Eight Pressure Points for Physicians This Year

Never before has so much change affected the practicing physician. The everyday pressures that have an effect include changes in clinical guidelines, adjusted benchmarking measures, and new payment models. The current reality is that these pain points are just the beginning of healthcare reform in action. Here are the important items for physicians to watch in the coming year.

I. MEDICARE REIMBURSEMENTS AND VALUE BASED PAYMENTS

A key game changes for all physicians in 2016 is Medicare’s redesign of the physician payment methodology. As part of the 2015 agreement to replace the Sustainable Growth Rate, CMS has released a draft of the Merit-Based Incentive Payment System (MIPS), which combines several value-based programs and will increase or decrease physician payments 9 percent by 2022. CMS has clarified new payment policies for Alternative Payment Model participants detailing how to qualify for 5 percent incentive payments and to be excluded from MIPS.

Providers should expect CMS to do everything possible to meet its remaining 2016 and 2018 value-based goals -including expanding Comprehensive Care for Joint Replacement participation or introducing another mandatory bundle program.

II. MEDICARE POLICY CHANGES

This year Medicare adjusted several payment policies that is noteworthy to physicians, their patients, and extended care teams: the “Two-Midnight Rule” was mollified, allowing shorter inpatient stays. However, each case will be reviewed by QIOs for medical appropriateness. Also, for the first time Medicare will cover advance-care planning for physicians to discuss end-of-life care. Other changes include the fact that physician offices are no longer as attractive for hospital acquisition due to site neutral payment restrictions enacted by the 2016 budget deal and an expanded list of reimbursable telehealth services.

III. BUSINESS RELATIONSHIPS

2016 means greater clarity and flexibility for physicians participating in healthcare delivery and payment system reforms. Medicare Shared Savings Program participants received a long awaited formal waiver from CMS and OIG relaxing fraud and abuse regulations for ACOs and several easements to the Physician Self-Referral Law (“Stark Law”) became effective.

IV. MEANINGFUL USE

With several recent and pending changes to the Medicare EHR Incentive Programs, it can be cumbersome for physicians to keep the requirements straight. Here’s what matters in 2016:

1. 2015 Requirements - Participating physicians must have reported data for any continuous 90 period in CY 2015 by March 11th

2. 2016 Requirements - Physicians must either:

a) Apply for a hardship exception by July 1st using a new application that requires less information with a less stringent CMS review; or

b) Submit attestation data: new physicians must attest to meeting 10 new objectives for any continuous 90-day period and may report the results by Oct. 1, 2016 or by Feb. 28, 2017 (latter reporting avoids 2018 payment adjustments but not 2017).

V. ICD-10

The ICD-10 transition occurred without major disruptions last October, but  providers should have encountered the first wave of ICD-10 denials in the first quarter. That means 2016 will be an education year as clinical teams get a better sense for medical necessity requirements and common coding nuances. Providers and their revenue cycle teams have a short window to learn the 69,823 diagnostic codes and 71,924 procedural codes.

VI. MEGA-MERGERS

All eyes will be on the insurance industry’s proposed mega-mergers: Aetna’s $37 billion bid for Humana and Anthem’s $54 billion acquisition of Cigna. The Department of Justice and Federal Trade Commission will undertake a national level antitrust review, announcing outcomes in the middle or second half of 2016.

VII. PATIENT ENGAGEMENT

Patient engagement will be even more pressing for physicians in 2016 as patient financial responsibility increases (deductibles are up 67 percent from 2010 to 2015 for employer sponsored coverage) and health expenses eat up greater percent of household income (26 percent of households had problems paying medical bills last year). Physicians will be tasked with formulating sustainable treatment plans to meet patients’ constricted budgets and challenged to coordinate care with more partners as patients seek alternative or lower cost treatments locations.

VIII. SCOTUS & FEDERAL COURT CASES

There are several prominent court cases that the physician community should track: the Supreme Court’s ruling in Gobeille v Liberty Mutual Insurance Company clarified that self-funded ERISA plans are not required to report to a State’s all-payer claims database (APCD), limiting the breadth of claims and reimbursement data made transparent by 16 states’ APCDs. And in Universal Health Services v US ex rel. the Court will decide whether providers are implicitly certifying compliance with all regulations when requesting Medicare and Medicaid reimbursement, and thus are violating the False Claims Act when not in compliance and submitting claims.

On the Federal level, physicians should follow Teladoc’s antitrust challenge to the Texas Medical Board requirement. It will have national / state implications for telemedicine.

Jimmy W. Burnett is a managing director and national business unit leader for Navigant’s Physician Enterprise Solutions Practice, playing an integral role in advising healthcare clients on a range of strategic and operational issues. He has more than 25 years of experience managing and advising healthcare and physician organizations, and has a successful record of accomplishment driving operational growth, leading full-scale start-ups and turnaround efforts.