Medicare and Medicaid programs: Hospital Outpatient Prospective Payment and Ambulatory Surgical Center Payment Systems and Quality Reporting Programs; physician-owned hospitals: data sources for expansion exception; physician certification of inpatient hospital services; Medicare Advantage organizations and Part D sponsors: CMS-identified overpayments associated with submitted payment data. Final rule with comment period.

This final rule with comment period revises the Medicare hospital outpatient prospective payment system (OPPS) and the Medicare ambulatory surgical center (ASC) payment system for CY 2015 to implement applicable statutory requirements and changes arising from our continuing experience with these systems. In this final rule with comment period, we describe the changes to the amounts and factors used to determine the payment rates for Medicare services paid under the OPPS and those paid under the ASC payment system. In addition, this final rule with comment period updates and refines the requirements for the Hospital Outpatient Quality Reporting (OQR) Program and the ASC Quality Reporting (ASCQR) Program. In this document, we also are making changes to the data sources permitted for expansion requests for physician-owned hospitals under the physician self-referral regulations; changes to the underlying authority for the requirement of an admission order for all hospital inpatient admissions and changes to require physician certification for hospital inpatient admissions only for long-stay cases and outlier cases; and changes to establish a formal process, including a three-level appeals process, to recoup overpayments that result from the submission of erroneous payment data by Medicare Advantage (MA) organizations and Part D sponsors in the limited circumstances in which the organization or sponsor fails to correct these data.

The general NFP hospital model.

Throughout the past 30 years, there has been a lot of controversy surrounding the proliferation of new forms of health care delivery organizations that challenge and compete with general NFP community hospitals. Traditionally, the health care system in the United States has been dominated by general NFP (NFP) voluntary hospitals. With the number of for-profit general hospitals, physician-owned specialty hospitals, and ambulatory surgical centers increasing, a question arises: "Why is the general NFP community hospital the dominant model?" In order to address this question, this paper reexamines the history of the hospital industry. By understanding how the "general NFP hospital" model emerged and dominated, we attempt to explain the current dominance of general NFP hospitals in the ever changing hospital industry in the United States.

Community benefit laws, hospital ownership, community orientation activities, and health promotion services.

BACKGROUND: The hospital industry has exhibited a pattern of isomorphic change with regard to business operations. Many states have enacted community benefit laws to compel hospitals to provide community benefits to improve their community orientation. PURPOSES: We seek to identify what kinds of isomorphic change might be associated with the enactment of these state community benefit laws. To do this, we conducted a longitudinal study of changes in community benefit provided by hospitals in both states with community benefit laws and states without community benefit laws. METHODOLOGY/APPROACH: This study used a quasi-experimental panel design with the passage of community benefit laws/guidelines as the treatment variable. Our sample was composed of 390 not-for-profit hospitals and 129 investor-owned hospitals in 9 treatment states and 1,493 not-for-profit and 714 investor-owned hospitals in 35 control states. Community benefit was measured by the (a) community orientation activities reported and the (b) health promotion services offered by hospitals. FINDINGS: The not-for-profit hospitals in the states without community benefit laws had increased their community orientation activities and health promotion services in a manner similar to that of the not-for-profit hospitals in the states with community benefit laws. There was no significant difference between the not-for-profit hospitals in the states without community benefit laws and those in the states with community benefit laws in 1994 or 2006 for either dependent variable. The changes in the community benefit for the not-for-profit hospitals in the states without community benefit laws and in the states with community benefit laws were significant and positive for both dependent variables. PRACTICE IMPLICATIONS: Managers of acute care hospitals should engage in community orientation activities to maintain their legitimacy, differentiate themselves from other hospitals, avoid regulation, and manage resource dependency on managed-care payers.

Back in business. Heartland Spine & Specialty Hospital showed that a small, physician-owned hospital can beat the big guys in court.

It's too soon to tell if a precedent has been set, officials say, but the Heartland Spine settlement could serve as a "guidepost" for other physician-owned hospitals feeling squeezed out of their markets. But Jeff Micklos, left, the Federation of American Hospitals' general counsel, said: "I don't think this settlement or any settlement changes the underlying influence of conflict of interest of physician-owners who self-refer.