Announcement of Public Workshop, “Examining Health Care Competition”, 5533-5537 [2015-01856]
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Federal Register / Vol. 80, No. 21 / Monday, February 2, 2015 / Notices
persons may express their views in
writing on the standards enumerated in
the BHC Act (12 U.S.C. 1842(c)). If the
proposal also involves the acquisition of
a nonbanking company, the review also
includes whether the acquisition of the
nonbanking company complies with the
standards in section 4 of the BHC Act
(12 U.S.C. 1843). Unless otherwise
noted, nonbanking activities will be
conducted throughout the United States.
Unless otherwise noted, comments
regarding each of these applications
must be received at the Reserve Bank
indicated or the offices of the Board of
Governors not later than February 26,
2015.
A. Federal Reserve Bank of Dallas (E.
Ann Worthy, Vice President) 2200
North Pearl Street, Dallas, Texas 75201–
2272:
1. Guaranty Bancshares, Inc., Mount
Pleasant, Texas; to acquire 100 percent
of the voting shares of DCB Financial
Corp., and thereby indirectly acquire
voting shares of Preston State Bank,
both in Dallas, Texas.
Board of Governors of the Federal Reserve
System, January 28, 2015.
Michael J. Lewandowski,
Associate Secretary of the Board.
[FR Doc. 2015–01902 Filed 1–30–15; 8:45 am]
received at the Reserve Bank indicated
or the offices of the Board of Governors
not later than February 26, 2015.
A. Federal Reserve Bank of Richmond
(Adam M. Drimer, Assistant Vice
President) 701 East Byrd Street,
Richmond, Virginia 23261–4528:
1. Live Oak Bancshares, Inc.,
Wilmington, North Carolina; to acquire
100 percent of the voting shares
Independence Trust Company, Franklin,
Tennessee, a limited purpose savings
association, through the merger of its
parent company, Independence Holding
Corporation, Franklin, Tennessee, and
thereby engage in operating a savings
association, and providing trust
company and financial advisory
services, pursuant to sections
225.28(b)(4)(ii), (b)(5), and (b)(6)(ii),
respectively.
Board of Governors of the Federal Reserve
System, January 28, 2015.
Michael J. Lewandowski,
Associate Secretary of the Board.
[FR Doc. 2015–01903 Filed 1–30–15; 8:45 am]
BILLING CODE 6210–01–P
FEDERAL TRADE COMMISSION
Announcement of Public Workshop,
‘‘Examining Health Care Competition’’
BILLING CODE 6210–01–P
Federal Trade Commission.
Notice of public workshop and
opportunity for comment.
AGENCY:
ACTION:
Notice of Proposals To Engage in or
To Acquire Companies Engaged in
Permissible Nonbanking Activities
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FEDERAL RESERVE SYSTEM
SUMMARY:
The companies listed in this notice
have given notice under section 4 of the
Bank Holding Company Act (12 U.S.C.
1843) (BHC Act) and Regulation Y, (12
CFR part 225) to engage de novo, or to
acquire or control voting securities or
assets of a company, including the
companies listed below, that engages
either directly or through a subsidiary or
other company, in a nonbanking activity
that is listed in § 225.28 of Regulation Y
(12 CFR 225.28) or that the Board has
determined by Order to be closely
related to banking and permissible for
bank holding companies. Unless
otherwise noted, these activities will be
conducted throughout the United States.
Each notice is available for inspection
at the Federal Reserve Bank indicated.
The notice also will be available for
inspection at the offices of the Board of
Governors. Interested persons may
express their views in writing on the
question whether the proposal complies
with the standards of section 4 of the
BHC Act.
Unless otherwise noted, comments
regarding the applications must be
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The Federal Trade
Commission (‘‘FTC’’ or ‘‘Commission’’)
will hold a second public workshop on
February 24–25, 2015, as part of the
workshop series, ‘‘Examining Health
Care Competition,’’ 1 to study recent
developments related to health care
provider organization and payment
models that may affect competition and
consumer protection in the provision of
health care services. The workshop will
be co-hosted by the Department of
Justice, Antitrust Division (‘‘DOJ’’).
Specific topics for discussion may
include: early observations regarding
accountable care organizations;
alternatives to traditional fee-for-service
payment models; trends in provider
consolidation; trends in provider
network and benefit design strategies, as
well as contracting practices and
regulatory activity that may enhance or
undermine these strategies; and early
1 The first workshop in the Examining Health
Care Competition series was held on March 20–21,
2014, and examined issues concerning occupational
regulation, interstate licensure and telehealth,
health information technology, and price and
quality transparency. See https://www.ftc.gov/newsevents/events-calendar/2014/03/examining-healthcare-competition.
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observations regarding health insurance
exchanges. This notice invites public
comments on a series of topics. The FTC
and DOJ (the ‘‘Agencies’’) will consider
these comments as they prepare for the
workshop and may use them in
subsequent reports or policy papers, if
any. For additional information, visit
the workshop Web site at https://www.
ftc.gov/news-events/events-calendar/
2015/02/examining-health-carecompetition or https://www.justice.gov/
atr/public/workshops/healthcare/2015/
02/.
DATES: The workshop will be held on
February 24–25, 2015, in the
Auditorium of the Constitution Center
at 400 7th Street SW., Washington, DC
20024. To be considered for the
workshop, comments in response to this
notice should be submitted by February
16, 2015. In addition, any interested
person may submit written comments in
response to this notice and workshop
discussions until April 30, 2015. Prior
to the workshop, the Agencies will
publish an agenda and additional
information on their Web sites.
ADDRESSES: Interested parties may file a
comment for this workshop at https://
ftcpublic.commentworks.com/ftc/exam
healthcareworkshop online or on paper,
by following the instructions in the
Request for Comment part of the
SUPPLEMENTARY INFORMATION section
below. Write ‘‘Health Care Workshop,
Project No. P131207,’’ on your
comment, and file your comment online
at https://ftcpublic.commentworks.com/
ftc/examhealthcareworkshop by
following the instructions on the webbased form. If you prefer to file your
comment on paper, write ‘‘Health Care
Workshop, Project No. P131207,’’ on
your comment, and on the envelope,
and mail your comment to the following
address: Federal Trade Commission,
Office of the Secretary, 600
Pennsylvania Avenue NW., Suite CC–
5610 (Annex X), Washington, DC 20580,
or deliver your comment to the
following address: Federal Trade
Commission, Office of the Secretary,
Constitution Center, 400 7th Street SW.,
5th Floor, Suite 5610 (Annex X),
Washington, DC 20024.
