Waivers Under the Medicare Shared Savings Program: An Outline of the Options

Transcription

1 Waivers Under the Medicare Shared Savings Prgram: An Outline f the Optins Duglas A. Hastings Rbert G. Hmchick Peter M. Leibld Arthur N. Lerner Beth Schermer Lisa D. Vandecaveye American Health Lawyers Assciatin 1620 Eye Street, NW 6 th Flr Washingtn, DC (202)

2 Waivers Under the Medicare Shared Savings Prgram: An Outline f the Optins American Health Lawyers Assciatin Public Interest Cmmittee Intrductin The Patient Prtectin and Affrdable Care Act f 2010 (PPACA) fsters the develpment f new patient care mdels designed t imprve the crdinatin, quality, and efficiency f healthcare services t Medicare and Medicaid patients. These new prgrams are intended, in part, t shift the emphasis in gvernment prgram fee-frservice payments frm the vlume f services prvided t the value f the services prvided. One f the primary initiatives fr delivery mdel innvatin under PPACA is the Medicare Shared Savings Prgram (PPACA, Sec. 3022), mre cmmnly referred t as Accuntable Care Organizatins (ACOs). T facilitate the establishment f ACOs, PPACA grants the Secretary f Health and Human Services the authrity t waive certain prvisins f the fraud and abuse laws under the Scial Security Act r ther prvisins f the Medicare law (herein ACO waivers ). Thrugh the develpment and distributin f this ptins utline, the AHLA Public Interest Cmmittee is endeavring t prvide bth gvernment and industry a descriptin f sme f the ptins available t the Secretary in crafting the ACO waivers and t serve as a public resurce n selected healthcare legal issues in furtherance f ur public interest missin. There are waiver ptins ther than thse described belw and the scpe and terms f thse listed in this utline culd be altered in a number f ways. The purpse f this utline is nt t prvide an exhaustive review f all f the ptential chices r t advcate fr ne apprach ver anther but rather t explre a range f the ACO waiver ptins and the respective prs and cns f each ptin presented. Backgrund ACOs will be required t accept respnsibility fr the verall care f at least 5,000 Medicare beneficiaries. In general, ACO prviders will be paid n a fee-fr-service basis. If the ACO meets quality benchmarks and reduces the cst f prviding care t the Medicare enrllees attributed t the ACO (as measured against a benchmarked per enrllee expenditure target), the ACO will receive a percentage f the savings. Mre detail cncerning ACOs structure and peratins will be included in regulatins t be prmulgated by the Secretary. While the industry is waiting fr guidance, many interested in this new mdel are struggling with practical questins cncerning the funding, frmatin and peratin f ACOs. Sme f the questins include: (1) Can a hspital fund the cst f develping the legal and peratinal infrastructure f an ACO if physicians wh refer t that hspital will be members f the ACO, have an active rle in gvernance and are entitled t a Pg. 2/15

3 Waivers Under the Medicare Shared Savings Prgram: An Outline f the Optins American Health Lawyers Assciatin prtin f the ACO s shared savings? (2) Can the ACO pay primary care physician members a per patient per mnth management fee fr verseeing the delivery f care t the beneficiaries attributed t that ACO? (3) Can the ACO ffer Medicare beneficiaries cash r ther remuneratin t induce the beneficiaries t seek care frm prviders affiliated with the ACO? Applicable Fraud and Abuse Laws Sectin 3022(f) grants the Secretary the authrity t waive thse requirements f Sectins 1128A and B and Title XVIII f the Scial Security Act as may be required t carry ut the Shared Savings Prgram prvisins. These prvisins include: Civil Mnetary Penalty Law Prhibitin n Payments t Reduce r Limit Care, 42 U.S.C. 1320a 7a(b). A hspital r critical access hspital may nt knwingly make a payment, directly r indirectly t a physician as an inducement t reduce r limit services prvided t a Medicare r Medicaid beneficiary under the direct care f the physician. Beneficiary Inducement Prhibitin, 42 U.S.C. 1320a 7a(a)(5). Persns may nt prvide remuneratin t a Medicare r Medicaid beneficiary where the persn knws r shuld knw that the remuneratin is likely t influence the beneficiary t rder r receive a service frm a particular prvider, practitiner r supplier where the item may be cvered in whle r in part under the Medicare r Medicaid prgram. The Stark Law, 42 U.S.C. 1395nn. A physician may nt refer Medicare patients fr certain designated health services t an entity with which the physician r an immediate family member has a financial relatinship, unless an exceptin applies. An entity receiving a prhibited referral may nt bill the Medicare prgram fr the resulting items and services. The Anti-Kickback Statute, 42 U.S.C. 1320a 7b(b)(1) and (2). Persns may nt knwingly ffer r receive, directly r indirectly, vertly r cvertly, in cash r in kind, any remuneratin t induce r influence the furnishing, arrangement, purchase, leasing, r rdering f items r services fr which payment may be made in whle r in part under a federal healthcare prgram. Prhibitins Against Charging r Cllecting Mre Than the Medicare Allwable, 42 U.S.C.1320a-7a(a)(2). Assignment ccurs when a beneficiary asks that a Medicare payment be made directly t the prvider. If a prvider accepts assignment, Medicare will directly pay the fee schedule amunt fr the services, and the beneficiary will be respnsible fr paying the cinsurance and any remaining deductible. Cllectively, the fee schedule payment and cinsurance/deductible are referred t as the allwed amunt. By accepting assignment, the prvider agrees t accept the allwed amunt as payment in full fr the services. Pg. 3/15

