Structuring Physician-Pharmacy Ventures

Presenting a live 90-minute webinar with interactive Q&A

Structuring Physician-Pharmacy Ventures: Minimizing Regulatory Risks, Ensuring Reimbursement Navigating Corporate Practice of Medicine/Pharmacy, Anti-Kickback and Stark Laws, and State Regulation

WEDNESDAY, MAY 3, 2017 1pm Eastern | 12pm Central | 11am Mountain | 10am Pacific

Today’s faculty features:

Reesa N. Handelsman, Partner, Wachler & Associates, Royal Oak, Mich.

Rick L. Hindmand, Member, McDonald Hopkins, Chicago

Todd A. Nova, Shareholder, Hall Render Killian Heath & Lyman, Milwaukee

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Reesa Handelsman Rick Hindmand Todd Nova Wachler & Associates, P.C. McDonald Hopkins LLC Hall Render [email protected] [email protected] [email protected] 248.544.0888 312.642.2203 414.721.0464

Agenda

• Overview - Drivers of Increased Pharmacy Integration Chatter • State Law, AMA • Stark & Anti-Kickback • Risk Profile • Institutional Considerations • Pharmacy Management Agreements

5 Integration Drivers – Payment Systems

• Current: PPS Model • Effective October 1983. • Today includes - Acute Care I/P (DRG); Outpatient (APC); FQHC (Visit PPS) • Some limited exceptions - RHC; Hospice; CAH; etc. • Future: Value-Based Purchasing (VBP) and Bundled Payments • Per CMS, current payment systems reward quantity, rather than quality • What is VBP? • Reward quality of care through incentives and transparency • Link payment more directly to the quality of care provided • May 6, 2011 VBP Regulation: • “The overarching goal of these initiatives is to transform Medicare from a passive payer of claims to an active purchaser of quality health care for its beneficiaries.”

6 Integration Drivers – Reimbursement

Office-Based Professional Component

• Physician Fee Schedule (“PFS”) RVU (non-facility) drug administration CPT codes • PFS E&M CPT Code (non-facility) Drug cost

• Part B: ASP + 6% (was percentage of AWP) Hospital-Based Technical Component

• APC

Professional Component

• PFS E&M and/or procedure CPT Code (facility)

Drug cost

• PPS - Part B: • ASP + 6 % (if drug cost greater than drug packaging threshold of $100 for 2016) • Bundled into APC (if drug cost lower than drug packaging threshold of $100 for 2016) • Limited subset of drugs with “pass-through” status (separate payment regardless of price) • Status indicator G – roughly 40 in 2016 OPPS Final Rule

• CAH • 101% of reasonable costs Pharmacy • Part D ingredient cost plus dispensing fee (plan specific)

• Part B reimbursement not available for any drug usually self-administered

7 Issues Impacting Drug Cost and Reimbursement

Costs Revenues

• Care coordination • Part A Reforms • ACO/Shared Savings • Site Neutral • Bundled Payments • Bundled Payments • VBP • Therapeutic substitutions • Part B Reforms • System-wide P&T Committees • From ASP + 6% to? • VBP • Advanced Practice Clinicians • Pharmacists as providers? • PBM Consolidation • MAC Transparency • 340B • DIR Fees • Rural to Urban Reclass • Contract Terms

• Specialty Pharmacy Partnering & Development • Any willing provider laws • 340B Contract Pharmacy and Prescription Transfers • Patient Assistance Programs • Pricing Power via Provider Integration (Vertical and Horizontal) – GPO Considerations Other Factors • Price negotiations – Part D • Access

8 Integration Drivers –VBP… And Beyond

CMS: Better Care. Smarter Spending. Healthier People: Paying Providers for Value, Not Volume (January 26, 2015)

Consider – Role of pharmacy and other vertically integrated providers

Source: Centers for Medicare and Medicaid Services – January 26, 2015.

9 Integration Drivers –VBP… And Beyond

Source: Centers for Medicare and Medicaid Services – January 26, 2015.