FOR FURTHER INFORMATION CONTACT:
Stephanie Wilkinson, Attorney Advisor,
Office of Policy Planning, Federal Trade
Commission, 600 Pennsylvania Avenue
NW., Washington, DC 20580, 202–326–
2084, examininghealthcareworkshop@
ftc.gov. For more detailed information
about the workshop, including an
agenda, please visit the workshop Web
site: https://www.ftc.gov/news-events/
events-calendar/2015/02/examininghealth-care-competition or https://www.
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justice.gov/atr/public/workshops/
healthcare/2015/02/.
SUPPLEMENTARY INFORMATION: The
Federal Trade Commission and U.S.
Department of Justice seek to better
understand the competitive dynamics
and effects of evolving health care
provider and payment models. In recent
years, changes in the way that health
care services and products are delivered
and reimbursed have been occurring in
response to diverse market trends,
including pressure to reduce costs and
improve quality in the health care
industry. The Patient Protection and
Affordable Care Act (‘‘ACA’’) may have
accelerated many of these changes.
Providers are increasingly seeking ways
to improve the coordination of health
care services to patients. Meanwhile,
payers are seeking ways to incentivize
providers to practice more efficient,
outcomes-based medicine and to avoid
the overutilization of services and
products. This workshop and comment
process are expected to identify and
examine strategies currently used by
providers and payers seeking to reduce
costs and improve quality, with a
particular emphasis on the strategies’
potential implications for competition
and consumer protection. Information
obtained during this workshop and
through comments will enrich the
Agencies’ knowledge in this critical
sector of the economy and thereby
support their enforcement, advocacy,
and consumer education efforts.
This Notice invites comments on a
number of topics, including:
• The kinds of changes occurring
with respect to health care provider
organization and payment models;
• the economic, quality enhancing,
technological, regulatory, and legislative
factors that may be influencing such
changes; and
• additional empirical research that
would be helpful in evaluating these
topics.
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The Agencies are particularly interested
in receiving comments on the specific
topics discussed below, and this Notice
includes questions as examples of the
types of information that are likely to be
helpful. Commenters should feel neither
compelled to answer each question nor
constrained by the questions listed.
1. Early Observations of Accountable
Care Organizations
Accountable care organizations
(‘‘ACOs’’) are networks formed by
physicians, hospitals, and other health
care providers to coordinate patient
care. Although the term ACO is used to
describe a wide range of provider
collaboration, ACO members typically
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share clinical and financial
responsibilities for designated patient
populations, and are held accountable
for the quality, appropriateness, and
efficiency of the health care services
they provide. ACOs can be structured to
serve commercial patient populations,
Medicare or Medicaid patient
populations, or a combination of patient
populations.
Some health policy experts and
economists have raised concerns that
ACOs might increase the ability of
providers to obtain and exercise market
power. For example, providers
participating in ACOs may be able to
exercise market power through
collective negotiations with payers.
Furthermore, in preparing to form
ACOs, some providers argue that they
need to consolidate through merger,
claiming that increased scale and
resources will better position them to
achieve positive results as an ACO.
However, this may lead to more
concentrated provider markets.
In 2011, the FTC and DOJ issued a
joint statement regarding the antitrust
enforcement policy that would be
applied to ACOs participating in the
Medicare Shared Savings Program.2
Since that time, the Agencies have
continued to monitor developments
within the Medicare ACO programs, not
only to enhance their understanding of
these programs, but also to assess how
they may impact the formation and
operation of ACOs in commercial
markets. For example, some health
policy experts have observed that the
Medicare ACO programs may encourage
the development of ACOs that operate
in commercial markets. Also, some have
warned about the potential for costshifting from Medicare ACOs to
commercial ACOs, which could result
in higher prices for commercial patients.
Comments regarding early
observations of ACOs might address the
following types of questions:
• How are ACOs defined, and what
are some of the challenges associated
with clearly defining an ACO?
• How do ACOs operate? Are ACOs
an effective mechanism for aligning the
clinical and financial incentives of
providers, payers, and patients?
• What strategies do ACOs use when
trying to achieve the goals of reducing
costs, improving quality, and increasing
patient satisfaction?
• What are some similarities and
differences between ACOs and patient2 See FTC–DOJ Statement of Antitrust
Enforcement Policy Regarding Accountable Care
Organizations Participating in the Medicare Shared
Savings Program, 60 FR 67,026 (Oct. 28, 2011),
available at https://www.gpo.gov/fdsys/pkg/FR-201110-28/pdf/2011-27944.pdf.
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centered medical homes? Are there
potential benefits to using these
provider models in combination with
each other?
• What preliminary observations can
be made regarding the success or failure
of ACOs that operate in Medicare,
Medicaid, or commercial markets?
Æ Is there any evidence of
efficiencies, cost savings, or quality
improvements?
• What preliminary observations can
be made regarding the competitive
impact of ACOs, particularly in
commercial markets?
Æ Is there any evidence of cost
reductions or quality improvements as a
result of increased competition among
providers participating in ACOs?
Æ What spill-over effects, if any, have
been observed between Medicare and
commercial ACOs, both positive and
negative?
Æ Is there any evidence to suggest that
ACO formation has been a mechanism
for competing or non-competing
providers to achieve and exercise
market power?
• What impact, if any, has ACO
formation had on patient referral
patterns?
• Has the FTC–DOJ joint policy
statement provided helpful guidance to
market participants?
2. Alternatives to Traditional Fee-forService Payment Models
Traditional fee-for-service payment
models reimburse health care providers
for services rendered. Some have argued
that traditional fee-for-service payment
models have contributed to the high
cost of health care in the United States
because these models may create
incentives to maximize the volume of
health care services provided. In recent
years, various health policy experts,
providers, and payers have emphasized
the importance of shifting away from
traditional fee-for-service payment
models toward alternative payment
models that seek to use performance
indicators and patient outcomes to
reward higher quality and more efficient
use of medical services.