4 Waivers Under the Medicare Shared Savings Prgram: An Outline f the Optins American Health Lawyers Assciatin In crafting the ACO waivers, the Secretary will face a familiar challenge. On the ne hand, a liberal apprach wuld send a psitive signal t the industry, encurage the private sectr t invest in ACO develpment, and prvide the predictability and stability needed fr the private sectr t make lng term investments. On the ther hand, a narrw apprach with mre specific safeguards wuld better preserve Prgram prtectins and ptentially prtect the patients that might be harmed by ver r undertreatment. Sme will argue that the bigger risk is that the regulatry burdens will stifle ACO develpment; thers will argue that the bigger risk is the Prgram r patient abuse that culd result frm giving ACOs a free pass. The waivers, hwever, need nt be set in stne. As ACOs develp, the Secretary shuld be able t make apprpriate adjustments. This utline examines the ACO waiver ptins, fcusing first n a glbal apprach and then n separate waivers fr each f the laws referenced abve. 1. The Glbal Appraches Waiver Optin 1. Maintain the Status Qu. Prs: Cns: Preserves the prtectins affrded by the existing fraud & abuse laws, permitting parties t rely n existing safe harbrs, if applicable, advisry pinins, and gvernment discretin in enfrcement Fails t address cncerns abut the legality f ACO shared savings distributins and ther aspects f ACO frmatin and peratin Discurages the frmatin f ACOs because f legal risks Discurages the frmatin f ACOs because sme risk adverse prviders will incur the csts and suffer the delays assciated with btaining ne r mre advisry pinins Impses a burden n the OIG and/r CMS t review and prcess individual requests fr advisry pinins Arguably is incnsistent with Cngress intent when it granted the Secretary waiver authrity Waiver Optin 2: Establish a prcess fr prviders t apply fr an ACO waiver. The Secretary wuld grant such waivers if, based n a review f the specific arrangement, the benefits utweigh the risks r ther specified criteria are satisfied. 1 1 This ptin culd vary frm a single applicatin per ACO that addresses all f the relevant statutry prhibitins t individual applicatins fr each statutry prhibitin fr which the ACO spnsr wishes t btain a waiver. The prcess fr seeking an ACO waiver culd be patterned after the OIG Advisry Opinin prcess and the Secretary culd either make it mre streamlined t encurage prmpt develpment f ACOs r mre detailed t ensure that there are adequate safeguards t address the full range f issues raised by the ACO waiver applicatin. Pg. 4/15

5 Waivers Under the Medicare Shared Savings Prgram: An Outline f the Optins American Health Lawyers Assciatin Prs: Cns: Permits individualized assessment f the risks f Prgram and patient abuse created by the prpsed ACO and allws the Secretary t structure r limit the ACO waiver accrdingly Preserves prtectins f existing fraud and abuse laws under apprpriate circumstances Prcessing the ACO waiver applicatins wuld likely require significant resurces and highly trained persnnel Depending n hw the prcess is structured, preparatin f the ACO waiver applicatin culd well be cstly fr the applicant, and review f the waiver applicatins culd require significant gvernment resurces The time required t administer the waiver prcess wuld likely delay ACO frmatin It may be difficult t ensure cnsistency in the ACO waiver determinatins 2. Prhibitin n Hspital Payments t Physicians t Reduce r Limit Care Waiver Optin 1: Maintain the Status Qu. Prs: Preserves prtectins against inapprpriate inducements t limit services Cns: Fails t address cncerns abut the legality f bth ACO shared savings distributins and patient management fees t ACO physicians Discurages frmatin f ACOs because f legal risks May impair ACO s ability t cntrl csts and imprve utcmes because it will be mre difficult t link the incentives t desired physician cnduct Waiver Optin 2: Issue a blanket waiver stating that ACO shared savings distributins and patient management fees are nt payments by a hspital t physicians t reduce r limit care within the meaning f the statute. Prs: Encurages ACO frmatin by reducing legal risks Waiver is limited t ACOs and thus nt likely t affect the applicatin f the statute in ther cntexts CMS culd limit risks f inapprpriate limitatins n care thrugh the ACO perfrmance standards Pg. 5/15

