um, you can't focus on things that are non-quantifiable. That's something that we see all the time. Um, there's definitely ways to deploy metrics where you're working on program development or , um, the identification and memorialization of, of new policies and, and protocols. Um, thirdly , uh, I often hear that there's reticence to , uh, involve employed providers. That's also something that I see very, very frequently in practice. Um, it , it works, it can be a little nuanced, but it's something that that's become very, very common, if not ubiquitous.
Speaker 2:Great . Thank Thanks, Jamie . Um, back to Bruce. Um, you know, Bruce, or , or regarding the co-management agreement that was the subject of 12 dash 22 , could you tell us about kind of how that arrangement , uh, played out and , and what kind of came next for your system? Sure . Uh , down the road ,
Speaker 3:Sure, it , it , it played out quite well. Um , but we did reach a point that the metrics that we, and we kept tweaking them and , and raising the bar in certain areas, but it had kind of run its lifecycle and the physicians got a little , um, antsy, I should say. Now. Part of that is the regulatory landscape is changing both on a federal and state level, on the state level and Mississippi. They then allowed for , uh, joint venturing of cardiac cath labs. Uh , and that, that was something that was going on in other parts of the state. And we looked at it as, that's really not that good for the health system. It's not good for patients to spend millions of dollars to build another cardiac cath lab outside of the hospital. And even if you try to go ahead and, and , uh, take one of the labs out of the four we have and, and use that, that that is encompassed with all the changes to different signage and who's responsible. And we were concerned , uh, not, not necessarily saying it would happen, but concerned that all the , uh, commercial pay , uh, <laugh> patients would end up in the joint venture in the , uh, Medicaid and self-insured would end up in the one that is wholly owned by the hospital. So in order to avoid that splitting, which I, I think is , um, dangerous from a, a coordination of care standpoint , uh, and also the push from private equity, I mean, that's a challenge I think others have faced, but we're really facing now in our area, we looked at and , and moved it to a, with , uh, Jamie's help and , and her firm's help. We've moved it to APSA, but not just a standard PSA, we had APSA that had, again , uh, some elements of 1222, the quality metrics , uh, but also moved it into, now we're working with the cardiologist on a fellowship, the development of a fellowship for , uh, cardiology. So we can have a constant supply of fellows rotating through, which would allow us the opportunity perhaps to, for the group to retain one or two as time goes on, to keep the program moving. So it, it really has evolved. The group wanted to stay as a private group as opposed to an employed group, so that PSA has elements , uh, that allow them to retain their independence, but give them some assurance of what their incomes would be, but gives the organization assurance of coordination of care, as well as not worrying where the patients would go based upon their payer source.
Speaker 2:Thanks, Bruce. Um, another question for, for Jamie . Um , we talk about 12 dash 22 being 10 years old now, and, and of course there's been some evolution of co-management in the industry , uh, over , over the years. Um, you know , what are, what have been , uh, from your perspective, some of the influences on the evolution of co-management and, and , and how does that , uh, impact arrangements out there in the market?
Speaker 4:So , um, you know, I would say there's kind of in my mind two categories of evolution. One would be , uh, evolution from a system or a facility standpoint. You know, some of the obvious , um, influence influences that would , um, incent change in an immediate arrangement is expansion of services or other operational modifications. So you may onboard staff that has , um, clinical capacity or can, can provide , um, additional service offerings. Um, another is with a push towards standardization across an enterprise and quality outcomes, you might see , um, multi-service line arrangements wherein there's a sharing of best practices. Um, there are a number of HQEP arrangements that have evolved from co-management. Um, so that kind of thing on a, on a micro scale , on a macro scale , uh, I think largely co-management has, has served as a vehicle to prepare for success in other types of , um, arrangements within the marketplace or other types of reimbursement , um, changes that we're seeing. So a lot of practices and a lot of metrics that were leveraged within co-management were sort of a, a , a launching point for success in APMs. Um, bundled pay was a big one. There were a number of years where I think every co-management minded , um, party out there was thinking, well, this is what's going to prepare us , um, for bundled payments. Um, or, you know, now this may be something that helps us to hardwire processes or , um, build in a , a cadence of touch points for better transparency to where we can , um, pivot more so toward value-based care. So , um, you know, there's a lot of drivers for those things, but that's, that's more on a, on a macro scale , um, what I would observe.
