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Presented by PYA’s Jim Lloyd (Consulting Principal) and Robert Mundy (Consulting Senior Manager), "Valuation of Dental Practices,” provide valuable insights regarding dental practice operations, merger and acquisition activity, and valuation approaches. The presentation also covers: Key operating statistics that drive the value of dental practices. Compensation trends for dentists. Regulatory constraints and related issues.

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The transformation towards more integrated and accountable healthcare delivery systems is aligning physicians, outpatient care, hospitals and ultimately payers in unprecedented numbers. Yet creating a successful clinically integrated network can be a daunting and complicated undertaking. Yale New Haven Health System (YNHHS), a nonprofit academic medical center, is following a seven-phase plan to achieve a regional, clinically integrated network with the ultimate goal of population health management. Conifer Health President of Value-Based Care, Megan North and Gayle Capozzalo, FACHE Executive Vice President/Chief Strategy Officer, Yale New Haven Health System (YNHHS), co-presented at the the Becker’s Hospital Review 7th Annual Meeting in Chicago. North and Capozzalo shared “A Seven-Step Approach to a Clinically Integrated Network,” to provide insights into each step of the clinical integration road map.

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Radiologists in the United States are currently facing a dilemma as far as “meaningful use” (MU) of Electronic Health Records (EHRs) is concerned. The American College of Radiology (ACR) IT and Informatics Committee leaders and staff have met the National Coordinator for HIT (ONC) as well as Center for Medicare and Medicaid Services (CMS) staff to discuss the HR incentive program from the point of view of radiologists, on October 13, 2011.

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Since the launch of the Marketplaces and Medicaid expansion, one out of every 20 Americans has been added to the Medicaid roll. More than 51 million Americans receive physical health benefits from a private Medicaid health plan (or 70% of all beneficiaries) and as of Q3 2015, 41 states had some form of private managed Medicaid. Along with the rapid expansion of Medicaid, comes the push for managed care plans to adopt value-based care approaches that tie provider reimbursement to quality measures and better outcomes. This presentation gives physicians crucial details about Medicaid and CHIP Managed Care Proposed Rule CMS 2390-P, and the five factors for value-based payment success in the era of Managed Medicaid.”

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Charlie Alfero, MA presents on financing for community health work. Description This workshop will report on the development of “CHISPAS” a Medicaid Community Health Worker service and payment model that is being piloted in New Mexico. CHISPAS provides PMPM (per member per month) for Basic Patient Support, Intensive Care Coordination and support policy, systems and environmental changes to improve health and reduce costs. It is a national model for providing an on-going financing / payment source for CHW services.

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PYA Principal Jim Lloyd along with Polsinelli’s Douglas Anning presented “Doing the Deal” in which they utilized case studies in analyzing both hospital-hospital transactions and hospital-physician practice transactions. The presentation also covered: Helping clients successfully negotiate and structure the transaction and keeping the deal on track Recognizing sample contract provisions common to these types of deals Working with valuation firms to ensure the transaction terms are within fair market value and commercially reasonable Evaluating and dealing with potential anti-trust concerns Dealing with potential compliance issues identified during the due-diligence process

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PYA Principal Carol Carden co-presented “The Vicissitudes of Valuing Value--Legal and Valuation Issues Associated with Value-Based Payment Models” at the 2017 American Health Lawyers Association Physician and Hospitals Law Institute, February 1-3, 2017, in Orlando, Florida. The presentation addressed: Emerging alternative payment models (APMs) The application of fraud and abuse laws and IRS rules to provider network payments Existing market data and regulatory guidance Considerations in determining fair market value and commercial reasonableness

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In the coming years the United States will find themselves going through a number of changes within the Social Security Administration which will affect the Health Care Industry as we know it “Hospital size has long been an area of discussion and debate in the U.S. healthcare industry. Questions have consistently focused on cost management or efficiency in large versus small hospitals. A persistent question among researchers is whether efficiencies are associated with larger facilities through economies of scale, or if there are alternate scenarios that play a significant part in hospital cost and efficiency” (2009, JHM). Since the Affordable Health Care Act was established it made obtaining health care much more affordable and accessible, but at the same time there has to be some cut back.