10 Integration Drivers –VBP… And Beyond

• CMS Bundled Payments for Care Improvement (BPCI) Initiative • Organizations to enter into payment arrangements that include financial and performance accountability for episodes of care • 4 Models (Participants as of April 2016): • Model 1 (1): Episode of care focused on the acute care inpatient hospitalization. Awardees provide a standard discount to Medicare from the usual Part A hospital inpatient payments • Separate TC and PC, but gainsharing permitted • Model 2 (649): Starting at inpatient admission, episodic care payments for a 30-, 60- or 90-day period • Model 3 (862): Starting at post-acute admission, episodic care payments for a 30-, 60-or 90-day period • Model 4 (10): Prospective bundled payment arrangement • Lump sum payment made to a provider for the entire episode of care includes PC and TC

11 Integration Drivers –VBP… And Beyond

• In Models 2 and 3, bundle includes: physicians’ services, post-acute provider care, readmissions, and other related Part B services Including: • Clinical lab services; DMEPOS; and Part B drugs. • Part B Drugs include physician administered drugs. • CMS BPCI Initiative Models 2-4: Years 1 and 2 Annual Reports to CMS • 2015 • “…BPCI appears to have affected provider performance.” • “We observed statistically significant declines in SNF use and increases in HHA use…” • “Readmissions dropped more for BPCI Model 2 participants, although ED visits without a hospitalization increased…” • 2016 • “We remain limited in our ability to estimate the impact of the initiative under most Model and episode combinations because of insufficient sample size and the limited time the initiative has been underway.”

Integration Drivers –VBP… And Beyond

• December 20, 2016 Episode Payment Model Final Rule: • Heart attacks; • Coronary bypass surgery; or • Surgical treatment of hip or femur fractures • Episode begins with inpatient admission and extends to 90 days after the date of discharge. The Medicare is automatically included in the applicable EPM. • Proposed that related items and services for EPM episodes would include the following items and services paid under Parts A and B: • Services: Physicians; I/P hospital; I/P psychiatric facility; LTCH; IRF; SNF; HHA; Hospital outpatient ; Independent outpatient therapy ; Clinical laboratory; and Hospice • Items: DME; and Part B drugs • Start date for the EPMs has been delayed for an additional three months, from July 1, 2017 to October 1, 2017

13 Integration Drivers - Impact

• With shift to population health and cost reduction incentives, what are we to do? • Focus first on the clear quality and cost drivers through coordination (including pharmacy/specialty) • Highest cost patients are demonstrably concentrated

14 Integration Drivers – Drug Payment

• 2016 CMS Proposed Part B Drug Payment Rule (Withdrawn)

15 Integration Drivers – Practical Issues

• Consider: Role of physician, APC and pharmacist medication management in readmissions and HACs

• Collaborative Practice Arrangements

• Benefit has to be provided directly by Hospital or agent of hospital under hospital direction and control • Bedside delivery

• Self-administered drugs (generally Part D)

• Establishes refill relationship

16 Pharmacist Professional Practice

• Various states (e.g., WA, VA, WI) • Wis. Stat. 450.033 (2014)

• Incident-to billing for professional fees an option (in the office setting – not in the hospital setting) • Must meet direct supervision standards: “immediately available,” meaning at least in the office suite

17 PBM MAC Issues (Advocacy Opportunities)

I. MAC Transparency Act (H. R. 244)(Introduced 1/9/2015): A. Would codify above (exists only in regulatory form now) and extend it to Tricare and Federal Employee Health Benefits Program B. Would amend Part D to require that PDP sponsor contracts obligate the PDP sponsor to include the following provision in PDP/PBM contracts: 1. “The PBM may not require that a plan enrollee use a pharmacy in which the PBM has an ownership interest or provide an incentive to an enrollee to encourage the use of such a pharmacy.” II. Since unlikely to be passed, carefully review your PBM agreements. PBM MAC Issues (Advocacy Opportunities)

MAC Transparency – State Laws I. State Laws: A. 2015

1. Approximately 17 states have laws governing PBM MAC application

2. Wisconsin and Illinois not among them B. 2016

1. Approximately 31 states have PBM MAC laws

2. Wisconsin - effective July 1, 2016

3. Illinois - Introduced February 2016; Re-referred to Rules Committee in April 2016 Integration Drivers – Pharmacy-Specific

• Risk Evaluation & Mitigation Strategies (REMS)/Limited Distribution • Competing interests for REMS manufacturers: • Difficult for small (physician) pharmacies to gain access to certain drugs • Technology and full-spectrum data access • Integrated EMRs • E-Prescribing • PDMP reporting • Shortages • Narrow payor networks • Disconnect between specialty pharmacy locations and regional payor networks • Less of an issue as more payors require national delivery scope • As clinically integrated networks (CINs) more frequently include payors, complexity increases. What if a specialty pharmacy with access to a limited distribution drug refuses to participate in a provider-sponsored plan? • State pharmacy society concerns regarding specialty consolidation