6 Waivers Under the Medicare Shared Savings Prgram: An Outline f the Optins American Health Lawyers Assciatin Cns: Narrws the statute s prtectins against inapprpriate inducements t limit services Waiver Optin 3: Issue a waiver stating that the statutry prhibitin is nly triggered if the payment is made t reduce r limit medically necessary care. Prs: Cns: Narrws prhibitin t fcus n what sme cntend is the real mral hazard that prmpted Cngress t enact the statute Encurages ACO frmatin by reducing legal risks CMS culd further limit risks f inapprpriate limitatins n care thrugh the ACO perfrmance standards May significantly narrw the prtectins affrded by the statute Whether care is medically necessary is nt always clear and, at least partially, a subjective determinatin 2 May nt be sufficiently explicit t eliminate legal risk assciated with ACO shared savings distributins r patient management fees because critics culd assert either that the management fee inherently encurages limiting medically necessary care r assert after the fact that the shared savings were achieved by limiting medically necessary care Waiver Optin 4: Issue a waiver stating that ACO patient management fees and shared savings payments are subject t the Health Plan Physician Incentive Plan regulatins 3 rather than the statute prhibiting hspital payments t physicians t reduce r limit care. Prs: Cns: Narrws prhibitin n limiting care while retaining sme safeguards Treats ACOs in the same manner as managed care plans Encurages ACO frmatin by reducing legal risks CMS culd further limit risks f inapprpriate limitatins n care thrugh the ACO perfrmance standards Health plan physician incentive plan safe harbr culd be tweaked if necessary May significantly limit the prtectins against hspital incentives t reduce r limit care 2 PPACA acknwledges the difficulty f making medical necessity determinatins and the need t develp evidence-based standards CFR ; 42 CFR Pg. 6/15

7 Waivers Under the Medicare Shared Savings Prgram: An Outline f the Optins American Health Lawyers Assciatin Arguably inapprpriate t treat an ACO like a managed care plan given that ACO prviders are paid n a fee-fr-service basis and patients d nt vluntarily enrll Sme health plan physician incentive safeguards (i.e., stp lss insurance) are nt apprpriate in the ACO cntext 3. Beneficiary Inducement Prhibitin Waiver Optin 1: Maintain the Status Qu. Prs: Cns: Preserves prtectins affrded by the statute Prevents ACOs frm buying patient lyalty/cperatin Encurages beneficiaries t select the best qualified prviders regardless f ACO affiliatin Decreases ability f ACO t crdinate patient care, achieve better utcmes, r decrease csts Undermines clinical integratin and quality initiatives amng ACO participants May increases pressure n ACO-affiliated physicians t steer patients t ther prviders in the same ACO Waiver Optin 2: Issue a waiver that states that if an ACO incrprates certain safeguards it may ffer remuneratin t encurage beneficiaries t seek care frm ACO-affiliated prviders. The safeguards might include: (1) limitatins n the types and amunt f remuneratin that may be ffered; (2) requiring disclsure t beneficiaries f the ACOs internal financial incentives; (3) requiring ACO prviders t identify ther prviders wh culd treat the beneficiary; and/r (4) impsing quality f care prcess r utcme standards. Prs: Cns: Increases ability f ACO t crdinate care and/r achieve savings Encurages clinical integratin and quality initiatives amng ACO participants Safeguards reduce risk f undue influence n beneficiaries CMS culd further limit risks f inapprpriate incentives thrugh the ACO perfrmance standards May erde prtectins affrded by the statute, such as maintaining a level playing field amng cmpeting prviders Arguably allws ACOs t buy patient lyalty/cperatin based n factrs ther than quality f care May discurage selectin f best qualified prviders Pg. 7/15

