EXCERPTS OF RECENT MEDIA COVERAGE
THE BDO CENTER FOR HEALTHCARE
EXCELLENCE & INNOVATION
A SAMPLING OF BDO THOUGHT LEADERSHIP
IN THE MEDIA FOR Q3 2016
THE NEW YORK TIMES
CNBC
JUSTICE DEPT. WILL SEEK
TO BLOCK 2 HEALTH
INSURANCE MERGERS
AETNA AND HUMANA STILL
TALKING TO DOJ
By Leslie Picker and Reed Abelson
Antitrust officials are concerned that
Aetna’s $37 billion deal with Humana,
and Anthem’s $48 billion pursuit of Cigna,
will harm competition in the health
insurance industry...
Challenges to the health insurance deals
would be the latest in a string of suits
against what the government perceives to
be anticompetitive mergers…
While the two mergers were aimed at
very different types of insurance markets,
consumer advocates and others raised
concerns that the deals would result in
higher insurance prices for consumers.
Even if the larger companies were able to
drive down the prices they paid for care
from hospitals and doctors, critics worried
those savings would not flow to the people
covered under the plans.
“Prices may go up either
way,” said David Friend,
managing director at
BDO, the consulting
firm. “But if they do
not block, people can
say you created this
problem by allowing
competition to disappear.”
By Bertha Coombs
Aetna and Humana remain in discussions
with the Department of Justice over
approval of their merger, trying to convince
federal regulators that their $37 billion deal
will be good for seniors in the Medicare
Advantage market. But the two firms are
prepared to fight in court if their deal is
blocked.
While the DOJ is widely expected to issue a
decision on the deal within days, both sides
were still talking Wednesday, according to
people familiar with the discussions who
spoke on condition of anonymity because of
the sensitive nature of the negotiations…
“There’s always a negotiation. It probably
goes to the 11th hour. If you’re the antitrust
folks you’d like them to divest as much as
you can get them to do,” said Dr. David
Friend, managing director of BDO’s
Center for Health Care Excellence…
BDO’s national team of
professionals offers the
hands-on experience and
technical skill to address
the distinctive business
needs of our healthcare
clients. We supplement
our technical approach by
analyzing and advising our
clients on the many elements
of running a successful
healthcare organization.
Whether or not antitrust regulators
decide to block deals, other market forces
will continue to impact consumers, said
Dr. Friend. “If they block these deals,
prices may yet continue to go up because
demographics are driving up prices… drugs
are driving up prices and the providers are
still consolidating,” he said. “No matter
what they do, these things are tending to
drive prices.”
Read more 
MEDIA COVERAGE OF THE BDO HEALTHCARE PRACTICE
PHARMALOT
BIOTECHS SAY THAT
CONTROVERSY OVER
PRICING IS A BIGGER RISK
EACH YEAR
By Ed Silverman
The clamor over prescription drug pricing
is weighing more heavily on biotech
managements. A recent review of risk
factors cited by the 100 largest companies
listed in the Nasdaq Biotechnology Index
found 89 percent cited worries over pricing
pressures, according to the BDO advisory
and consulting firm, which examined
filings with the US Securities and Exchange
Commission.
And concern has been steadily rising. In
2015, the firm noted that 79 percent of
biotechs cited anxiety over pricing as a risk
factor to their businesses, while 68 percent
did so in 2014 and 66 percent in 2013.
Thanks to increased controversy over the
cost of medicines, pricing is now the 16th
most worrisome issue.
The list of corporate concerns that rank
higher includes competition; regulation;
litigation; patent disputes; and payer
reimbursement, among other matters. (We
should note BDO did not previously break
out pricing as a separate risk factor, so this
chart does not display a direct comparison
to earlier years. However, we asked the firm
for the data).
“They’re moving away from a world where
they could price what they wanted, so
maybe they didn’t understand the risk
until now,” said David Friend, who heads
BDO’s Center for Healthcare Excellence
and Innovation. “But it’s a huge, systemwide problem and they’re just beginning to
grapple with it.”…
TAMPA BAY BUSINESS
JOURNAL
HOW A NEW WAY OF
PAYING FOR HIPS AND
KNEES COULD LOWER
TAMPA BAY EMPLOYERS’
COSTS
By Margie Manning
For hip and knee replacements, Medicare
is now bundling payments, or setting a
single price for all the care associated with
the procedures for 90 days, from hospital
admission to rehabilitation.
The program holds hospitals accountable
for all the costs…It is designed to lower
costs while improving quality of care.