Comments regarding alternatives to
traditional fee-for-service payment
models might address the following
types of questions:
• What are the alternatives to
traditional fee-for-service payment
models, including either reforms to feefor-service (e.g., maintaining a fee-forservice model and adding bonus
incentives for achieving certain cost
and/or quality benchmarks) or replacing
fee-for-service with some type of
prospective payment approach (e.g.,
global payment, bundled payment,
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partial capitation)? How are these terms
defined?
Æ Who bears the financial risk in each
model?
Æ How are prices established in each
model? Is competition a significant
factor in establishing prices for these
models?
• How does the use of alternative
payment models affect the incentives of
payers, providers, and patients? How
does this differ from the incentives
created by traditional fee-for-service
payment models?
• What are the challenges of
transitioning from traditional fee-forservice to an alternative payment
model?
• What are the economic, quality,
legal, or regulatory factors influencing
this shift away from traditional fee-forservice reimbursement?
• What impact, if any, do alternative
reimbursement methods have on
efficient forms of provider organization?
• Is there a relationship between the
size and scale of a provider organization
and its capacity to bear financial risk?
What size and scale is sufficient for a
provider organization to participate in
existing or future risk-bearing programs?
• What are the competitive
implications of this shift away from
traditional fee-for-service
reimbursement?
• Is there any evidence that
alternative payment models increase
competition among providers?
• Is there any evidence that
alternative payment models improve
coordination and quality of care or
reduce costs?
• Is there any evidence of alternative
payment models leading to restrictions
on the availability of, or patient use of,
essential health care services?
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3. Trends in Provider Consolidation
Over the last two decades, there has
been significant consolidation among
health care providers, particularly
among hospitals. Some economists and
health policy experts point to this
consolidation as a contributor to the rise
in health care costs in the United States.
The Agencies have a long history of
analyzing this consolidation and
bringing enforcement actions against
specific mergers and acquisitions when
they believe an antitrust violation has
occurred. Since the passage of the ACA,
some providers have argued that further
consolidation is necessary to achieve
quality improvements and cost
reductions through more efficient health
care delivery systems. The Agencies
have long observed that in many cases
providers may achieve these benefits
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through various forms of collaboration
rather than consolidation.
Comments regarding trends in
provider consolidation might address
the following types of questions:
a. Hospital-Physician Practice
Consolidation
• What economic, quality, legal, or
regulatory factors may be influencing
consolidation between hospitals and
physician practices?
• What factors should be considered
when analyzing the competitive effects
of mergers of complementary service
providers?
• What evidence exists regarding the
competitive effects of these
arrangements, both positive and
negative?
• What does evidence show regarding
physician service fees and facility
charges following the acquisition of
physician practices by hospitals?
• Is there any evidence that merged
hospital systems and physician
practices have more bargaining power
than they would have independently,
thereby allowing them to negotiate
higher reimbursement rates or otherwise
increase prices?
• What does evidence demonstrate
about the quality of health care services
following the acquisition of physician
practices by hospitals?
• Is there any evidence demonstrating
that common ownership (e.g., hospitals
employing physicians or acquiring
physician practices) produces better
quality or cost outcomes than other
forms of collaboration (e.g., physicians
of different specialties forming
organizations that are not owned by
hospitals, or virtual networks of
physicians)?
b. ‘‘Cross-Market’’ Hospital Mergers
• Is there theory or evidence that
mergers between hospitals that operate
in different geographic or service
markets may increase the combined
entity’s ability to negotiate higher
reimbursement rates with health plans?
• If such mergers can lead to
anticompetitive effects, what kinds of
evidence and economic analysis would
help to identify such effects?
• If traditional antitrust analysis of
relevant product and geographic
markets does not adequately identify
anticompetitive harm in these
situations, what other factors, if any,
may help identify such harm?
c. Provider-Payer Consolidation
• What are the recent trends and
some examples of providers and payers
that have consolidated, or otherwise
partnered, to offer integrated health care
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services and insurance plans to
consumers?
• What are the competitive
implications of such consolidation in
both payer and provider markets?
Æ Does this type of consolidation
increase the incentives for exclusionary
conduct or otherwise facilitate the
exercise of market power? If so, under
what circumstances?
Æ Does this type of consolidation
affect incentives to coordinate and
improve the quality of health care, as
well as reduce costs?
Æ Does this type of consolidation
increase competition in health
insurance markets, by allowing
providers to compete with payers?
4. Provider Network and Benefit Design
There are many ways for health plans
to design provider networks and
benefits packages for consumers, which
range from individuals purchasing
health insurance to large national
employers contracting for health
insurance coverage for their employees.
Recent developments include strategies
that limit the number of providers in a
network. Certain contracting practices
or regulatory activity may potentially
enhance or undermine the use of these
strategies to spur competition among
providers and reduce health care costs.
Comments regarding provider
network and benefit design might
address the following types of
questions:
• What types of provider network and
benefit design strategies have been
implemented recently or are under
consideration?
• What are the competitive effects of
network design strategies that limit the
number of providers in a network (e.g.,
narrow networks, tiered networks,
reference pricing, etc.)?
Æ Can these strategies lead to cost
reductions or improved coordination
and quality of care?
Æ Are there circumstances under
which they might create or facilitate the
exercise of market power, or otherwise
be anticompetitive?
• What is the relationship between
market structure and network and
benefit design?
Æ Is robust provider competition a
predicate for successful implementation
of any of these designs?
Æ Does concentration in health
insurance markets impact provider
network and benefit design strategies?
Æ To what extent might some network
and benefit designs enhance
competition, even when provider or
payer markets are highly concentrated?
• What types of provider-payer
contracting practices may limit the
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implementation of these types of
network design strategies (e.g., antitiering/anti-steering provisions, gag
clauses, all-or-nothing contracting, and
most-favored nation provisions)?
Æ How prevalent are these contracting
practices and which parties seek to
include them?
Æ What are the procompetitive
rationales for adopting these provisions,
and what are their potential
anticompetitive effects?
Æ To what extent might these
practices affect incentives for
innovation in health plan pricing
models?
• What types of regulatory or
legislative interventions may enhance or
undermine innovative network and
benefit design strategies (e.g., essential
benefits and network adequacy
requirements, any willing provider
legislation, price transparency
legislation, or prohibitions on certain
provider-payer contracting practices)?