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1 Running Head: CRITICAL THINKING: NEW HOSPITAL PROPOSAL CRITICAL THINKING: NEW HOSPITAL PROPOSAL 2 Introduction The system of healthcare in most of the countries is national based healthcare system whereby the government offers health care services to the public using governmental agencies. In Saudi Arabia for example, there are some growing private healthcare facilities. The government of many nations remains the full controller of the healthcare sectors both private and public. The private hospitals are both non-profit and profit for example in Saudi Arabia, most of these private hospital attracts several expats. Both the standards of both private and government hospitals are of more similarity. Some of the private healthcare facilities are of the world class but with poor health service delivery (Penm,2015). Comparing and Contrasting the Legal Structure and Governance of the Profit and Non-profit international entities Differences The selected international entities include the Joint Commission International (non-profit), International Hospital Federation (non-profit) and the Kaiser Permanente (non-profit and profit). The legal structure of the Joint Commission International (JCI) follows the certification and accreditation of the hospital. The hospital must be evaluated first to see if the hospital complies with the standards and meets the activities needed by this entity. There are accreditation programs that any hospital must go through. This is then followed by the certification which can either be based on associated health care organization (Joint Commission, 2016). On the other hand, the International Hospital Federation requires a formal and documented request addressed to the Chief Executive Officer for one to be a member. The legal structure of Kaiser Permanente is consisting of two or three independent legal entities in each region of California (Finz, 2012). The applying employee must have been hired as a new Kaiser Permanente for an award-eligible post. The governance of the International Hospital Federation is consisting of three organs i.e. the general assembly, governing council, and the executive committee. There are also the designated positions which consist of the president, chairman designate, immediate past president, treasurer, and the chief executive officer (International Hospital Federation, 2015). On the other hand, Kaiser Permanente is consisting of entities with each entity having its management and governance structure. There are regional entities and twelve Permanente Medical groups which were created by the Permanente Federation. The role of the Permanente is to standardized patient care as well as the performance (Finz, 2012). The governing of JCI is under the leadership of the President and the chief executive officer (Matt, 2011). Advantages of the Entities Join Commission International provides a wide variety of health care programs l ...

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Running header: THE CURRENT FINANCIAL ENVIRONMENT IN HEALTHCARE AND ITS INFLUENCE ON DECISION MAKING 1 THE CURRENT FINANCIAL ENVIRONMENT IN HEALTHCARE AND ITS INFLUENCE ON DECISION MAKING 2 The Current Financial Environment in Healthcare and its Influence on Decision Making It is essential that healthcare managers understand the external factors that have a profound influence on the practice of healthcare finance. A key factor to understanding healthcare finance is the knowledge of all the different and unique setting that provide health services. Healthcare services are provided in numerous settings, including hospitals, ambulatory care offices and clinics, long-term care facilities, and integrated delivery systems. Hospitals afford diagnostic and therapeutic services to those who need more than several hours of care. Hospitals must be licensed by the state and undergo inspections for compliance with state regulations (Gapenski 2013). Most hospitals are accredited by The Joint Commission, which is intended to promote high standards of care. Accreditation provides eligibility for participation in the Medicare and Medicaid programs. Hospitals are classified as either general acute care facilities or specialty facilities. General acute care facilities provide general medical and surgical services and selected acute specialty services (Gapenski 2013). These facilities account for most hospitals and have comparatively short spans of stay. Specialty hospitals limit the admission of patients to specific ages, sexes, illnesses, or conditions (Gapenski 2013). Specialty hospitals frequently sustain lower expenses than general hospitals because they do not need the overhead connected with providing various diverse forms of care and services. Hospitals are classified by proprietorship as governmental, private not-for-profit, or investor owned. Government hospitals constitute 25% of all hospitals and are divided into federal and public entities. Federal hospitals serve special purposes such as DOD and VA hospitals. Public hospitals are funded wholly or in part by a city, county, tax district, or state. Federal and Public hospitals provide substantial services to indigent patients (Gapenski 2013). Private not-for-profit hospitals are nongovernment entities organized for the sole purpose of providing inpatient healthcare services (Gapenski 2013). Roughly 80% of all private hospitals are not-for-profit entities and 60% of all hospitals are private hospitals. For serving a charitable purpose, these hospitals obtain several benefits, including exemption from federal and state income taxes, exemption from property and sales taxes, eligibility to receive tax-deductible charitable contributions, favorable postal rates, favorable tax-exempt financing, and tax-favored annuities for employees. The residual 15% of all hospitals are investment-owned hospitals, whose titleholders profit directly from the revenues created by .

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DQ 3-2 Integrated health care delivery systems (IDS) was developed to initiate excellence health care access and quality of care to entire populations and community by collaborating and coordinating diverse healthcare professionals. Main driving force of IDS is patient centered care by using resources such as collaborating care from physicians and allied health care professionals to construct continuum of care, to deliver care in the most cost-effective way, utilize trained and competent providers by utilizing evidenced -based practice and combine innovation such as EHR (Electronic Health Records) system and team work to produce improved healthcare system. Excellence in care is attainable by incorporating allied healthcare professional, as high quality care is possible when coordination is unified and covers all areas of responsibilities. For an example-combining resources and coordination of care by involving physicians, dietitian, physical therapy or occupational therapy to work with patient diagnosed with obesity by promoting teamwork approach and ultimately delivering endurance in care and utilizing various resources. Barriers to IDS can be a huge block in delivering quality care. Among many one limitation is physicians not participating in integrated healthcare system, which disconnect physicians from team based approached by deterring continuous quality improvement (essentialhospitals.org, n.d). This is because, system such as EHR or new innovative quality assurance programs are time consuming and overwhelming, thus decline in physicians support in IDS programs. By implementing user friendly system approach, enforcing focused based care and accepting the necessity of evidenced based practice can improve these barriers. Hence, increasing clinical expertise to produce better service and quality of care in integrated delivery system. Essentialhospitls.org (n.d). Retrieved from: http://essentialhospitals.org/wp-content/uploads/2013/12/Integrated-Health-Care-Literature-Review-Webpost-8-22-13-CB.pdf Dq 3-1 1. In the US, there is not one type of health care system but rather a subset of systems, some of them catering to specific populations. These subsystems include managed care, military, and vulnerable populations. Managed care is a health care delivery system that seeks to achieve efficiency by integrating the basic functions of health care delivery, employs mechanisms to control utilization of medical services, and determines the price at which the services are purchased and how much the providers get paid, military health care system is available free of charge to active duty military personnel and covers preventative and treatment services that are provided by salaried health care personnel and this system combines public health with medical services, and vulnerable population subsystem offers comprehensive medical and enabling services targeted to the needs of vulnerable populations and government health insurance programs provide.