The Tampa St. Petersburg-Clearwater
metropolitan area is among the 67 metro
areas involved in the test, which began April
2
1 and runs for five years. The Tampa metro
is one of five markets where Medicare data
suggests spending on care related to joint
replacements exceeds the regional average
— meaning that under the pilot program,
hospitals must trim costs or lose money...
While the pilot program only applies to
Medicare payments for a couple of types
of procedures now, it’s likely to expand to
additional procedures,
including cardiology
and oncology, and to
Medicaid and eventually
commercial insurers,
said Patrick Pilch,
managing director of
the BDO Center for
Healthcare Excellence & Innovation.
“As a businessperson, I have to understand
what networks do I want my employees in,
in order to make sure that my costs and the
care for my employees are at the respective
lowest and highest levels,” Pilch said.
“Ultimately employers can say, ‘how can I
create my own network based on the data
out there?’ so I can say to an Aetna, a Blue,
whomever, ‘this is the network I want for
these episodes of care and this is who I want
to have in that network.’”
HEALTHCARE DIVE
HOW THE DOJ USED DATA
TO NET $1B HEALTHCARE
FRAUD CASE
By Heather Caspi
The DOJ has charged three healthcare
professionals with conspiracy, obstruction,
money laundering, and healthcare fraud in
a Miami-area scheme that bilked Medicare
and Medicaid of more than $1 billion over
14 years, officials announced Friday…
The government has touted the successful
use of data-driven law enforcement in this
case, a key strategy in its hardline approach
to fighting against healthcare fraud in
general, and in the recent announcement
of $42 billion in savings from program
integrity efforts…
Read more 
MEDIA COVERAGE OF THE BDO HEALTHCARE PRACTICE
Recently, Venson
Wallin, consulting
managing director at
accounting firm BDO,
shared with Healthcare
Dive some tips to
avoid healthcare fraud.
Relating to healthcare
data, he said administrators don’t want
to be surprised if the data point to audit
records or documentation leading to
embarrassing results or banishment from
a Medicare program. “You need to know
what’s going on in your shop from a data
perspective,” Wallin said. “There needs to
be monitoring and tracking of the billing,
claims data.”
Unfortunately, management is inundated
with data and knowing where to focus
oversight, which data to include, how often
to look at it, and setting up appropriate
monitoring and tracking techniques can
prove difficult. It still needs to happen to
receive initial compliance issues notices and
minimize financial risk, Wallin said.
SAN FERNANDO VALLEY
BUSINESS JOURNAL
TELEMEDICINE: HOSPITALS
DON’T HAVE ENOUGH
MENTAL HEALTH
SPECIALISTS. HERE’S THE
SOLUTION.
By Stephanie Henkel
Aligned TeleHealth Inc., a Calabasas
company that provides psychiatric
counseling on a computer screen, has
received $12 million in venture capital to
keep up with the rising demand of mental
health services in hospitals and nursing
homes…The company provides behavioral
health doctors via a robot with a monitor
on top. Therefore, the psychiatrist doesn’t
have to physically be available but can
still see patients virtually, greatly reducing
wait times--often as low as 30 minutes to
an hour--as well as costs associated with
increasing staff. When doctors remotely
diagnose and treat patients through
telecommunications technology, it is
known as telemedicine or telehealth. In
health care, this practice has become a
growing trend that is beginning to receive
higher reimbursement rates by insurance
providers and further implementation by
health care providers…
One major challenge for Aligned is the
doctor credentialing process, which can
take up to three months. For a doctor to
practice telemedicine at hospitals A, B
and C, he or she must be independently
verified at each facility. Thus, sometimes a
doctor may be hired in January but won’t
be able to start work until May… Aligned is
working on implementing what Nanda calls
credentialing by proxy, which essentially
means if a doctor is credentialed at a major
hub hospital in a system, then he or she
is automatically credentialed at other
hospitals within the system.
Another issue is state-specific licensure,
so on top of having to be credentialed at
each hospital, each doctor must be licensed
in each state he or
she practices in. Dr.
Bill Bithoney, chief
physician executive at
consulting firm BDO
Center for Healthcare
Excellence and
Innovation, said there
are efforts afoot that may help Aligned
down the road.
“There is a movement for standardized
medicine licensure,” he said. “Twentythree states are trying to put together a
conjoined licensure program. I can tell you
pneumonia and cardiac arrest are the same
state by state. It (standardized licensure)
makes all the sense in the world, technically
and medically.”
