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Thinking of the selling products in your office? Here's what you need to know before taking the plunge.

Review ethics guidelines when selling products

If your business slows, you might consider giving free consults. Find out why this might not be the best idea.

Use caution when offering free consults

Think you don't need to read your contracts? Think again.

Reviewing provider contracts is worth the effort

Management Service Organizations (also referred to as an MSO or MSOs), remain a popular approach to structuring health care relationships and transactions. Although easy to organize and operate, there are many legal and compliance issues of which to be aware in order to assure a long-term and successful undertaking. This article will explore how and why MSOs are used in health care and some of the specific challenges in the current health care legal environment.

What is an MSO and what is its role in health care?

An MSO is a third-party entity that provides a variety of non-clinical services to health care providers. These services can include practice management, revenue cycle management, human resources, compliance, IT support, marketing, billing, collections, compliance, payor contract negotiation, vendor contract negotiation, payroll, payment of taxes, and more. Some MSOs also provide infrastructure, such as practice space, surgical suites, and equipment.Essentially, MSOs act as business partners, enabling health care facilities to outsource administrative burdens and optimize their resources.

For physician practices, an effective MSO can play an important role in implementing quality improvement programs, enhancing patient satisfaction, and maximizing efficient administration by offering industry insight, consulting and related guidance. Additionally, byoutsourcing non-clinical functions, health care providers can arguably reduce overhead costs associated with maintaining in-house departments and allocate more time and resources to patient care, improving overall health care quality and patient outcomes.

Many practices seem to thrive when using an effective MSO, with streamlined operations and improved efficiency. From a compliance perspective, MSOs can also be an excellent way for a practice to stay current, and ensure ongoing compliance, with a variety of significant legal concerns, such as the Health Insurance and Portability Act (

 (AKS), Physician Self-Referral (Stark) Law , billing and coding compliance, contractual relationships, state licensing laws, and Medicare and Medicaid reimbursement rules. Many MSOs also help practices structure and run effective fraud and abuse compliance programs that they otherwise would not be able to support on their own. Addressing these legal challenges requires MSOs to have a comprehensive understanding of health care laws and regulations, engage legal counsel with expertise in health care law, and implement robust compliance measures to mitigate legal risks effectively. At a time when many independent providers are overwhelmed with administrative, legal, and other burdens of operating a health care business, MSOs can often be the solution for practices that feel challenged to remain independent.

What is the Role of the MSO in health care transactions?

In many states, clinical practices can only be owned by licensed health care practitioners.This is based on the corporate practice of medicine (CPOM) doctrine. Generally, the CPOM doctrine is intended to prevent unlicensed people from involving themselves in key decision-making of a clinical practice in a manner that would impact patient care. In some states this doctrine is codified, while in others it has been developed through case law or administrative decisions.

To avoid the CPOM doctrine in applicable states, MSOs do not directly own the clinical practice, and instead enter into long term management agreements with a practice. Through these agreements, the MSOs manage and provide all non-clinical needs of the practice. In return for its management services, MSOs are paid a significant management fee, with MSO profits ultimately distributed to the MSO owners. With the wide array of services and items being provided by the MSO, the management fee typically draws out all revenue of the practice, other than clinical provider compensation.

The MSO approach is also the structure used in most physician practice sales to private equity (PE) entities. In the typical model, the PE buyer acquires all of the non-clinical assets of the practice (furniture, equipment, space and equipment leases, etc.) and hires all of the non-clinical staff providing services to the practice through the MSO. The management agreement between the MSO and the “acquired” practice will then provide and control nearly all of the operational needs and services of the practice. The only function of the practice at that point is the clinical care of patients and the payment of management fees to the MSO for handling all other non-clinical aspects of the practice.

Most MSOs are careful to comply with CPOM by taking steps to assure that only physicians make decisions impacting clinical care and operations. Often this is done through the creation of physician-led advisory boards that retain the power to control clinical-related decisions, as well as having all licensed health care providers directly employed by the practice and not the MSO.However, many decisions controlled by the MSO can still impact clinical operations, such as non-clinical staffing levels, scheduling, choice of equipment and supplies and similar matters. For this reason, there are still many who argue that this approach has allowed MSOs to become a vehicle for unlicensed persons to become overly involved in the day-to-day operation of health care practices, which ultimately influences physician decision-making and impacts patient care. This very issue is the subject of a lawsuit against Envision Healthcare, which is facing a challenge from the American Academy of Emergency Medicine. The AAEM has accused Envision of violating CPOM. The accusation is based on the assertion that establishing medical protocols, setting staffing levels, establishing patient encounter quotas, and determining physician best practices and quality metrics constitutes a level of control in violation of CPOM. This case has not yet been decided but is a good example of the type of risk that may be faced by MSOs that do not take the time to carefully construct their roles in a manner that does not pose legal risk of violating the CPOM.