20 Integration Drivers - Impact

• Healthcare moving away from acute care toward: • Integrated post-acute, home health, primary/preventive and specialty pharmacy networks • BUT, vertically integrated networks are complex

• Without an integrated network: i) control over population health components of care (including pharmacy) is reduced; and ii) cost to subcontract for services included in the bundle are higher • Past focus: horizontal integration • Future focus: vertical integration

21 Integration Headwinds

• Medicare (and private payor) site neutral payments

• Physician desire for independence

• Physician practice inertia

22 Future Trends

• What are we seeing? • Physician practices shifting from infusion to retail/oral pharmacies • Providers and payors ramping up non-infusion pharmacy operations • Enhanced physician involvement in institutional pharmacy operations (management) • Increased mail order pharmacy operations • Challenges for smaller vertically integrated network acquisitions • Challenges for smaller physician practice (e.g., bundled payments, compliance) • What are you seeing?

23 State Medical & Pharmacy Practice Acts

• State variations • Written prescription • Disclosure • Registration • Supervision • Security • Temporary or emergency supply • Labelling & record-keeping • Dispensing device • Location restrictions

24 State Fee-splitting/Fraud & Abuse

• State variations • % of fees • Referrals • Anti-kickback

25 AMA Code of Medical Ethics

• Opinion 9.6.6 (previously 8.06) – prescribing and dispensing ― Prescribe based solely on medical considerations, patient need & reasonable expectations of effectiveness ― No payment or compensation from drug company for prescribing ― Dispensing must primarily benefit the patient

26 AMA Code of Medical Ethics (cont’d)

• Opinion 9.6.9 (previously 8.0321) – Physician self-referral ― Generally, physicians should not refer if: ― Financial interest ― outside the office ― physician doesn’t provide care ― Based on objective and medically relevant criteria ― Appropriate & high quality ― Steps to mitigate conflicts of interest ― Informed consent

27 Stark overview

• 42 U.S.C. § 1395nn • Generally prohibits a physician from making a referral to an entity in which he or she (or an immediate family member) has a financial relationship for a designated health service (DHS) unless the arrangement is covered by a statutory or regulatory exception. • Stark’s 3 main concepts as applied to physician-owned pharmacies: ― DHS: includes outpatient prescription drugs ― Referral: satisfied if physicians will prescribe outpatient prescription drugs payable under Medicare or Medicaid to the Practice’s patients ― Financial interest: satisfied if either a direct or indirect (i) ownership or investment interest or (ii) compensation arrangement exists

28 In-Office Ancillary Services (IOAS) Exception to Stark

• 42 CFR 411.355(b) • Applies to both ownership and investment interests and compensation arrangements • Available to a single physician or a physician group that meets the definition of “group practice” under Stark • With regard to DME, is limited and only applies to infusion pumps, canes, crutches, walkers, folding manual wheelchairs and blood glucose monitors that meet certain requirements • Carves out from Stark’s prohibition on physician referrals for outpatient prescription drugs that meet requirements relating to: ― The performance and supervision of services ― The location of services ― The billing of services

29 IOAS Exception – Performance & Supervision of Services

• Pharmacist must be supervised by the referring physician or another physician in the group practice, provided that the supervision complies with all other applicable Medicare payment and coverage rules for the services.

• What level of supervision is then required to meet the IOAS exception?

• General supervision? ― Service furnished under physician’s overall direction and control ― No physical presence requirement ― Training requirement ― Maintenance of equipment and supplies

30 IOAS Exception – Location of Services

• The pharmacy services must be furnished in either ― A “centralized building” used by a group practice for the provision of some of all of the group practice’s DHS; or ― Exclusive use by group practice on a full-time basis ― A group practice may have more than one centralized building ― Is this available for a wholly-owned subsidiary pharmacy of a group practice? ― The “same building” in which one of three tests, involving certain availability, practice and other requirements, is met. ― Shared street address ― Excludes exterior spaces ― Does not mandate exclusive use of space

