RAND ReseARch AReAsChildren and FamilieseduCation and .docx
Med Tourism Regulatory Presentation
1. Pioneering The Future in Global Healthcare23rd– 24th May, 2011 Las Vegas Overview of U.S. Regulatory Environment for 3rd Party Payers Dale C. Van DemarkEpsteinBeckerGreenDVandemark@ebglaw.com
2. 2 THE CORE CONTEXT EMPLOYER PROVIDER PAYOR GOVERNMENT (Payor, Regulator and Employer) PATIENT
3. 3 THE PAYMENT DYNAMIC PROVIDER Fee for Service (Increasingly, bundled payment and shared risk models) Premiums PAYOR Private InsuranceEmployer PlanMedicareMedicaidCHAMPUSTRICARE EMPLOYER Premiums Co-pay; Deductible; Self-Pay PATIENT
4. 4 THE REGULATORY DYNAMIC EMPLOYER PROVIDER PATIENT PAYOR EMPLOYER PLAN INSURANCE STATE REGULATION FEDERAL REGULATION
5. 5 THE REGULATORY SCOPE State Regulation Providers: Licensure Insurers: Licensure Scope of Covered Services Federal Regulation Providers: Accreditation / Fraud and Abuse Employer Plan: Fiduciary Duty Insurers: Coverage Employer: Coverage; Financial Incentives to provide Patient: Financial Incentives to participate
6. 6 THE MEDICAL TRAVEL CONTEXTPart I (Self-Pay) Payment Dynamic Fee PATIENT FOREIGN PROVIDER FACILITATOR Regulatory Dynamic: “Buyer Beware” Fee Fee
7. 7 THE MEDICAL TRAVEL CONTEXTPart 2 (Insurance) EMPLOYER PATIENT Premiums FOREIGN PROVIDER Fee Premiums INSURANCE Fee FACILITATOR STATE REGULATIONS THE CONUNDRUM Will a State approve a plan that includes providers over which it has no regulatory control? The California Approach
8. 8 THE MEDICAL TRAVEL CONTEXTPart 3 (Employer Plans) EMPLOYER PATIENT Premiums FOREIGN PROVIDER Fee Premiums EMPLOYER PLAN Fee FACILITATOR FEDERAL REGULATION THE CONUNDRUM Will Plan trustees approve a plan that includes providers over which no state nor the federal government has control? The Fiduciary Decision
9. WILL GOVERNMENT PAYORS INCLUDE MEDICAL TRAVEL? Some Small steps; but…… Admitting failure? Fraud and abuse – how to enforce? Quality – how to oversee? 9
10. 10 QUESTIONS? Dale C. Van DemarkEpstein Becker & Green, P.C. Tel: +1 202.861.4187Fax: +1 202.861.3587Email: dvandemark@ebglaw.com Web: EBGLaw.com EBGGlobalAdvisors.com