5. Early Observations of Health
Insurance Exchanges
Most Americans receive health
insurance through their employers. As a
result of the ACA, individuals without
employer-sponsored coverage can now
purchase health insurance on public
exchanges. Small group employers also
can utilize public exchanges to make
coverage available to their employees. In
addition to public exchanges, private
exchanges created by private sector
companies, such as health insurance
companies or consulting firms, also are
emerging.
Comments regarding early
observations of health insurance
exchanges might address the following
types of questions:
• How many and what types of plans
are being offered on the exchanges?
• Who is buying on the exchanges
and what types of plans are they
choosing?
Æ Have actuarial values and other
information created greater transparency
and helped consumers make meaningful
decisions about the health plans that
they purchase?
Æ What does evidence demonstrate
about the use of narrow provider
networks in the exchange plan
offerings?
• How do the state-based exchanges
differ from the federally facilitated
exchanges?
• How have the exchanges and
related regulatory developments
impacted competition in health
insurance markets?
Æ Have the exchanges had any impact
on the pricing of health insurance
plans?
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Æ Has there been entry or exit from
the individual health insurance
market as a result of the exchanges?
Æ Have incumbent health insurers
offered new types of products or
lowered their prices in response to
competition from the exchanges?
Æ What has been the competitive
impact of the multistate plans and
cooperatives?
Æ Have there been any discernible
changes to concentration levels in
health insurance markets since the
exchanges were introduced?
Æ Have requirements like minimum
benefits, medical loss ratios, and
guaranteed issue affected
competition among health insurers?
• How do the exchanges impact
antitrust enforcement?
Æ Is there potential for
anticompetitive practices that may
undermine competition on the
exchanges?
• What are the recent trends in health
insurance markets (e.g., increased use of
private exchanges, increasing selfinsurance by employers, employers
migrating employees to public or private
exchanges, increased small-employer
coverage)?
You can file a comment online or on
paper. To be considered for the
workshop, comments in response to this
notice should be submitted by February
16, 2015. In addition, any interested
person may submit written comments in
response to this notice and workshop
discussions until April 30, 2015.
Comments should refer to ‘‘Health Care
Workshop, Project No. P131207.’’
Comments filed in electronic form
should be submitted using the following
web link: https://ftcpublic.comment
works.com/ftc/examhealthcare
workshop and by following the
instructions on the web-based form. If
this notice appears at https://
www.regulations.gov, you may also file
an electronic comment through that
Web site. The Agencies will consider all
comments that regulations.gov forwards
to them.
A comment filed in paper form
should include the ‘‘Health Care
Workshop, Project No. P131207’’
reference both in the text and on the
envelope, and should be mailed to the
following address: Federal Trade
Commission, Office of the Secretary,
600 Pennsylvania Avenue NW., Suite
CC–5610 (Annex X), Washington, DC
20580, or delivered to the following
address: Federal Trade Commission,
Office of the Secretary, 400 7th Street
SW., 5th Floor, Suite 5610 (Annex X),
Washington, DC 20024. If possible,
submit your paper comment to the
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Commission by courier or overnight
service.
Please note that your comment—
including your name and state—will be
placed on the public record of this
proceeding, including on the publicly
accessible FTC and DOJ Web sites, at
https://www.ftc.gov/os/public
comments.shtm and https://www.justice.
gov/atr/public/workshops/healthcare/
2015/02/. As a matter of
discretion, the Commission tries to
remove individuals’ home contact
information from comments before
placing them on the Commission’s Web
site.
Because comments will be made
public, you are solely responsible for
making sure that your comment does
not include any sensitive personal
information, such as an individual’s
Social Security Number; date of birth;
driver’s license number or other state
identification number, or foreign
country equivalent; passport number;
financial account number; or credit or
debit card number. You are also solely
responsible for making sure that your
comment does not include any sensitive
health information, such as medical
records or other individually
identifiable health information. In
addition, comments should not include
‘‘trade secret or any commercial or
financial information which . . . is
privileged or confidential,’’ as discussed
in Section 6(f) of the Federal Trade
Commission Act (‘‘FTC Act’’), 15 U.S.C.
46(f), and FTC Rule 4.10(a)(2), 16 CFR
4.10(a)(2). In particular, do not include
competitively sensitive information
such as costs, sales statistics,
inventories, formulas, patterns, devices,
manufacturing processes, or customer
names.
Comments containing material for
which confidential treatment is
requested must be filed in paper form,
must be clearly labeled ‘‘Confidential,’’
and must comply with FTC Rule 4.9(c),
16 CFR 4.9(c). For any copyrighted
material, please provide authorization
(signed by the publisher or author if
they retain the copyright) so that the
material may be republished on the
Agencies’ Web sites.
The FTC Act and other laws that the
Commission administers permit the
collection of public comments to
consider and use in this proceeding as
appropriate. The Commission will
consider all timely and responsive
public comments that it receives,
whether filed in paper or electronic
form. More information, including
routine uses permitted by the Privacy
Act, may be found in the FTC’s privacy
policy, available at https://www.ftc.gov/
ftc/privacy.htm.
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By direction of the Commission.
Donald S. Clark,
Secretary.
[FR Doc. 2015–01856 Filed 1–27–15; 8:45 am]
BILLING CODE 6750–01–P
DEPARTMENT OF HEALTH AND
HUMAN SERVICES
Centers for Disease Control and
Prevention
Meeting of the Community Preventive
Services Task Force
Centers for Disease Control and
Prevention (CDC), Department of Health
and Human Services (HHS).
ACTION: Notice of meeting.
AGENCY:
The Centers for Disease
Control and Prevention (CDC)
announces the next meeting of the
Community Preventive Services Task
Force (Task Force). The Task Force is an
independent, nonpartisan, nonfederal,
and unpaid panel. Its members
represent a broad range of research,
practice, and policy expertise in
prevention, wellness, health promotion,
and public health, and are appointed by
the CDC Director. The Task Force was
convened in 1996 by the Department of
Health and Human Services (HHS) to
identify community preventive
programs, services, and policies that
increase healthy longevity, save lives
and dollars and improve Americans’
quality of life. CDC is mandated to
provide ongoing administrative,
research, and technical support for the
operations of the Task Force. During its
meetings, the Task Force considers the
findings of systematic reviews on
existing research and issues
recommendations. Task Force
recommendations provide information
about evidence-based options that
decision makers and stakeholders can
consider when determining what best
meets the specific needs, preferences,
available resources, and constraints of
their jurisdictions and constituents. The
Task Force’s recommendations, along
with the systematic reviews of the
scientific evidence on which they are
based, are compiled in The Guide to
Community Preventive Services
(Community Guide).