31 IOAS Exception – Billing of Services

• Pharmacy services must be billed by one of the following: ― The physician supervising the service ― The group practice if the supervising physician is a member of the group practice or a “physician in the group practice” (as defined under Stark) under a billing number assigned to the group practice ― An entity that is wholly owned by the supervising physician or by that physician’s group practice under the entity’s own billing number or under a billing number assigned to the physician or group practice ― An independent third party billing company acting as an agent of the physician, group practice, or entity specified above under a billing number assigned to the physician, group practice, or entity, provided that the billing arrangement meets certain legal requirements

32 Additional Stark Exceptions for Wholly-Owned Subsidiary Pharmacies

• Rental of Office Space Exception (42 CFR 411.357(a))  if referring physician or group practice owns/leases space to the pharmacy ― Set out in writing, signed by the parties, specifies the premises ― Duration of at least one year ― Space is exclusively used by lessee when used by lessee and does not exceed that which is reasonable and necessary for the legitimate business purposes of the arrangement ― Commercially reasonable even in absence of referrals ― Rent is set in advance, consistent with FMV and not determined: ― In manner taking into account volume/value of referrals or business generated, or ― Formula based on % revenue or per-unit of service rental charges (for services provided to patients referred by lessor to lessee) ― Complies with specified holdover-related provisions

Additional Stark Exceptions

• Personal Service Arrangements Exception (42 CFR 411.357(d)) ― Arrangement in writing, signed by the parties, specifies the services ― Covers all services to be furnished by the physician to the pharmacy ― Services are reasonable and necessary for legitimate business purposes ― Duration of at least one year ― Compensation set in advance, does not exceed FMV and is not determined in a manner that takes into account the volume or value of any referrals or other business generated ― Does not involve counseling or promotion of business arrangement or activity that violates state or federal law ― Complies with specified holdover-related provisions

34 Additional Stark Exceptions

• Bona Fide Employment Relationships Exception (42 CFR 411.357(c)) ― Employment is for identifiable services ― Compensation is consistent with FMV of services and, except for productivity bonus based on personally performed services, is not determined in a manner that takes into account (directly or indirectly) the volume or value of any referrals by the referring physician ― Compensation is commercially reasonable even if no referrals were made to the employer

35 Federal Anti-Kickback Statute (AKS) Overview

• 42 U.S.C. § 1320a-7b(b) • Prohibits a person or entity from knowingly and willfully offering, paying, soliciting or receiving remuneration, directly or indirectly, overtly or covertly, in cash or in kind, to induce or reward the: ― Referral of an individual for the furnishing of any item or service that may be reimbursed under a federal health care program, or ― The purchase, lease, ordering or arranging for or recommending the purchasing, leasing or ordering of any item, facility or service that may be reimbursed under a federal health care program. • Remuneration includes the transfer of anything of value, directly or indirectly, overtly or covertly, in cash or in kind.

36 AKS Overview (cont’d)

• Intent-based criminal statute ― Statutory exceptions and regulatory safe harbor protection requires strict compliance with terms ― Failure to comply with an exception or safe harbor does not mean an arrangement is per se illegal  facts and circumstances analysis • Covers arrangements where “one purpose” of the remuneration was to induce referrals • Violation is a felony punishable by a maximum fine of $25,000, imprisonment up to five years, or both. • OIG may impose civil monetary penalties and exclude parties from federal health care programs

37 AKS: If Practice Directly Owns the Pharmacy

• Investments in group practices safe harbor (42 CFR 1001.952(p)) • Protects return on investments made to practitioners investing in their own solo or group practices if: ― Equity interests in the practice/group are held by licensed health care professionals who practice in the practice/group ― Equity interests are in the practice/group itself, and not a subdivision of the practice/group ― If a group practice: (a) must meet definition of “group practice” definition under Stark, and (b) be a unified business with centralized decision-making, pooling of expenses and revenues, and a compensation/profit distribution system that is not based on satellite offices operating substantially as if they were separate enterprises or profit centers ― Revenues from ancillary services, if any, must be derived from “in-office ancillary services” (as defined under Stark)

38 AKS: If Practice Directly Owns the Pharmacy

• Employees safe harbor (and statutory exception) applies to referring physicians who are employees of the group practice • 42 CFR 1001.952(i) • Remuneration does not include any payment made by an employer to an employee, who has a bona fide employment relationship with the employer, for employment in the furnishing of any item or service for which payment may be made in whole or in part under Medicare, Medicaid or other Federal health care programs. • Employee has the same meaning as it does for the purposes of 26 U.S.C. 3121(d)(2) (Internal Revenue Code)

39 AKS: If Practice Directly Owns the Pharmacy

• Personal services and management contracts safe harbor applies to referring physicians who are independent contractors of the group practice • 42 CFR 1001.952(d) • In general, must meet the personal service arrangements Stark exception requirements in addition to the following requirements: ― If part-time services, agreement must specify the exact schedule of such intervals, their precise length, and the exact rent for such intervals; and ― The aggregate compensation must be set in advance and the aggregate services contracted for must not exceed those which are reasonably necessary to accomplish the commercially reasonable business purpose of the services.

