The American healthcare system is undergoing a complete transformation. IMG_1114As healthcare reform forces payors and providers to change how they deliver and pay for care, system participants face tremendous uncertainty. Because much money is at stake in this uncertain environment, the healthcare industry will encounter a spike in complex disputes that will besiege healthcare payors and providers as never before.

As hospital systems face payment reform, Medicare/Medicaid payment shortfalls, and financial risks associated with participating in accountable care organizations (ACOs) based on quality of care and outcomes, they must change their business models to survive.

As ACOs receive lump sum payments for episodes of care and try to reach agreement concerning who gets what amongst the participating primary care, specialists, hospitals, labs, imaging, hospice, nursing homes, pharma, etc., negotiations will be increasingly contentious.

Governance issues will proliferate (how will decisions be made and by whom?), and defining quality of care standards, which will be more subjective and more hotly contested than today’s fee for service models, will arise.

To meet these challenges, healthcare providers and payors need fast, confidential, expert, and less expensive solutions for dealing with disputes. And because most disputes eventually settle before trial, healthcare payors and providers must embrace the considerable advantages of alternative dispute resolution (ADR), over judge/jury trials.

Jim Purcell is an ADR professional who understands these complex, game changing issues and what they mean for the American healthcare industry. Jim’s professional experience gives him inside knowledge into the legal, financial, and community issues in healthcare disputes as well as the delicate balance required in payor and provider contracts when guiding parties through mediation, facilitation, or arbitration disputes.

As the former CEO of Blue Cross & Blue Shield of RI (BCBSRI), Rhode Island’s dominant health insurer, Jim was integrally involved in the negotiations, contracts, data, and the financing related to virtually every healthcare relationship in Rhode Island. This experience forged his deep understanding of the complexity, intensity, and nuances of such disputes.

Jim has an extensive background in facilitating contract negotiations with hospitals, physicians, laboratories, imaging companies, and pharma companies. Jim ‘brings peace to the room’ in difficult healthcare payment disputes, contract renewals, or extension negotiations, and has repeatedly helped disputing parties find common ground and reach acceptable resolutions.

As a former trial lawyer, Jim specializes in bringing healthcare and complex business disputes to conclusion through mediation and facilitation. He helps to bring parties to agreement and enjoy the following benefits:

  • Confidentiality. ADR assures no media attention, politics, frightened patients, or disclosure of confidential data. This is particularly important in payor/provider disputes where the same contract forms are often used with other payors and providers.
  • Subject Matter Expertise. When mediators and facilitators possess industry knowledge, outcomes are more predictable and outlier results less likely. Because attorneys select ADR professionals, it provides counsel and clients reassurance that the ADR practitioner knows the ropes and will not veer off on destructive tangents.
  • Neutrality. ADR assures an unbiased mediator/facilitator or arbitrator through conflict disclosure requirements and counsel’s ability to research practitioners’ backgrounds. And, unlike arbitration, a mediator/facilitator does not decide cases, nor can he or she compel a party to settle.

Read Jim’s article in Industry Week