DATES: The meeting will be held on
Wednesday, February 25, 2015 from
8:30 a.m. to 6:00 p.m. EST and
Thursday, February 26, 2015 from 8:30
a.m. to 1:00 p.m. EST.
ADDRESSES: The Task Force Meeting
will be held at CDC Edward R. Roybal
Campus, Tom Harkin Global
Communications Center (Building 19),
mstockstill on DSK4VPTVN1PROD with NOTICES
SUMMARY:
VerDate Sep<11>2014
19:24 Jan 30, 2015
Jkt 235001
1600 Clifton Road NE., Atlanta, GA
30333. You should be aware that the
meeting location is in a Federal
government building; therefore, Federal
security measures are applicable. For
additional information, please see
Roybal Campus Security Guidelines
under SUPPLEMENTARY INFORMATION.
Information regarding meeting logistics
will be available on the Community
Guide Web site
(www.thecommunityguide.org).
Meeting Accessibility: This meeting is
open to the public, limited only by
space availability in the meeting
location. All meeting attendees must
RSVP to ensure the required security
procedures are completed to gain access
to the CDC’s Global Communications
Center.
U.S. citizens must RSVP by 2/15/
2015.
Non U.S. citizens must RSVP by 2/9/
2015 due to additional security steps
that must be completed.
In addition to in-person participation,
individuals may view presentations via
live video stream on the Internet. Those
interested in accessing the live stream
must also RSVP, and additional
information will be sent to registrants
requesting connectivity via the Internet
in advance of the meeting. Failure to
RSVP by the dates identified could
result in an inability to attend the Task
Force meeting due to the strict security
regulations on federal facilities.
For Further Information and to RSVP
Contact: Terica Scott, The Community
Guide Branch; Division of
Epidemiology, Analysis, and Library
Services; Center for Surveillance,
Epidemiology and Laboratory Services;
Office of Public Health Scientific
Services; Centers for Disease Control
and Prevention, 1600 Clifton Road, MS–
E–69, Atlanta, GA 30333, phone: (404)
498–6360, email: CPSTF@cdc.gov.
SUPPLEMENTARY INFORMATION:
Purpose: The purpose of the meeting
is for the Task Force to consider the
findings of systematic reviews and issue
findings and recommendations. Task
Force recommendations provide
information about evidence-based
options that decision makers and
stakeholders can consider when
determining what best meets the
specific needs, preferences, available
resources, and constraints of their
jurisdictions and constituents.
Matters To Be Discussed:
Vaccinations, Obesity, Cardiovascular
Disease, and Health Equity. Topics are
subject to change.
Roybal Campus Security Guidelines:
The Edward R. Roybal Campus is the
headquarters of the U.S. Centers for
PO 00000
Frm 00036
Fmt 4703
Sfmt 4703
5537
Disease Control and Prevention and is
located at 1600 Clifton Road NE.,
Atlanta, Georgia. The meeting is being
held in a Federal government building;
therefore, Federal security measures are
applicable.
All meeting attendees must RSVP by
the dates outlined under Meeting
Accessability. In planning your arrival
time, please take into account the need
to park and clear security. All visitors
must enter the Roybal Campus through
the entrance on Clifton Road. Your car
may be searched, and the guard force
will then direct visitors to the
designated parking area. Upon arrival at
the facility, visitors must present
government issued photo identification
(e.g., a valid federal identification
badge, state driver’s license, state nondriver’s identification card, or passport).
Non-United States citizens must
complete the required security
paperwork prior to the meeting date and
must present a valid passport, visa,
Permanent Resident Card, or other type
of work authorization document upon
arrival at the facility. All persons
entering the building must pass through
a metal detector. Visitors will be issued
a visitor’s ID badge at the entrance to
Building 19 and may be escorted to the
meeting room. All items brought to
HHS/CDC are subject to inspection.
Dated: January 27, 2015.
Ron A. Otten,
Acting Deputy Associate Director for Science,
Centers for Disease Control and Prevention.
[FR Doc. 2015–01875 Filed 1–30–15; 8:45 am]
BILLING CODE 4163–18–P
DEPARTMENT OF HEALTH AND
HUMAN SERVICES
Centers for Medicare & Medicaid
Services
[CMS–9088–N]
Medicare and Medicaid Programs;
Quarterly Listing of Program
Issuances—October Through
December 2014
Centers for Medicare &
Medicaid Services (CMS), HHS.
ACTION: Notice.
AGENCY:
This quarterly notice lists
CMS manual instructions, substantive
and interpretive regulations, and other
Federal Register notices that were
published from October through
December 2014, relating to the Medicare
and Medicaid programs and other
programs administered by CMS.
FOR FURTHER INFORMATION CONTACT: It is
possible that an interested party may
SUMMARY:
E:\FR\FM\02FEN1.SGM
02FEN1
]]>Agencies
[Federal Register Volume 80, Number 21 (Monday, February 2, 2015)]
[Notices]
[Pages 5533-5537]
From the Federal Register Online via the Government Printing Office [www.gpo.gov]
[FR Doc No: 2015-01856]
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FEDERAL TRADE COMMISSION
Announcement of Public Workshop, ``Examining Health Care
Competition''
AGENCY: Federal Trade Commission.
ACTION: Notice of public workshop and opportunity for comment.
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SUMMARY: The Federal Trade Commission (``FTC'' or ``Commission'') will
hold a second public workshop on February 24-25, 2015, as part of the
workshop series, ``Examining Health Care Competition,'' \1\ to study
recent developments related to health care provider organization and
payment models that may affect competition and consumer protection in
the provision of health care services. The workshop will be co-hosted
by the Department of Justice, Antitrust Division (``DOJ''). Specific
topics for discussion may include: early observations regarding
accountable care organizations; alternatives to traditional fee-for-
service payment models; trends in provider consolidation; trends in
provider network and benefit design strategies, as well as contracting
practices and regulatory activity that may enhance or undermine these
strategies; and early observations regarding health insurance
exchanges. This notice invites public comments on a series of topics.