8 Waivers Under the Medicare Shared Savings Prgram: An Outline f the Optins American Health Lawyers Assciatin Limiting the types f permitted cmpensatin may stifle innvatin Nt clear that payments t beneficiaries are necessary t fulfill bjectives f ACOs The alternative f using full ntice and rule making t amend the antiinducement regulatins wuld permit mre deliberatin regarding financial arrangements that are nt essential t the immediate rllut f ACOs Waiver Optin 3: Issue a waiver that states that an ACO may ffer remuneratin t encurage beneficiaries t seek care frm ACO-affiliated prviders but d nt require safeguards such as thse listed in the preceding ptin Prs: Cns: Increases ability f ACO t crdinate care and/r achieve savings Encurages clinical integratin and quality initiatives amng ACO participants CMS culd limit risks f inapprpriate incentives thrugh the ACO perfrmance standards Erdes prtectins affrded by the statute such as maintaining a level playing field amng cmpeting prviders Arguably allws ACOs t buy patient lyalty/cperatin based n factrs ther than quality f care May discurage selectin f best qualified prviders Nt clear payments t patient are necessary t fulfill bjectives f ACOs The alternative f using full ntice and rule making t amend the antiinducement regulatins wuld permit mre deliberatin regarding financial arrangements that are nt essential t the immediate rllut f ACOs 4. The Stark Law Waiver Optin 1: Maintain the Status Qu. Prs: Cns: Preserves the prtectins affrded by the statute Prevents ACOs frm making payments based n the vlume r value f the physician s referrals fr designated health services Fails t address cncerns abut Stark law issues raised by ptential financial relatinships arising ut f ACO frmatin, funding and shared savings distributins r ther cmpensatin arrangements Discurages frmatin f ACOs because f legal risks Pg. 8/15

9 Waivers Under the Medicare Shared Savings Prgram: An Outline f the Optins American Health Lawyers Assciatin Frces ACOs t be structured with an eye tward Stark cmpliance even if that structure is nt the best frm either a cst r quality f care perspective Increases the cst and cmplexity f ACOs because f need fr expert advice n Stark law cmpliance and nging mnitring May increase CMS wrklad as parties seek advisry pinins addressing individual ACO structures Applies a law premised n limiting the influence f financial incentives n physicians referral patterns t a new mdel expressly intended by Cngress t incentivize physicians t reduce the cst f care Waiver Optin 2: Issue a waiver that states that if an ACO incrprates specific safeguards, any remuneratin arising ut f the funding, frmatin and gvernance f the ACO 4 and distributin f either patient management fees r shared savings wuld nt create a financial relatinship as that term is defined under Stark. The specific safeguards culd include: (1) impsing limits n the amunt f shared savings r ther payments that may be paid t an ACO prvider; (2) requiring disclsure t beneficiaries f the ACOs internal financial incentives; (3) requiring ACO prviders t prvide beneficiaries a list f nn-aco prviders wh culd treat the beneficiary r ntice that a referral culd be made t nn-aco prviders; and /r (4) impsing quality f care prcess r utcme standards. Prs: Cns: Establishes means fr ACO participants t address Stark risks Encurages ACO frmatin by reducing legal risks Scpe f waiver clear and sufficiently brad t address the full range f issues Safeguards reduce risk f inapprpriate incentives and/r harm t beneficiaries CMS culd further limit risks f inapprpriate incentives thrugh the ACO perfrmance standards Undermines the prtectins affrded by the statute by allwing payments t physicians arguably based at least in part n the vlume r value f the physicians referrals Ptentially discurages ACO frmatin because f cmplexity f requirements fr qualifying fr waiver 4 The Secretary culd refine the scpe f the waiver addressing remuneratin relating t the funding, frmatin and gvernance f the ACO in this and the ther ptins in this utline. Fcusing n gvernance, fr example, the waiver culd prvide that if the party frming an ACO grants ther ACO members gvernance rights that wuld nt cnstitute remuneratin under either the Stark law r the antikickback statute. Taking a similar tact, the Secretary culd prvide that if ne party pays the legal and infrastructure csts f establishing an ACO that neither cnstitutes remuneratin t the ther members f the ACO nr creates an unexpected financial relatinship between the party wh prvided the funding and the ther ACO members. Pg. 9/15

