Starks' Law, Corporate Safe-harbor in Contradiction of Impartiality to Physician Decree

Originally published at on November 4, 2019.

Bribery and its formalized version; the kickback practice under the current definition is undoubtedly among the most unethical live out ever been committed by humankind. It will probably stay that way for generations to come. Besides, its legality will be the subject of controversies between those who condemn its rationale in one way or another. In the impartial and organized ecosphere, the deed of giving or receiving no matter what of value in exchange for some form of impact or exploit is unreservedly unethical. In the majority of the circumstances, it is also deemed illicit. Yet, criminality is somehow subject to significant variance from one society to another. The bribery, along with its formally conveyed foil- the kickback or warrant has invariably applied to give, offering, or soliciting any service or item in exchange for something prized, such as monetary compensation. Black’s Law Dictionary defines bribery as “The public to influence the actions of an official or another person responsible for a public or legal duty.” Like other defining points in the modern vocabulary, kickback and bribery also carry their peculiar legitimized versions of interpretations.

Despite mixed sentiments of the public opinion, some arrangements are defined as perceptually legal, where others are punishable to the extreme. Some actions may be unarguably legit yet painstakingly unethical enough to be outlined as illegal at the other end of the spectrum. Such intended maleficence fall potentially under an assortment of delineations, including but not limited to Annates, Anti-competitive practices, Baksheesh, Bid rigging, Charbonneau Commission, Conflict of interest, Fraud, Kickbacks, Tangentopoli. Very nearly in every circumstance, the extortionate has, in one way or another, been able to vindicate their actions, with the foremost variance that some have the power to with authorization sway those defining facts; In contrast, others with the lower hands may well miss the mark despite having a benevolent objective.

The processes of Legitimizing the immoral, legalizing the unscrupulous, and illegalizing the right are the ways to delineate veracious from corrupt hypocritically. It’s imperative to realize back in history, not every accomplishment on some financial favoritism to gain lead has been perpetually reflected as an illegal activity and to the same magnitude, and by no means has righteousness been without the unjustified label associated with an act of bribery at all times. For an action to be reflected fraudulent under the front of Subornation, two or more persons (two but third intermediaries or kickback brokers) must partake. As a direct upshot of their action, the recipient of the enticement or the beneficiary must receive something of value sovereign of the overhaul provided. Almost every single industry has its stake of bad apples that entertain some form of fraudulent sweeteners. Similarly, the healthcare industry is not immune to such practices.

The Concept of Anti-kickback and Stark Law

The Federal Anti-Kickback Statute (AKS) is a well-known federal fraud and abuse bill in the United States. It’s Down to the wide-ranging conflict of interest corruption has on business relationships in the patient care, pharmaceutical, and medical device sectors. The AKS is a criminal edict that prohibits contacts envisioned to encourage or reward referrals for items or services reimbursed under federal healthcare programs. The Stark Law (“Stark”) is another comparable legislative action by a federal government that prohibits self-referral of patients by treating physicians those of certain services reimbursable by Medicare or Medicaid. Such amenities are also denoted as designated health services (“DHS”) by entities that the physicians or their immediate family members have a fiscal rapport with. In short, three main concepts of Stark’s ban on physician self-referral include- physician referral, DHS, and financial interest. Theoretically, all three ideas must be implicated for Stark to apply to a given circumstance. Thus, Stark is also known as a strict liability law. It means that the party intending to violate the law is not considered lawfully accountable until the government determines whether a violation has occurred. As a result, understanding whether Stark is drawn in an arrangement involving a physician is essential. Stark law is a technical degree, as it applies differently to diverse fact arrays.