The FTC and DOJ (the ``Agencies'') will consider these comments as they
prepare for the workshop and may use them in subsequent reports or
policy papers, if any. For additional information, visit the workshop
Web site at https://www.ftc.gov/news-events/events-calendar/2015/02/examining-health-care-competition or https://www.justice.gov/atr/public/workshops/healthcare/2015/02/.
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\1\ The first workshop in the Examining Health Care Competition
series was held on March 20-21, 2014, and examined issues concerning
occupational regulation, interstate licensure and telehealth, health
information technology, and price and quality transparency. See
https://www.ftc.gov/news-events/events-calendar/2014/03/examining-health-care-competition.
DATES: The workshop will be held on February 24-25, 2015, in the
Auditorium of the Constitution Center at 400 7th Street SW.,
Washington, DC 20024. To be considered for the workshop, comments in
response to this notice should be submitted by February 16, 2015. In
addition, any interested person may submit written comments in response
to this notice and workshop discussions until April 30, 2015. Prior to
the workshop, the Agencies will publish an agenda and additional
---------------------------------------------------------------------------
information on their Web sites.
ADDRESSES: Interested parties may file a comment for this workshop at
https://ftcpublic.commentworks.com/ftc/examhealthcareworkshop online or
on paper, by following the instructions in the Request for Comment part
of the SUPPLEMENTARY INFORMATION section below. Write ``Health Care
Workshop, Project No. P131207,'' on your comment, and file your comment
online at https://ftcpublic.commentworks.com/ftc/examhealthcareworkshop
by following the instructions on the web-based form. If you prefer to
file your comment on paper, write ``Health Care Workshop, Project No.
P131207,'' on your comment, and on the envelope, and mail your comment
to the following address: Federal Trade Commission, Office of the
Secretary, 600 Pennsylvania Avenue NW., Suite CC-5610 (Annex X),
Washington, DC 20580, or deliver your comment to the following address:
Federal Trade Commission, Office of the Secretary, Constitution Center,
400 7th Street SW., 5th Floor, Suite 5610 (Annex X), Washington, DC
20024.
FOR FURTHER INFORMATION CONTACT: Stephanie Wilkinson, Attorney Advisor,
Office of Policy Planning, Federal Trade Commission, 600 Pennsylvania
Avenue NW., Washington, DC 20580, 202-326-2084,
examininghealthcareworkshop@ftc.gov. For more detailed information
about the workshop, including an agenda, please visit the workshop Web
site: https://www.ftc.gov/news-events/events-calendar/2015/02/examining-health-care-competition or https://www.
[[Page 5534]]
justice.gov/atr/public/workshops/healthcare/2015/02/.
SUPPLEMENTARY INFORMATION: The Federal Trade Commission and U.S.
Department of Justice seek to better understand the competitive
dynamics and effects of evolving health care provider and payment
models. In recent years, changes in the way that health care services
and products are delivered and reimbursed have been occurring in
response to diverse market trends, including pressure to reduce costs
and improve quality in the health care industry. The Patient Protection
and Affordable Care Act (``ACA'') may have accelerated many of these
changes. Providers are increasingly seeking ways to improve the
coordination of health care services to patients. Meanwhile, payers are
seeking ways to incentivize providers to practice more efficient,
outcomes-based medicine and to avoid the overutilization of services
and products. This workshop and comment process are expected to
identify and examine strategies currently used by providers and payers
seeking to reduce costs and improve quality, with a particular emphasis
on the strategies' potential implications for competition and consumer
protection. Information obtained during this workshop and through
comments will enrich the Agencies' knowledge in this critical sector of
the economy and thereby support their enforcement, advocacy, and
consumer education efforts.
This Notice invites comments on a number of topics, including:
The kinds of changes occurring with respect to health care
provider organization and payment models;
the economic, quality enhancing, technological,
regulatory, and legislative factors that may be influencing such
changes; and
additional empirical research that would be helpful in
evaluating these topics.
The Agencies are particularly interested in receiving comments on the
specific topics discussed below, and this Notice includes questions as
examples of the types of information that are likely to be helpful.
Commenters should feel neither compelled to answer each question nor
constrained by the questions listed.
1. Early Observations of Accountable Care Organizations
Accountable care organizations (``ACOs'') are networks formed by
physicians, hospitals, and other health care providers to coordinate
patient care. Although the term ACO is used to describe a wide range of
provider collaboration, ACO members typically share clinical and
financial responsibilities for designated patient populations, and are
held accountable for the quality, appropriateness, and efficiency of
the health care services they provide. ACOs can be structured to serve
commercial patient populations, Medicare or Medicaid patient
populations, or a combination of patient populations.
Some health policy experts and economists have raised concerns that
ACOs might increase the ability of providers to obtain and exercise
market power. For example, providers participating in ACOs may be able
to exercise market power through collective negotiations with payers.
Furthermore, in preparing to form ACOs, some providers argue that they
need to consolidate through merger, claiming that increased scale and
resources will better position them to achieve positive results as an
ACO. However, this may lead to more concentrated provider markets.
In 2011, the FTC and DOJ issued a joint statement regarding the
antitrust enforcement policy that would be applied to ACOs
participating in the Medicare Shared Savings Program.\2\ Since that
time, the Agencies have continued to monitor developments within the
Medicare ACO programs, not only to enhance their understanding of these
programs, but also to assess how they may impact the formation and
operation of ACOs in commercial markets. For example, some health
policy experts have observed that the Medicare ACO programs may
encourage the development of ACOs that operate in commercial markets.
Also, some have warned about the potential for cost-shifting from
Medicare ACOs to commercial ACOs, which could result in higher prices
for commercial patients.
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\2\ See FTC-DOJ Statement of Antitrust Enforcement Policy
Regarding Accountable Care Organizations Participating in the
Medicare Shared Savings Program, 60 FR 67,026 (Oct. 28, 2011),
available at https://www.gpo.gov/fdsys/pkg/FR-2011-10-28/pdf/2011-27944.pdf.
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Comments regarding early observations of ACOs might address the
following types of questions:
How are ACOs defined, and what are some of the challenges
associated with clearly defining an ACO?
How do ACOs operate? Are ACOs an effective mechanism for
aligning the clinical and financial incentives of providers, payers,
and patients?
What strategies do ACOs use when trying to achieve the
goals of reducing costs, improving quality, and increasing patient
satisfaction?