Speaker 2:Thanks. Thanks, Jamie. Um, I , I have one last question and I'll direct this question to Bruce. Jamie, you can certainly tack on if, if, if you have something to add. But , uh, Bruce, do you, do you think any of the recent government , uh, market or payer activities going to impact co-management? And if so, how?
Speaker 3:Uh, yes. Uh, Jamie touched on one one point, I think from a private , uh, insurer standpoint, as we're seeing from, from the commercial payers, the push toward more and more bundle payments and, and those payments have a effect that we then have to the hospital or , or our surgery center that we own in conjunction with physicians, we have to go ahead and work together on quality and, and expenses, which is what the gist of 1222 was. And so we're moving forward with those. But also, Medicare Advantage, I think, is probably one of the bigger aspects that is forcing , uh, health systems and physicians to work more closely together for us. Uh, Medicare is the biggest payer we have, and then if you add Medicaid to it , um, although I would like to see Medicaid expanded in the state of Mississippi, but that's a whole nother topic for another day , uh, that those two account for close to 60% of our payers. So it's Medicare Advantage plans that I think the government is, is pushing. In fact, I think you can also see in the other side where we've changed some of the stark laws and the anti-kickback laws to reflect some of what was going on and allowed in 1222. Now , I'm not saying 1222 resulted in those changes. I'd like to think so, but I , uh, don't wanna pat , uh, myself and Jamie on the back for that. But you could see some of that language in there. And, and so these innovative models now that we're starting to see, I think that the genesis may have been, or the germ nation may have been out of 1222, and the government recognizing that it's , they push forward on the payment side, you have to allow for flexibility for physicians and hospitals or health systems and surgery centers to all work together to go ahead and reduce costs and improve quality. And to me, that's what 1222 is all about, reducing cost , unnecessary costs , but at the same time improving quality. And if you can achieve both of those, everyone, everyone, so to speak, wins.
Speaker 4:Mm-Hmm, <affirmative> , yeah, I, I would, I think that if you read, you know, 1222 and, and look at some of the features of, of the subject agreement, it , I have a hard time not immediately thinking of some of the recent changes. Um, there were things like an opportunity for corrective action. I don't know if anybody's ears are perked at that. Um, but that's certainly something that if you read the vbe e language sounds a whole lot like what we were talking about here. Um, you know, anytime there are trends in government reporting or reimbursement , um, or regulation, I think if you have co-management in place, or if it's something that you're working on or something that's on the horizon, there should be some reactivity to that. Um, for example, you know , I think if you've got co-management in place now, or considering that it could be a great forum to introduce concepts like health equity, which is something that we're certainly gonna see in Medicaid and the Medicare Advantage , um, ACO reach , there's a lot of places where, where concepts like this are being , um, introduced. Another thing we have to think about is, you know, I'm not sure that this is going to happen on the timeline that the government has given us, but things like lifting of the inpatient only rules , um, I certainly think that , uh, whether it's APSA or co-management, you , you've got to have your eye toward how you will become reactive and succeed in light of some of those changes.
Speaker 2:Thanks , uh, Bruce, and, and thanks Jamie . Uh, really appreciate your time today. Uh, and , and thanks to everyone who's tuned into this podcast. I encourage you to pick up , uh, a , a copy of a a 12 dash 22. I think it's about 16 pages long. It's, it's a worthwhile read. And as Jamie and , and Bruce touched on, I I think it's, it's very relevant to structuring arrangements today. Um, it , it provides a , a , a roadmap as to the, the components that you could build into a , a coverage agreement. Um, it , it, there's definitely some best practices that , uh, it can be found within those pages as well. And it gives you a , a better sense of , uh, the , the operation, the anti-kickback statute, and how safeguards can be built to address some of the risk there as well. So, again, i, I encourage everyone to, to pick up a copy and, and , and give it a read. It's, it's as relevant today as it was back then. Um, I also encourage you to tune into our other podcasts. Uh, we recently had a podcast on the super value case and potential impacts on the False Claims Act cases. Um, and another on, on trends in healthcare fraud settlements. Uh , we have one coming out soon that will discuss the performance of downstream financial analysis and some of the risks involved in that space. Um, and, and lastly, we're, we're always looking for volunteers. Please reach out , um, to members of the Fraud Abuse Practice group, reach out to me on LinkedIn and, and we'd love to have , uh, those of you listening in to , to tackle a topic on a future podcast. And we're always trying to find ways to get more and more people , um, involved and in the mix within the Fraud and Abuse Practice Group. Again, thanks for tuning in and , and have a great day.
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