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Accountable Care Organizations and Physician Joint Ventures Jeffrey P. Harrison Chapter 9 “I will continue with diligence to keep abreast of advances in medicine. I will treat without exception all who seek my ministrations, so long as the treatment of others is not compromised thereby, and I will seek the counsel of particularly skilled physicians where indicated for the benefit of my patient.” —from The Hippocratic Oath (modern version) Copyright 2016 Foundation of the American College of Healthcare Executives. Not for sale. 1 Learning Objectives Demonstrate an understanding of the interparty relationships associated with healthcare joint ventures and accountable care organizations. Understand some of the dynamics and controversies surrounding the concept of accountable care organizations as an alternative approach to the current marketplace. Demonstrate a basic understanding of the patient-centered medical home with attention to how it supports network-based delivery systems. Master the concept of physician–hospital alignment and health system integration including consumer, provider, and regulatory developments. Assess the emerging role of medical groups and hospital-owned group practices across the continuum of healthcare services. Copyright 2016 Foundation of the American College of Healthcare Executives. Not for sale. 2 Key Terms and Concepts Accountable care organization (ACO) Clinical integration Equity-based joint venture Hospitalist model Integrated physician model Medical foundation Patient-centered medical home (PCMH) Copyright 2016 Foundation of the American College of Healthcare Executives. Not for sale. 3 Introduction A positive relationship between hospitals and physicians is important to the success of the US healthcare system, because hospitals and physicians can be both collaborators and competitors. Many hospitals and healthcare systems have moved to various models of physician integration through which hospitals hope to capture market share and physicians seek financial security. After the Affordable Care Act (ACA) was passed in 2010, physician–hospital alignment became driven by another factor: cost control and quality outcomes in the accountable care era (Reiboldt 2013). Physicians work in a wide range of settings and serve in leadership positions that have significant responsibility for quality of care. Copyright 2016 Foundation of the American College of Healthcare Executives. Not for sale. 4 Clinical Integration What Is It? Coordination of patient care between hospitals and physicians across the healthcare continuum— e.g., an accountable care organization (ACO). Provides an opportunity to coordinate services through centralized scheduling, electronic health records, clinical pathways, management of chronic diseases, and innovative quality improvement programs. Clinical integration is necessary to delivering high-quality, affordable care in the current environment (Jacquin 2014). Clinical.

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In our research paper titled "Qualitative Analysis on Tax Evasion and Reasons for Reluctance to Join ATL in Pakistan," we delve into the intricate dynamics of tax compliance and explore the underlying reasons why individuals in Pakistan might hesitate to become a part of the Active Taxpayer List (ATL) within the framework of business law and taxation. With a multidisciplinary approach, our team of five researchers embarked on an in-depth exploration of tax evasion behaviors and the factors influencing them. Through qualitative analysis, we aimed to unravel the complex interplay of socio-economic, cultural, and institutional factors shaping tax compliance attitudes among Pakistani taxpayers. Drawing on a diverse range of qualitative research methods, including interviews, focus groups, and content analysis, we gathered rich insights from a diverse sample of individuals representing various sectors of the economy. By immersing ourselves in the lived experiences and perceptions of taxpayers, tax advisors, and legal experts, we uncovered nuanced perspectives on tax evasion practices and attitudes toward ATL membership. Our findings highlight the multifaceted nature of tax evasion in Pakistan, shedding light on both the motivations driving non-compliance and the barriers to ATL enrollment. From perceived inefficiencies in the tax system to cultural norms and trust deficits in governmental institutions, our research identifies a myriad of factors contributing to tax evasion behavior and reluctance to join ATL. Furthermore, our study offers valuable implications for policymakers, tax authorities, and business stakeholders seeking to enhance tax compliance and foster a culture of transparency and accountability in Pakistan's taxation landscape. By addressing the underlying drivers of tax evasion and promoting the benefits of ATL membership, policymakers can design more effective strategies to broaden the tax base and promote sustainable economic development. In conclusion, our research paper represents a comprehensive endeavor to deepen our understanding of tax compliance dynamics in Pakistan and elucidate the complexities surrounding ATL enrollment. By unraveling the intricacies of tax evasion behaviors and attitudes, we hope to contribute to informed policymaking and foster a culture of tax compliance and integrity in Pakistan's business and taxation environment.

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