What are some similarities and differences between ACOs
and patient-centered medical homes? Are there potential benefits to
using these provider models in combination with each other?
What preliminary observations can be made regarding the
success or failure of ACOs that operate in Medicare, Medicaid, or
commercial markets?
[cir] Is there any evidence of efficiencies, cost savings, or
quality improvements?
What preliminary observations can be made regarding the
competitive impact of ACOs, particularly in commercial markets?
[cir] Is there any evidence of cost reductions or quality
improvements as a result of increased competition among providers
participating in ACOs?
[cir] What spill-over effects, if any, have been observed between
Medicare and commercial ACOs, both positive and negative?
[cir] Is there any evidence to suggest that ACO formation has been
a mechanism for competing or non-competing providers to achieve and
exercise market power?
What impact, if any, has ACO formation had on patient
referral patterns?
Has the FTC-DOJ joint policy statement provided helpful
guidance to market participants?
2. Alternatives to Traditional Fee-for-Service Payment Models
Traditional fee-for-service payment models reimburse health care
providers for services rendered. Some have argued that traditional fee-
for-service payment models have contributed to the high cost of health
care in the United States because these models may create incentives to
maximize the volume of health care services provided. In recent years,
various health policy experts, providers, and payers have emphasized
the importance of shifting away from traditional fee-for-service
payment models toward alternative payment models that seek to use
performance indicators and patient outcomes to reward higher quality
and more efficient use of medical services.
Comments regarding alternatives to traditional fee-for-service
payment models might address the following types of questions:
What are the alternatives to traditional fee-for-service
payment models, including either reforms to fee-for-service (e.g.,
maintaining a fee-for-service model and adding bonus incentives for
achieving certain cost and/or quality benchmarks) or replacing fee-for-
service with some type of prospective payment approach (e.g., global
payment, bundled payment,
[[Page 5535]]
partial capitation)? How are these terms defined?
[cir] Who bears the financial risk in each model?
[cir] How are prices established in each model? Is competition a
significant factor in establishing prices for these models?
How does the use of alternative payment models affect the
incentives of payers, providers, and patients? How does this differ
from the incentives created by traditional fee-for-service payment
models?
What are the challenges of transitioning from traditional
fee-for-service to an alternative payment model?
What are the economic, quality, legal, or regulatory
factors influencing this shift away from traditional fee-for-service
reimbursement?
What impact, if any, do alternative reimbursement methods
have on efficient forms of provider organization?
Is there a relationship between the size and scale of a
provider organization and its capacity to bear financial risk? What
size and scale is sufficient for a provider organization to participate
in existing or future risk-bearing programs?
What are the competitive implications of this shift away
from traditional fee-for-service reimbursement?
Is there any evidence that alternative payment models
increase competition among providers?
Is there any evidence that alternative payment models
improve coordination and quality of care or reduce costs?
Is there any evidence of alternative payment models
leading to restrictions on the availability of, or patient use of,
essential health care services?
3. Trends in Provider Consolidation
Over the last two decades, there has been significant consolidation
among health care providers, particularly among hospitals. Some
economists and health policy experts point to this consolidation as a
contributor to the rise in health care costs in the United States. The
Agencies have a long history of analyzing this consolidation and
bringing enforcement actions against specific mergers and acquisitions
when they believe an antitrust violation has occurred. Since the
passage of the ACA, some providers have argued that further
consolidation is necessary to achieve quality improvements and cost
reductions through more efficient health care delivery systems. The
Agencies have long observed that in many cases providers may achieve
these benefits through various forms of collaboration rather than
consolidation.
Comments regarding trends in provider consolidation might address
the following types of questions:
a. Hospital-Physician Practice Consolidation
What economic, quality, legal, or regulatory factors may
be influencing consolidation between hospitals and physician practices?
What factors should be considered when analyzing the
competitive effects of mergers of complementary service providers?
What evidence exists regarding the competitive effects of
these arrangements, both positive and negative?
What does evidence show regarding physician service fees
and facility charges following the acquisition of physician practices
by hospitals?
Is there any evidence that merged hospital systems and
physician practices have more bargaining power than they would have
independently, thereby allowing them to negotiate higher reimbursement
rates or otherwise increase prices?
What does evidence demonstrate about the quality of health
care services following the acquisition of physician practices by
hospitals?
Is there any evidence demonstrating that common ownership
(e.g., hospitals employing physicians or acquiring physician practices)
produces better quality or cost outcomes than other forms of
collaboration (e.g., physicians of different specialties forming
organizations that are not owned by hospitals, or virtual networks of
physicians)?
b. ``Cross-Market'' Hospital Mergers
Is there theory or evidence that mergers between hospitals
that operate in different geographic or service markets may increase
the combined entity's ability to negotiate higher reimbursement rates
with health plans?
If such mergers can lead to anticompetitive effects, what
kinds of evidence and economic analysis would help to identify such
effects?
If traditional antitrust analysis of relevant product and
geographic markets does not adequately identify anticompetitive harm in
these situations, what other factors, if any, may help identify such
harm?
c. Provider-Payer Consolidation
What are the recent trends and some examples of providers
and payers that have consolidated, or otherwise partnered, to offer
integrated health care services and insurance plans to consumers?
What are the competitive implications of such
consolidation in both payer and provider markets?
[cir] Does this type of consolidation increase the incentives for
exclusionary conduct or otherwise facilitate the exercise of market
power? If so, under what circumstances?
[cir] Does this type of consolidation affect incentives to
coordinate and improve the quality of health care, as well as reduce
costs?
[cir] Does this type of consolidation increase competition in
health insurance markets, by allowing providers to compete with payers?
4. Provider Network and Benefit Design
There are many ways for health plans to design provider networks
and benefits packages for consumers, which range from individuals
purchasing health insurance to large national employers contracting for
health insurance coverage for their employees. Recent developments
include strategies that limit the number of providers in a network.
Certain contracting practices or regulatory activity may potentially
enhance or undermine the use of these strategies to spur competition
among providers and reduce health care costs.
Comments regarding provider network and benefit design might
address the following types of questions:
What types of provider network and benefit design
strategies have been implemented recently or are under consideration?
What are the competitive effects of network design
strategies that limit the number of providers in a network (e.g.,
narrow networks, tiered networks, reference pricing, etc.)?