Healthcare vs. other Industries

Bribery in medicine is exponentially critical when paralleled to other industries. Merely because of its covenants with the issues of human life, trust between the patient and the doctor, and the sacred bond solely built to protect the most critical asset of a person called health. Well-being is valuable, and the quality upholding such value is profoundly sustained by the individual values entertained by the two parties. Thus, the Act of subornation is a destructive element of norms and the importance of care. Even so,- does it mean all the rules that directly or indirectly prohibit the business part of medical practice are necessary to stop a few bad apples from giving a wrong label to the whole stock?! To delineate intentional fraudulent extortion from innocent referral to a physician's system with a financial interest in are two different spectacles. Even so, the consequences of the widespread application of Stark’s law are overwhelming; one may disagree with my later assumption based on the presumption that “the parties who intend to violate the law are not considered unlawful while the government defines whether a violation has occurred.” Yet, Despite licit reasoning, such a gray zone in the system would spare the privilege of innocence at limbo. The upshot of the stark law enforcement in the government's eyes, as who should be punished is the prevailing cause of barring referral altogether by physicians.

Stark Law and Value-based Reimbursement

Anti-kickback and the Starks law can be applied conveniently to any fee-for-service reimbursement system. Later holds a fixed value with less variability. In contrast, value-based reimbursement is more composite, as it relies primarily on engaging individual patients unswervingly with their care and incorporates personal and social determinants of health and sickness. Hence, Merit-based compensation within the existing law’s perspective forbids referral to facilities that may have better transparency to the referring physician or self-referral will open new doors for conflict of interest, imposing an added burden on independent physician healthcare professionals.

How does Value Play in Starks's Law?

We all need to concur that value is the measure of the quality of any service conveyed, which in turn is converted into a tangible item or thing to be traded for another thing or service with poles apart proportions. We can also all agree that for an action to be considered kickback or bribery, a person or an entity must be a financier of a valuable item and another recipient of the reimbursement. If something of value is a form of monetary compensation, it would be imperative to differentiate win over typical marketing and recommendation. Most of us agree that what makes marketing and promotion different is the legal statute of physician referral, DHS, and financial interest surrounding the Medicare and Medicaid programs. Meaning that- even if there were no direct 3rd party reward that existed during the referral process, still crime would be considered to have been committed in the eyes of the law. Hence, when we contemplate a valuable reward, such value is merely referred to as the repayment for the services rendered. Having said that, if referral of a patient to a facility that physician has an economic interest in was intended solely for delivering quality care, still by law would be reckoned criminal. That setup and scenarios alike are in apparent conflict with the concept of value-based reimbursement unless that price established is the imitation plagiaristic of some theoretical formulation. The Concept of Quality Measures in Healthcare hosts the good, the bad, and the ugliness that would be handed sorted out through transparency and accountability. It ultimately derives from the unique encounter between a patient and a physician.

Self-Referral and Physician’s Clinical Judgment

Self-referral in the medical field stereotypically defines the referral of a patient to a medical facility by a doctor who has a financial actuation within that establishment. The American medical association (AMA) is one of the organizations that reached out to lawmakers to pass a conflict-of-interest law preventing doctors from profiting from the route of referring patients to such facilities, even if there was no more reward anticipated by anyone other than the actual value of services rendered. At a short glimpse, the intention may seem to be impartial. But, such a broad-based approach has outright destabilized the integrity of those physicians who have nothing but legitimate objectives. Self-referral for the unsubstantiated indication is wrong; nevertheless, there is no arguable reason to hold someone accountable for an unbiased professional-quality service provided by a medical group with a common financial interest. After all, the legitimacy and transparency of the intent matters than the actual action, more so if the patient is aware of what to anticipate.

Designed Health Services and Stark’s Law

Designated Health Services (DHS) including Clinical laboratory services, Physical therapy, occupational therapy, and outpatient speech-language pathology services, Radiology and certain other imaging services, Radiation therapy services, supplies, Durable medical equipment, medical supplies, Parenteral and enteral nutrients, equipment, Prosthetics, orthotics, and prosthetic devices, Home-health services, Outpatient prescription drugs, Inpatient and outpatient hospital services are considered among those covered u