40 AKS: If Wholly-Owned Subsidiary of Practice Owns Pharmacy

• Investments in group practices safe harbor (42 CFR 1001.952(p)) ― Protects return on investments in solo or group practices (that meet group practice definition under Stark) ― Only protects equity interests in the group/practice itself and not subdivisions of the practice/group ― Compliance with IOAS as evidence of intent • Small Entities Investment Interests Safe Harbor (42 CFR 1001.952(a)) ― Unavailable for arrangements that comply with the IOAS exception to Stark • Compliance with IOAS exception as evidence of intent under AKS

41 AKS: If Wholly-Owned Subsidiary of Practice Owns Pharmacy

• Personal Services and Management Contracts Safe Harbor (42 CFR 1001.952(d)) – discussed above ― e.g., physician supervision services & other physician remuneration relationships between practice physicians and the pharmacy • Space rental safe harbor (42 CFR 1001.952(b)) ― If referring physician or group practice owns/leases space rented to pharmacy ― In general, must meet the rental of office space Stark exception requirements in addition to the following requirements: ― Lease must cover all of the premises leased during the term; ― Aggregate rental charge is set in advance; and ― If part-time lease, must specify the exact schedule of such intervals, their precise length, and the exact rent for such intervals

42 Jointly-Owned Pharmacy

• Joint ownership by multiple physicians (not in the same group practice) or by multiple group practices, or a combination of both • Stark: Will not comply with IOAS exception • AKS: May comply with small entity investment interests safe harbor ― Likely problematic requirements (of the 8 safe harbor requirements): ― No more than 40% of the value of investment interests in the pharmacy be held by investors who are in a position to make or influence referrals, furnish items or services, or otherwise generate business for the pharmacy ― No more than 40% of the pharmacy’s gross revenue may come from referrals or business otherwise generated by investors ― The terms on which the investment interest is offered to a passive investor (i.e., an investor not responsible for the day-to-day management of the pharmacy) who is in a position to make or influence referrals, furnish items or services to, or otherwise generate business for the pharmacy be no different from the terms offered to other passive investors • State laws may prohibit this type of arrangement for non-Medicare/Medicaid arrangements

43 Payer Considerations

• Role of pharmacy benefit manager (PBM) ― Medicare Part D ― Payer plans ― Credentialing - network • Payer/PBM contract • Policies and procedures • Formulary • Limits on compounded drugs

44 Payer Considerations (cont’d)

• Medicare Part B ― Administered by a physician or other health care professional ― Incident to ― Direct supervision

45 Expanded Risk Profile

• Audits • Regulatory scrutiny • Expanded responsibilities • Controlled substances – DEA/state, security, registration, employee screening, records, reporting obligations, disposal • Compounded drugs • Sales records • Second-guessing • Sunshine laws

46 Pharmacy Startup Considerations (Institutional and Group Practice)

Strategic Considerations I. Payor Leverage A. Traditional Payor Consolidation (vertical and horizontal) B. Formulary management C. Headwinds: 1. Patient Steerage Case: Trone et al. v Express Scripts, E.D. Missouri (filed August 1, 2016). II. Provider Leverage/Efficiencies A. Traditional Provider Consolidation (vertical and horizontal) 1. Purchasing Power (GPO) 2. Reimbursement Leverage a. Higher rates or request revised formularies B. Care Coordination 1. Pharmacists as Providers – Anticoagulation Clinics 2. VBP 3. Shared Savings

Pharmacy Startup Considerations (Institutional and Group Practice)