[cir] Can these strategies lead to cost reductions or improved
coordination and quality of care?
[cir] Are there circumstances under which they might create or
facilitate the exercise of market power, or otherwise be
anticompetitive?
What is the relationship between market structure and
network and benefit design?
[cir] Is robust provider competition a predicate for successful
implementation of any of these designs?
[cir] Does concentration in health insurance markets impact
provider network and benefit design strategies?
[cir] To what extent might some network and benefit designs enhance
competition, even when provider or payer markets are highly
concentrated?
What types of provider-payer contracting practices may
limit the
[[Page 5536]]
implementation of these types of network design strategies (e.g., anti-
tiering/anti-steering provisions, gag clauses, all-or-nothing
contracting, and most-favored nation provisions)?
[cir] How prevalent are these contracting practices and which
parties seek to include them?
[cir] What are the procompetitive rationales for adopting these
provisions, and what are their potential anticompetitive effects?
[cir] To what extent might these practices affect incentives for
innovation in health plan pricing models?
What types of regulatory or legislative interventions may
enhance or undermine innovative network and benefit design strategies
(e.g., essential benefits and network adequacy requirements, any
willing provider legislation, price transparency legislation, or
prohibitions on certain provider-payer contracting practices)?
5. Early Observations of Health Insurance Exchanges
Most Americans receive health insurance through their employers. As
a result of the ACA, individuals without employer-sponsored coverage
can now purchase health insurance on public exchanges. Small group
employers also can utilize public exchanges to make coverage available
to their employees. In addition to public exchanges, private exchanges
created by private sector companies, such as health insurance companies
or consulting firms, also are emerging.
Comments regarding early observations of health insurance exchanges
might address the following types of questions:
How many and what types of plans are being offered on the
exchanges?
Who is buying on the exchanges and what types of plans are
they choosing?
[cir] Have actuarial values and other information created greater
transparency and helped consumers make meaningful decisions about the
health plans that they purchase?
[cir] What does evidence demonstrate about the use of narrow
provider networks in the exchange plan offerings?
How do the state-based exchanges differ from the federally
facilitated exchanges?
How have the exchanges and related regulatory developments
impacted competition in health insurance markets?
[cir] Have the exchanges had any impact on the pricing of health
insurance plans?
[cir] Has there been entry or exit from the individual health
insurance market as a result of the exchanges?
[cir] Have incumbent health insurers offered new types of products
or lowered their prices in response to competition from the exchanges?
[cir] What has been the competitive impact of the multistate plans
and cooperatives?
[cir] Have there been any discernible changes to concentration
levels in health insurance markets since the exchanges were introduced?
[cir] Have requirements like minimum benefits, medical loss ratios,
and guaranteed issue affected competition among health insurers?
How do the exchanges impact antitrust enforcement?
[cir] Is there potential for anticompetitive practices that may
undermine competition on the exchanges?
What are the recent trends in health insurance markets
(e.g., increased use of private exchanges, increasing self-insurance by
employers, employers migrating employees to public or private
exchanges, increased small-employer coverage)?
You can file a comment online or on paper. To be considered for the
workshop, comments in response to this notice should be submitted by
February 16, 2015. In addition, any interested person may submit
written comments in response to this notice and workshop discussions
until April 30, 2015. Comments should refer to ``Health Care Workshop,
Project No. P131207.'' Comments filed in electronic form should be
submitted using the following web link: https://ftcpublic.commentworks.com/ftc/examhealthcareworkshop and by following
the instructions on the web-based form. If this notice appears at
https://www.regulations.gov, you may also file an electronic comment
through that Web site. The Agencies will consider all comments that
regulations.gov forwards to them.
A comment filed in paper form should include the ``Health Care
Workshop, Project No. P131207'' reference both in the text and on the
envelope, and should be mailed to the following address: Federal Trade
Commission, Office of the Secretary, 600 Pennsylvania Avenue NW., Suite
CC-5610 (Annex X), Washington, DC 20580, or delivered to the following
address: Federal Trade Commission, Office of the Secretary, 400 7th
Street SW., 5th Floor, Suite 5610 (Annex X), Washington, DC 20024. If
possible, submit your paper comment to the Commission by courier or
overnight service.
Please note that your comment--including your name and state--will
be placed on the public record of this proceeding, including on the
publicly accessible FTC and DOJ Web sites, at https://www.ftc.gov/os/publiccomments.shtm and https://www.justice.gov/atr/public/workshops/healthcare/2015/02/. As a matter of discretion, the
Commission tries to remove individuals' home contact information from
comments before placing them on the Commission's Web site.
Because comments will be made public, you are solely responsible
for making sure that your comment does not include any sensitive
personal information, such as an individual's Social Security Number;
date of birth; driver's license number or other state identification
number, or foreign country equivalent; passport number; financial
account number; or credit or debit card number. You are also solely
responsible for making sure that your comment does not include any
sensitive health information, such as medical records or other
individually identifiable health information. In addition, comments
should not include ``trade secret or any commercial or financial
information which . . . is privileged or confidential,'' as discussed
in Section 6(f) of the Federal Trade Commission Act (``FTC Act''), 15
U.S.C. 46(f), and FTC Rule 4.10(a)(2), 16 CFR 4.10(a)(2). In
particular, do not include competitively sensitive information such as
costs, sales statistics, inventories, formulas, patterns, devices,
manufacturing processes, or customer names.
Comments containing material for which confidential treatment is
requested must be filed in paper form, must be clearly labeled
``Confidential,'' and must comply with FTC Rule 4.9(c), 16 CFR 4.9(c).
For any copyrighted material, please provide authorization (signed by
the publisher or author if they retain the copyright) so that the
material may be republished on the Agencies' Web sites.
The FTC Act and other laws that the Commission administers permit
the collection of public comments to consider and use in this
proceeding as appropriate. The Commission will consider all timely and
responsive public comments that it receives, whether filed in paper or
electronic form. More information, including routine uses permitted by
the Privacy Act, may be found in the FTC's privacy policy, available at
https://www.ftc.gov/ftc/privacy.htm.
[[Page 5537]]
By direction of the Commission.
Donald S. Clark,
Secretary.
[FR Doc. 2015-01856 Filed 1-27-15; 8:45 am]
BILLING CODE 6750-01-P
