To achieve the objectives of improving quality and reducing the cost of health care, the health care industry continues to seek ways to align hospital interests more closely with physician interests through incentive compensation. The IRS generally believes that incentive compensation plans have a potential for significant benefit to an exempt organization's functions by improving the quality of patient care and productivity, thereby reducing patient costs. Notwithstanding that general position, the IRS will closely scrutinize plans on a case-by-case basis to ensure that each plan complies with the prohibitions against private inurement and impermissible private benefit.
In a 2002 IRS information release, the IRS exempt organizations division advised that there is "no prohibition" or "per se rule" that prevents 501(c)(3) tax-exempt health care organizations from making incentive payments to physicians. As discussed below, the IRS generally reviews twelve factors in determining whether a health care organization utilizing an incentive compensation program for physicians complies with the prohibitions against private inurement and impermissible private benefit.
1. Independent Board of Directors and Conflicts of Interest Policy
Is the compensation arrangement established by an independent board of directors or by an independent compensation committee? Does the conflicts of interest policy bar the physician, who is a voting member of the board and who receives compensation from the organization, from discussing and voting on matters pertaining to that member's compensation? In General Counsel Memoranda ("G.C.M.") 38394, the IRS's General Counsel states that compensation arrangements with physicians result from arm's-length bargaining if they are established by independent compensation committees consisting of non-physician employees or independent boards of directors.
2. Reasonable Compensation
Does the compensation arrangement with the physician result in total compensation that is reasonable? An exempt organization may pay reasonable compensation for services without triggering the private inurement or impermissible private benefit provisions. Reasonable compensation is generally defined as the amount that would be paid for like-services by like-enterprises under like-circumstances.
3. Arm's-Length Relationship
Is there an arm's-length relationship between the health care organization and the physician or does the physician participate impermissibly in the management or control of the organization in a manner that affects the compensation? In G.C.M. 35638, the IRS's General Counsel approved a compensation plan in which participants shared savings generated by productivity improvements. The General Counsel allowed this plan because it was established at arm's-length, and it was a means of providing reasonable compensation to employees without any potential for reducing the charitable services provided by the tax exempt organization.
4. Ceiling
Does the compensation arrangement include a ceiling or reasonable maximum on the amount a physician may earn to protect against windfall benefits? In the FY 2000 CPE Text, the IRS emphasized the importance of a cap on total compensation. In one instance, while siding with the IRS, the tax court held that private inurement existed where a minister's compensation was 69-86% of gross contributions with no cap on total compensation.
5. Quality of Care and Patient Satisfaction
Does the compensation arrangement take into account data that measures quality of care and patient satisfaction? In G.C.M. 39674, the General Counsel approved two profit sharing incentive compensation plans based on the economic performance of the hospitals. Under these plans, all employees were eligible to participate, not just the physicians. The amounts that could be paid were subject to a minimum percentage of each employee's base compensation, and payments depended on standards designed to measure quality of patient care and patient satisfaction.
6. Reduction in Charitable Programs
Does the compensation arrangement have the potential for reducing the charitable services or benefits that the organization would otherwise provide? There is no bright line rule for this factor. However, the IRS may view the compensation arrangement negatively if it means a potential reduction in charitable activities.
7. Net Revenue Based
Does the physician compensation depend on net revenues? If so, does the arrangement accomplish the organization's charitable purposes? A defectively structured revenue-sharing arrangement could be one that allows the disqualified person to receive additional compensation without providing proportional benefits to the organization that contribute to its exempt purposes. Examples of defectively structured arrangements may include giving a disqualified person the equivalent of an equity interest in the exempt organization or allowing the disqualified person to manipulate expenses to increase his or her compensation.
8. Joint Venture
Does the compensation arrangement transform the principal activity of the organization into a joint venture between it and the physician? In one instance, a percentage compensation arrangement structured as a point system resulted in the loss of an organization's exempt status where it transformed the organization's principal activity into a joint venture with physicians. Under this arrangement, a sum of money was set aside as total salary, which would be divided among physicians in a ratio based on each physician's point score. Points were based on the amount of the physician's charges, the number of patient visits, the number of new patients, and the length of time the physician was associated with the clinic during which the physician had total charges above a certain minimum.
9. Distribution of Profits
Is the compensation arrangement merely a device to distribute all or a portion of the health care organization's profits to persons who are in control of the organization? In one case, a court denied an incorporated business college exempt status where the taxpayer's charter provided for payment of salaries to stockholders in proportion to their holdings and where the stockholders in fact treated the college as a commercial venture by operating it as a business and causing it to distribute large portions of its net earnings for their benefit.
10. Business Purpose
Does the compensation arrangement serve a real and discernible business purpose of the exempt organization? For example, the organization may want to achieve maximum efficiency and economy in operations by shifting away the principal risk of operating costs to the service provider to reduce the organization's need to carry large insurance-type reserves.
11. Abuse or Unwarranted Benefits
Does the compensation arrangement result in no abuse or unwarranted benefits? For example, prices and operating costs should compare favorably with those of similar organizations, and controls should be in place to avoid increases in compensation predicated on increases in fees charged to patients.
12. Services Personally Performed
Does the compensation arrangement reward the physician based on services the physician actually performs, or is it based on performance in an area where the physician performs no significant function? For example, the IRS found that a hospital was operated, to a considerable extent, for the private benefit of two founding doctors, rather than exclusively as a charitable organization. The doctors, who previously owned the hospital facilities and founded the hospital, shared in the fees from the privately operated laboratory and x-ray department, within the hospital, even though they performed no associated services.
In sum, when structuring an incentive compensation arrangement, these factors should be closely scrutinized to determine whether the plan adopted exposes the organization to any unwanted IRS scrutiny. Although complying with each factor will not guarantee that the IRS will approve of the arrangement, this information release provides guidance for health care organizations when considering physician incentive compensation programs.