From a compliance perspective, parties must be cognizant of many other laws that can impact arrangements between MSOs and health care practices. This includes the federal Stark Law and AKS, as well as the state equivalent of such laws, which can impact the structure and amount of management fees that can be charged. Additionally, other state laws, including fee-splitting restrictions, can impact the management arrangement and fees between an MSO and a practice.All of these laws must be reviewed with regulatory healthcare counsel.

What are the recent challenges for MSOs involved in health care transactions?

Due to increasing concerns about the role that non-clinical parties are playing in the health care industry, many states have started to scrutinize health care transactions by requiring advance state approval. The new laws involving health care practices are intended to capture transactions that are too small to trigger federal antitrust filings under the Hart-Scott-Rodino Antitrust Improvements Act of 1976, which mandates reporting of significant transactions to the Federal Trade Commission and the U.S. Department of Justice Antitrust Division. States with these laws now have the opportunity to evaluate the potential impact of certain health care transactions within their borders, but it is too soon to determine the ultimate impact of such laws. As of Jan. 1, 2024, the following states have reporting requirements for health care transactions: Connecticut, Illinois, Massachusetts, Minnesota, New York, Oregon, Rhode Island and Washington. In any type of MSO-related health care transaction, it will be key for participants to check with counsel to determine whether these state laws apply to a transaction and, if so, how to meet the filing requirements.

As the health care landscape continues to evolve, MSOs are expected to play an increasingly integral role. Advances in technology, such as telemedicine and AI-driven analytics, likely will shape MSO offerings, thereby enhancing efficiency and patient engagement. Furthermore, MSOs may facilitate collaborative care models and support population health management initiatives, driving better health outcomes on a broader scale and reducing healthcare.

MSOs are pivotal in supporting health care providers by handling administrative complexities, enhancing operational efficiency, and ensuring compliance with regulatory standards. While challenges exist, the benefits of partnering with MSOs far outweigh the risks, making them a cornerstone of modern health care management strategies. As the industry continues to innovate, MSOs undoubtedly will remain indispensable partners in delivering high-quality, patient-centered care.

Ericka L. Adler is a shareholder and manager of the Healthcare Practice Group at Roetzel & Andress in Chicago. She focuses her practice on regulatory and transactional health care law, in compliance counseling, structuring, and implementing complex joint ventures to comply with state and federal laws and regulations. She can be reached at 

Management Service Organizations (MSOs) are third-party entities that provide non-clinical services to healthcare providers, enabling them to focus on patient care while ensuring compliance with legal and regulatory standards. MSOs help healthcare practices navigate complex legal environments, such as the corporate practice of medicine (CPOM) doctrine, by managing non-clinical operations through long-term agreements. They also play a crucial role in healthcare transactions, especially in physician practice sales to private equity entities. Despite challenges, MSOs are expected to remain integral to healthcare management, driven by technological advancements and evolving industry needs.

The legal and compliance issues of Healthcare Management Service Organizations

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What practices need to know about MSOs

The shocking truth about immigrants in health care

The US health care system is facing a looming 

 in the next decade. Some professions are facing bigger shortages than others, but immigrants are playing a key role.

 found that immigrants may be playing a much larger role now than some realize. Here are the key findings:

The US healthcare system is projected to experience significant shortages of physicians and nurses over the next decade, with certain specialties more affected than others. Immigrants are increasingly crucial in addressing these workforce gaps. A study by Remitly highlights the substantial contribution of immigrants to the healthcare sector, suggesting their role is more significant than commonly perceived. This underscores the importance of immigration policies that support the integration of foreign-trained healthcare professionals to mitigate the impending workforce shortages and ensure the sustainability of healthcare services.

With massive shortages looming for both the number of physicians and nurses in the U.S. in the coming decades, immigrants are set to play a key role. 