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HFMA
GETTING A CLEAN BILL OUT
THE DOOR
By Paul Gallese and Patrick Pilch
Regulations and payment methods are
shifting from traditional payment for units
of service rendered to payment for bundles
of service linked to quality, which are the
essence of value-based payment. This
shift requires healthcare organizations to
transform the way they deliver care—and to
adjust their billing processes accordingly…
Simply put, the ultimate goal for hospital
billing offices in this environment is to be
able to deliver an accurate and defensible
bill for services—i.e., what can aptly be
referred to as a “clean” bill…This prospect
requires much more than software
updates…The new billing processes
must be adapted to the new risks and
new provider relationships, so that every
provider involved with coordinating care
across an episode clearly understands the
need for alignment between “back office”
functions and new clinical and operational
processes…
A new taxonomy is required within network
and provider contracts, with explicit
Read more 
MEDIA COVERAGE OF THE BDO HEALTHCARE PRACTICE
definitions created to describe relationships
and responsibilities across newly formed
systems of care. The contracts, the new
taxonomy, and the agreements that
memorialize them will become the primary
points of connection among providers. In
laying the groundwork for accurate, timely
billing processes under bundled payments,
hospitals should focus efforts in four
key areas:
•Defining new roles, responsibilities,
and relationships
•Understanding the new risks and
preparing for them
•Knowing all of the partner organizations
participating in the bundle
•Contracting carefully and monitoring
contract performance
•Define New Roles, Responsibilities, and
Relationships.
HEALTHCARE IT NEWS
John Riggi and Judy Selby
of BDO Consulting share
three steps to effective
data mapping: third party
assessment, an infinite
response plan and a strong
employee training program
By Jessica Davis
The healthcare industry is one of the
most complex in terms of data. Patient
information of all types are being
transmitted both within organizations and
among third parties. Keeping that data safe
is a huge undertaking…Data mapping is one
technique designed to help organizations
understand all of the involved risks and
determine the location of the data at any
given time.
That’s according to
John Riggi, head of
the Cybersecurity and
Financial Crimes Unit
for BDO Consulting
and former chief of the
FBI’s Cyber Division
Outreach Section.
“The most fundamental premise is that
cyber risk can’t be eliminated – it can only
be mitigated,” Riggi said. “Healthcare
organizations need to understand what
criminals want to steal and how to
protect it.”
Data mapping means determining the
assets held within an organization,
understanding networks within the
enterprise and how the data moves within
it. It’s a lot like plumbing in a house: You
have to know where
the pipes go and how
the water flows, said
Judy Selby, managing
director, technology
advisory service for
BDO Consulting.
According to Selby,
healthcare leaders can accomplish this in
three steps: First, perform a third-party
assessment to determine where your
organization stands and its most prevalent
risks. For some, this may also mean finding
out if your organization has already been
breached. The second step is an ‘infinite
response and practice plan,’ which will
help leaders better respond when an
event occurs and mitigate the impact of
the breach. Third, leaders must institute a
strong training program for employees…
“When you think about it,” Selby added.
“Top down prioritization is the most
effective way to approach this issue. In
every instance (within an organization)
it’s the leaders that set the priorities and
control the purse strings. They are the
ones who can really set the tone for others
to follow.”
CONTACT:
STEVEN SHILL
Partner – Healthcare Leader
Orange County, Calif.
714-668-7370 / [email protected]
PATRICK PILCH
Managing Director – Healthcare Leader
BDO Consulting
New York, N.Y.
212-885-8006 / [email protected]
Material discussed in this article is meant to provide general information and should not be acted on without professional advice tailored to your firm’s individual needs.
ABOUT THE BDO CENTER FOR HEALTHCARE EXCELLENCE & INNOVATION
The BDO Center for Healthcare Excellence & Innovation unites recognized industry thought leaders to provide sustainable solutions across the full spectrum of healthcare
challenges facing organizations, stakeholders and communities. Leveraging deep healthcare experience in financial, clinical, data analytics and regulatory disciplines, we
deliver research-based insights, innovative approaches and value-driven services to help guide efficient healthcare transformation to improve the quality and lower the
cost of care.
ABOUT BDO
BDO is the brand name for BDO USA, LLP, a U.S. professional services firm providing assurance, tax, advisory and consulting services to a wide range of publicly traded and
privately held companies. For more than 100 years, BDO has provided quality service through the active involvement of experienced and committed professionals. The
firm serves clients through more than 60 offices and over 500 independent alliance firm locations nationwide. As an independent Member Firm of BDO International
Limited, BDO serves multi-national clients through a global network of 1,408 offices in 154 countries. BDO USA, LLP, a Delaware limited liability partnership, is the U.S. member of BDO International Limited, a UK company limited by guarantee, and forms part of the
international BDO network of independent member firms. BDO is the brand name for the BDO network and for each of the BDO Member Firms. For more information
please visit: www.bdo.com. © 2016 BDO USA, LLP. All rights reserved.
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