Operational Considerations

• With various coordinated/bundled care initiatives coming online, should a provider start their own? • Considerations: • REMS/limited distribution drugs • How to reach critical mass (chicken or the egg) • Payor contracting challenges • Some third-party payors already have their own vertically integrated specialty pharmacy operations • Legal Structure (separate entity, for-profit, non-profit) • Unrelated business income tracking and reporting • Scope of patient base – include non-patients? • Own use considerations • Licensure • Mail order, out of state, etc. • Accreditation as prerequisite • Regulatory Compliance (enrollment, billing/payment, USP)

48 Pharmacy Startup Considerations (Institutional and Group Practice)

Operational Considerations (cont.) I. MAC Transparency A. State laws B. Kmart v. Catamaran (Voluntarily Dismissed) 1. $38 million claim: failure to disclose WAC values where required 2. Violation of prompt pay laws 3. Breach of contract a. Failure to pay agreed upon rates b. Failure to honor “most favored customer” provisions C. PBM design - forced patient switching II. Pending DIR Fee Federal Legislation A. Retro DIR Fee Prohibition III. 340B Program Omnibus A. Proposed Rule withdrawn

Pharmacy Startup Considerations (Institutional and Group Practice)

Hospital System Affiliation Approaches/Considerations

– DHS includes “outpatient prescription drugs.” • “Outpatient Prescription Drugs” includes those payable by Part B and Part D

– Joint ventures between hospitals and physicians where the physicians refer to the JV pharmacy not feasible

– In the provider-based setting, referrals to physician-owned pharmacies must consider Stark IOASE standard • Includes 340B Contract Pharmacy arrangements with physician-owned pharmacies

– Physician dispensing/delivery in the institutional setting

Large Physician Practices as Quasi-Institutional Entities

– Consider multi-state, multi-entity group practice considerations • Central Fill pharmacies

50 Pharmacy Management – AKS Considerations

• AKS prohibits a person or entity from knowingly and willfully offering, paying, soliciting or receiving remuneration, directly or indirectly, overtly or covertly, in cash or in kind, to induce or reward the: ― Referral of an individual for the furnishing of any item or service that may be reimbursed under a federal health care program, or ― Referral includes marketing services, etc. ― The purchase, lease, ordering or arranging for or recommending the purchasing, leasing or ordering of any item, facility or service that may be reimbursed under a federal health care program

51 Pharmacy Management – AKS Safe Harbors

• Personal Services and Management Contracts Safe Harbor: ― Affects compensation structure, etc. • Equipment Rental Safe Harbor (42 CFR 1001.952(c)): ― Set out in writing and signed by the parties; ― Lease covers all equipment leased during the term; ― If part-time lease, specifies exact schdule, interval length and rent; ― Term of at least one year; ― Aggregate rental charge is set in advance, consistent with FMV in an arms- length transaction, and not determined in a manner that takes into account the volume/value of referrals or other bsuiness generated between parties; & ― Equipment rented does not exceed what is reasonably necessary to accomplish commercially reasonable business purpose of lease.

52 Pharmacy Management – AKS Safe Harbors (cont’d)

• Discount Safe Harbor (42 CFR 1001.952(h)) ― Is manager an ”offeror” of a discount? ― Safe harbor conditions: ― Offeror must inform the entity submitting the claim or request for payment in a manner reasonably calculated to give notice to the entity of its obligations to report such a discount and to provide information upon request to the Secretary of the Department of Health and Human Services or a state agency; and ― The offeror must refrain from doing anything that would impede the buyer’s or seller’s ability to meet their obligations under the discount safe harbor.

53 Pharmacy Management – AKS Contractual Joint Venture Risks

• OIG Special Advisory Bulletin of 2003 • Focuses on arrangements where health care provider in one line of business expands into a related healthcare business by contracting with an existing provider of a related item/service to provide the new item/service to the provider’s existing patient population • Suspect indicia of a “questionable” contractual joint venture arrangement: ― New line of business ― Captive referral base ― Little or No Bona Fide Business Risk ― Status of manager as would-be competitor ― Scope of services provided by manager ― Remuneration ― Exclusivity

54 Pharmacy Management – Key Contractual Terms for the Management Company

• Duration and Termination • Staffing and Non-solicitation • Management fee structure • Non-compete • Confidentiality

55 Management Agreement – Key Contractual Terms and Considerations for the Physicians

• Pharmacy management company • Physician concerns ― Due diligence ― Compliance ― Professional judgment and control/corporate practice of medicine ― Fee-splitting ― Marketing and contracting activities ― Flexibility/termination ― Modification for changes in law/reimbursement