In recent years, the demand for physicians in academic and hospital 

 roles has been on the rise. With an increasing number of retirements and a shrinking physician workforce, these critical positions are often filled by younger leaders who may not have extensive experience in bridging the gap between clinical practice and organizational leadership. As the health care landscape continues to evolve, the need for capable leaders who can navigate these changes has never been greater.

Embarking on a new career path requires more than just evaluating the job description. It involves understanding the deeper layers of 

, assessing the genuine need for the role and considering the impact a new role will have on your personal life.

We’ve seen a lot of positive movement to address some key issues leading to health care attrition and burnout. For example, there is stronger encouragement for work-life balance, more staff, mental health resources and overall better support systems for physicians. However, there is still work to do and some considerations at the onset of a career move.

I encourage physicians to look at these five areas before they consider a new role. It not only benefits them, but it helps the organization succeed and both are equally important.

One of the most crucial aspects of considering a new leadership role is evaluating the culture of the organization. This goes beyond the surface-level interactions and dives into the core values and behaviors of the team you will be working with. Do the people you’re interacting with show humility, preparation, respect, courtesy, and excellent organization? Positive culture indicators can be observed throughout your recruitment process, from initial interviews to more informal meetings with potential colleagues. A supportive and collaborative culture is essential for long-term success and job satisfaction.

Understanding why the organization is recruiting for this leadership role is paramount. Ask questions about the reasons for the recruitment and the history of the position. What strengths and accomplishments have been achieved, and what challenges or roadblocks have been encountered? This information will help you gauge the stability of the role. It’s also important to assess whether the organization's goals align with yours. A clear understanding of the position's viability can prevent potential disappointments and ensure that you are stepping into a role with realistic expectations.

Involve your significant other/appropriate family members early in the search process

A career change, especially one that involves a leadership position, is not just an individual decision—it’s a family decision. Relocation or increased responsibilities can significantly impact your family life. It’s crucial to involve your significant other and appropriate family members early in the process. Their support and understanding are vital as you navigate this significant change. Open communication about the potential impacts on your family’s lifestyle can help in making a well-informed decision that is beneficial for everyone involved.

Transparency is key when considering a new leadership role. If you have personal circumstances that could affect your job performance or have questions about the future of the department, it is essential to address these concerns early on. Voicing potential issues during the recruitment process ensures that you and the organization are on the same page and that your needs are considered. Your recruiter should be a resource in this process, ensuring all your questions are answered and helping to address any potential issues before they become problematic.

Embarking on a new leadership role shouldn’t be a solo experience. Having a trusted network of mentors can provide invaluable guidance and support. There are so many scenarios and challenges you’ll be presented with in a leadership position and chances are, there are retired or semi-retired experts who have already been there. There is a lot to learn from their successes and failures. By tapping into a network of leaders who are still passionate about improving health care, and nurturing upcoming leaders, you can gain invaluable insight and guidance. Mentorship can also provide a sense of community and belonging, which is crucial to avoiding burnout.

I work with so many physician leaders who inspire me every day. They’re focused on delivering life-changing care in their communities and have a passion for driving better health outcomes. We need these types of leaders driving research, clinical excellence and advancing care for all of us.

It’s important for the entire health care ecosystem that all career transitions are treated with great care. Culture, communication, personal needs and mentorship all play a critical role in a leader’s ability to achieve long-term professional and personal goals. As health care continues to face unprecedented challenges and opportunities, the importance of strong, thoughtful leadership cannot be overstated. By following these five principles, I believe physicians can navigate new leadership horizons and lead with confidence and purpose.

Marcel Barbey serves as Vice President of Search Services for

. With more than 20 years of experience, he is recognized nationally for his specialization and expertise in recruiting academic physicians and faculty leaders for complex medical schools, academic medical centers, academic children’s hospitals and integrated healthcare systems. Barbey earned a bachelor’s from the University of Alberta.

The demand for physicians in leadership roles is increasing due to retirements and a shrinking workforce. Aspiring leaders must evaluate workplace culture, role viability, and personal impacts before transitioning. Positive changes in healthcare, such as improved work-life balance and mental health resources, are encouraging, but challenges remain. Involving family, voicing concerns, and seeking mentorship are crucial steps in the decision-making process. Strong leadership is essential for navigating healthcare's evolving landscape, and thoughtful career transitions can help physicians achieve professional and personal success.