10 Waivers Under the Medicare Shared Savings Prgram: An Outline f the Optins American Health Lawyers Assciatin Increases csts because f need fr expert advice and mnitring t fulfill requirements fr waiver Scpe f waiver as applied t ACO frmatin and gvernance culd have unintended cnsequences Waiver Optin 3: Issue a waiver that amends the special rules n cmpensatin in the Stark regulatins 5 t prvide that payment f patient management fees and distributins f shared savings frm an ACO are deemed nt t be based n the vlume r value f referrals r ther business generated between the parties. Prs: Cns: Establishes a means fr ACO participants t address key risks under the Stark law Encurages ACO frmatin by reducing legal risks Scpe f waiver clear CMS culd limit risks f inapprpriate incentives thrugh the ACO perfrmance standards Undermines the prtectins affrded by the statute by allwing payments t physicians arguably based at least in part n the vlume r value f the physicians referrals Ptentially discurages ACO frmatin because waiver fails t address Stark issues arising ut f the funding, frmatin and gvernance f an ACO Ptentially discurages innvatin r mre effective ACO mdels by nt addressing the permissibility f ther cmpensatin arrangements within ACOs Waiver Optin 4. Issue a waiver amending the Stark shared risk exceptin 6 t state that remuneratin arising ut f r relating t the funding, frmatin and gvernance f an ACO and the payment f patient management fees r distributin f shared savings will nt create a financial relatinship under the Stark law. Prs: Encurages ACO frmatin by reducing legal risks Scpe f waiver clear and sufficiently brad t address the full range f issues CMS culd further limit risks f inapprpriate incentives thrugh the ACO perfrmance standards 5 42 CFR (d) CFR (n). Pg. 10/15

11 Waivers Under the Medicare Shared Savings Prgram: An Outline f the Optins American Health Lawyers Assciatin Cns: Undermines the prtectins affrded by the statute by allwing payments t physicians arguably based at least in part n the vlume r value f the physicians referrals Scpe f waiver very brad, particularly as applied t ACO frmatin and gvernance, and culd have unintended cnsequences It is arguably inapprpriate t treat an ACO like a managed care rganizatin given that ACO patients are Medicare fee-fr-service beneficiaries and did nt vluntarily enrll Waiver Optin 5: Issue a waiver amending the Stark electrnic health recrds (EHR) exceptin t make it permanent, expand the list f permissible dnrs, and create greater flexibility fr ACO spnsrs t fund and implement EHR systems that supprt ACO peratins. Prs: Cns: Establishes a Stark-cmpliant means fr ACO spnsrs t build the infrastructure necessary t crdinate the activities f the participants Scpe f waiver clear CMS culd limit risks f inapprpriate incentives thrugh the ACO perfrmance standards Undermines the prtectins affrded by the statute by expanding the ability f hspitals and ther ACO spnsrs t subsidize physician practices thereby ptentially cmprmising the physicians independence and clinical judgment Ptentially discurages ACO frmatin because waiver fails t address Stark issues arising ut shared savings distributins r ther cmpensatin terms as well as the funding, frmatin and gvernance f an ACO 5. The Anti-Kickback Statute Waiver Optin 1: Maintain the Status Qu. Prs: Preserves the prtectins affrded by the statute Prevents sham ACOs frm frming fr the purpse f inducing r influencing referrals Builds n existing advisry pinins addressing shared savings prgrams Pg. 11/15

12 Waivers Under the Medicare Shared Savings Prgram: An Outline f the Optins American Health Lawyers Assciatin Cns: Fails t address industry cncerns abut anti-kickback issues raised by ptential financial relatinships arising ut f ACO frmatin, funding and shared savings distributins r ther cmpensatin terms Discurages frmatin f ACOs because f legal risks Frces ACOs t be structured with an eye tward anti-kickback cmpliance even if that structure is nt the best frm either a business r quality f care perspective Increases the cst and cmplexity f ACOs because f need fr expert advice n anti-kickback cmpliance and nging mnitring May increase the OIG s wrklad as parties seek advisry pinins addressing individual ACO structures Waiver Optin 2: Issue a waiver creating a safe harbr fr ACOs that incrprate specific safeguards. The specific safeguards culd include: (1) limits n the amunt f shared savings r ther cmpensatin that may be paid t an ACO prvider; (2) requiring disclsure t beneficiaries f the ACO s internal financial incentives; (3) requiring ACO prviders t identify ther prviders wh culd treat the beneficiary r prvide ntice regarding availability f referrals t ther prviders, and/r (4) quality f care prcess r utcme requirements. Prs: Cns: Establishes means fr ACO participants t address anti-kickback risks Encurages ACO frmatin by reducing legal risks Scpe f waiver clear Safeguards reduce risk f inapprpriate incentives and/r harm t beneficiaries CMS culd further limit the risk f inapprpriate incentives thrugh the ACO perfrmance standards Undermines the prtectins affrded by the statute by permitting payments arguably intended t induce referrals f items r services t be paid fr by a federal healthcare benefit prgram Ptentially discurages ACO frmatin because f cmplexity f requirements fr qualifying fr waiver Increases csts because f need fr expert advice and mnitring t fulfill requirements fr waiver Scpe f waiver as applied t ACO frmatin and gvernance culd have unintended cnsequences Waiver Optin 3: Issue a waiver expanding the anti-kickback managed care and/r shared risk safe harbrs 7 t include all remuneratin arising ut f r 7 42 CFR (k), (l), (m), (t) and (u). Pg. 12/15

