Transcript of Interview With Robert E. Goff- Page One
With more than 30 years of experience in the health care industry, Robert E. Goff is a recognized expert in care delivery, organization and financing. His career has spanned a wide range of leadership positions as a hospital administrator, regulator, managed care executive, consultant and association executive. He has been an adjunct professor, at the New School University, instructing in Managed Care and Healthcare Strategic Planning and is a frequent lecturer to physicians and community organizations. Mr. Goff is published on health care topics, and author of several books and instructional manuals on physician revenue cycle management.
As an entrepreneur he has been responsible for the development of numerous health care businesses, including one of the first for-profit HMOs in New York State, the first network model Medicaid managed care plan in New York, one of the earliest physician practice management companies, a chain of urgent care centers, as well as a variety of provider based health care business initiatives.
Mr. Goff currently serves as CEO of University Physicians Network, LLC (UPN) in New York City, an organization of physicians engaged in supporting the private practice of medicine and its relationship with managed care companies. Additionally, Mr. Goff holds advisory roles with a number of emerging healthcare companies, and is active in consultative roles.
Questions and Answers:
JR: The American Psychiatric Association has an excellent article on anti-trust. http://www.psych.org/psych_pract/pract_mgmt/antitrust.cfm .
I am particularly interested in the Per Se violations i.e. conduct that are automatically considered to be so detrimental to the market that they are seen as being without possible redeeming merit. I wonder if providers calling for their colleagues to dis-enroll form a panel so that patients/ subscribers could complain is a Per Se violation or does it need to be demonstrated that there was an actual agreement to do so, or that it need be demonstrated that there was a negative effect on providers?
Also, among the things that concern me is the prevailing view by some or perhaps many of my colleagues that the DOJ would not bother to go after a small group of social workers and other mental health practitioners comparing notes on fees. They ask if anyone has identified an actual case where DOJ went after any group of private practitioners for comparing notes on fees--whether online, at a professional conference, or elsewhere. Can you provide any thoughts on these matters?
RG: The Per Se violations are actions that would lead to a reduction in marketplace competition. There does not need to be an agreement to dis-enroll, just an action/effort to obtain collective action leading to a dis-enrollment. There need not be a proof of harm to be a violation; the act itself is the violation, even if unsuccessful.
As always, the questions - who’s going to know? How are they going to catch me? Reality - who is going to complain? a payer that gets wind of the action? a disgruntled ex-employee? or commonly, the disgruntled ex-wife? Not to mention the patients that will get wind of it. The problem with this issue is that if there is a complaint, valid or not, the cost of defense will bankrupt you.
Believable? Unfortunately people don't believe they are going to get caught, that they are smarter than the health plans. The best motivator of learning coding & documentation was when a physician in the community was taken out of his office in handcuffs, with the press tipped of and waiting outside. Unfortunately people are not wiling to learn by the mistakes of others, but the risk is very, real.
Remember, it costs the complainant nothing to make the complaint; it costs the providers a fortune to defend, even if innocent, so this is why organization create policies and speak of those policies, to be in a position to defend themselves if there is a rogue employee, or an unwarranted complaint.
There are ways of educating a provider group as to reality, without violating the regulations, and if that results in dis-enrollment, then there is not a valid complaint, but this has to be done with the knowledge of the regulations and carefully. If an educated provide dis-enrolls, so be it, if 1000 providers get educated and then dis-enroll, then so be it. If one provider starts promoting dis-enrollment, then there is a violation.
JR: As an attempt to explain the relationship between insurers or managed care companies to their subscribers and to also explain that despite their size and power relative to providers the anti-trust laws apply to providers and not insurers I have used the analogy of a Sam’s Club or buying cooperative. Sam’s Club or any cooperative can buy all kinds of things in bulk from a host of suppliers or providers. Therefore they can demand low prices and if we want their business we settle. No one has to sell to Sam’s Club at the low prices that Sam’s Club says it will pay, but suppliers can't boycott Sam’s Club to make them pay more for their products or can providers/sellers agree on a minimum price for which they will settle. The Feds would be on them in a heartbeat.
And they should. Is my analogy on target or potentially useful?
RG: You analogy is on the mark - the antitrust laws are applicable among any competitors, be they independent practitioners in healthcare or independent manufacturers. Neither practitioners nor manufacturers are required to sell below their cost. However, they cannot combine in action to raise the price that they will offer their goods or services for.
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