Embarking on a new career path requires more than just evaluating the job description.

Navigating new horizons: Five tips for physicians considering leadership opportunities 

The best time to make a career change to concierge medicine

When is the best time to make a change to concierge medicine? Three physicians reveal their personal turning points at very different stages in their career, and how to know when converting to a concierge model may be your next best move.

Family medicine remains the “north star” of American health care, said the new president of the Amercian Academy of Family Physicians.

Jen Brull, MD, FAAFP, has taken the helm as president of AAFP, representing 130,000 family physicians, residents, and medical students across the nation.

“Family medicine is the north star of our health care system, and the AAFP is the compass that guides family physicians as we care for our communities,” Brull said in a news release. “I am deeply honored to lead an organization so focused on helping today’s family physicians and mentoring future family doctors as we share our unwavering commitment to providing excellent primary care to our patients and communities.”

A 20-plus-year family physician, Brull practiced in rural Plainville, Kansas. She also served 12 years as health officer for the Rooks County, Kansas, Health Department.

Brull is now vice president of clinical engagement for Aledade, a company that partners with independent primary care physicians to succeed in value-based care.

“Dr. Jen Brull is a true servant leader,” Aledade CEO and co-founder Farzad Mostashari said in a news release announcing Brull’s presidency election in October 2023.

“Whether running her own practice or leading the largest primary care medical society in the nation, she has always focused on what is most important: bringing the highest quality care to patients and their families,” Mostashari said. “We have been so fortunate to call her a colleague and leader here at Aledade, and are thrilled for her and our nation’s primary care professionals as she takes on this new role.”

AAFP started in 1947 and remains the largest medical society devoted solely to primary care. Family physicians conduct an estimated one in five office visits, or 192 million visits a year, or 48% more than the next most visited medical specialty.

“I’m deeply honored to have been entrusted with this role by so many family medicine friends and colleagues,” Brull said in the news release. “I’ve always drawn inspiration from the saying, ‘ad astra per aspera’ – to the stars, through difficulty. To me, it’s a reminder that every journey presents challenges but, by staying focused on your guiding star, you can draw lessons through those difficult moments.

“My guiding star has always been, and will continue to be, bringing excellent primary care to patients all across the country,” she said. “I’m deeply grateful to have the chance to advance that mission in this new role.”

A member of the AAFP since 1995, Brull has served the Academy as chair of the Commission on Membership and Member Services and convener of the Working Group on Rural Health. She has served during the AAFP’s Congress of Delegates on the Reference Committees on Organization and Finance, and as the New Physician Constituency delegate to the AAFP Congress of Delegates. At the state level, Brull has served the Kansas Academy of Family Physicians in various leadership roles including president-elect, president and board chair.

AAFP said Brull has made a remarkable impact on health care throughout her career. She served two years as a Health Information Technology Fellow for the Office of the National Coordinator and was recognized as a Hypertension Control Challenge Champion by the Centers for Disease Control and Prevention in 2014. She was named as a Top 25 Innovator by Modern Healthcare in 2019 and is a physician leader in performance improvement and change management.

Brull is board certified by the American Board of Family Medicine. She earned her medical degree from the University of Kansas School of Medicine in Kansas City. She completed her residency program at the Family Medicine Residency Program of Topeka, where she served as chief resident.

Jen Brull, MD, FAAFP, has been appointed president of the American Academy of Family Physicians (AAFP), representing 130,000 family physicians, residents, and medical students. With over 20 years of experience, Brull has been a significant figure in family medicine, emphasizing the importance of primary care. She has held various leadership roles within AAFP and has been recognized for her contributions to healthcare, including her work in health information technology and hypertension control. Brull aims to continue advancing primary care excellence across the nation.

Jen Brull, MD, FAAFP, takes lead of American Academy of Family Physicians, largest medical society dedicated exclusively to primary care.

New AAFP president begins term at helm of 130,000 family physicians

Dr. Richard Hogan and his wife and practice manager Linda discuss the concierge practice

Married to medicine in concierge medice

Dr. Richard Hogan and his wife and practice manager Linda Hogan share how they built a successful concierge practice together and learned to navigate the ups and downs of being “married to medicine.”

Dr. Richard Hogan and his wife and practice manager Linda share how they built a successful concierge practice together and learned to navigate the ups and downs of being “married to medicine.”

Jennifer Kirschenbaum, JD

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