13 Waivers Under the Medicare Shared Savings Prgram: An Outline f the Optins American Health Lawyers Assciatin relating t the funding, frmatin and gvernance f an ACO and the distributin f shared savings r ther cmpensatin. Prs: Cns: Encurages ACO frmatin by reducing legal risks Scpe f waiver clear CMS culd limit risks f inapprpriate incentives thrugh the ACO perfrmance standards Undermines the prtectins affrded by the statute by permitting payments arguably intended t induce referrals f items r services t be paid fr by a federal healthcare benefit prgram Scpe f waiver as applied t ACO frmatin and gvernance culd have unintended cnsequences It is arguably inapprpriate t treat an ACO like a managed care rganizatin given that ACO patients are Medicare fee-fr-service beneficiaries and did nt vluntarily enrll 6. Prhibitin Against Charging r Cllecting Mre than the Medicare Allwable Amunt Waiver Optin 1: Maintain the Status Qu. Prs: Cns: Preserves prtectins f statute Fails t address cncerns abut the legality f bth ACO shared savings distributins and patient management fees Discurages frmatin f ACOs because f legal risks Waiver Optin 2: Issue a waiver stating that ACO shared savings distributins and patient management fees d nt vilate prhibitins n charging r accepting mre than the Medicare allwable amunt fr services t beneficiaries. Prs: Cns: Encurages ACO frmatin by reducing legal risks Waiver is limited t ACOs and thus nt likely t affect applicatin f statute in ther cntexts CMS culd further limit the risks thrugh ACO perfrmance standards Narrws the statute s prtectins against inapprpriate payments t prviders Pg. 13/15

14 Waivers Under the Medicare Shared Savings Prgram: An Outline f the Optins American Health Lawyers Assciatin Waiver Optin 3: Issue a waiver stating that the statutry prhibitin is nly triggered if the payments in excess f the allwable amunt are in excess f fair market value. Prs: Cns: Gives guidance as t the amunt f the payments an ACO may make t participants Encurages ACO frmatin by recgnizing that payments in excess f Medicare allwable amunt are apprpriate It may be difficult t determine whether the amunt f either a patient management fee r shared savings distributin is fair market value Increases the cst f ACO frmatin because f the need fr valuatin data Discurages frmatin f ACOs because f legal risks Pg. 14/15

15 Waivers Under the Medicare Shared Savings Prgram: An Outline f the Optins American Health Lawyers Assciatin Authrs & Cntributrs: Duglas A. Hastings, Esq. Epstein Becker & Green PC th Street, NW Suite 700 Washingtn, DC Direct: (202) dhastings@ebglaw.cm Rbert G. Hmchick, Esq. Davis Wright Tremaine LLP rd Avenue Suite 2200 Seattle, WA Direct: (206) rberthmchick@dwt.cm Peter M. Leibld, Esq, Executive Vice President and Chief Executive Officer American Health Lawyers Assciatin 1620 Eye Street, NW 6 th Flr Washingtn, DC Direct: (202) pleibld@healthlawyers.rg Arthur N. Lerner, Esq. Crwell & Mring LLP 1001 Pennsylvania Avenue, NW Washingtn, DC Direct: (202) alerner@crwell.cm Beth Schermer, Esq. Cppersmith Schermer & Brckelman PLC 2800 Nrth Central Avenue Suite 1200 Phenix, AZ Direct: (602) bschermer@csblaw.cm Lisa D. Vandecaveye, Esq. Crprate Vice President, Legal Affairs Btsfrd Health Care Cntinuum Grand River Avenue Farmingtn Hills, MI Direct: (248) lvandecaveye@btsfrd.rg Pg. 15/15