The Upcoming Bipartisan, Bicameral, Dr. Fix

The Sustainable Growth Rate (SGR) formula was enacted into police describe inwards 1997 to necktie Medicare payment for services to physicians to the overall condition of the economy. Basically, if the United States of America Gross Domestic Product (GDP) does well, doctors acquire to a greater extent than money, in addition to if it does poorly, doctors acquire less coin for the same service. Influenza A virus subtype H5N1 decade of tinkering alongside legislation for circumventing the application of the SGR formula, preferably a few days earlier or afterward it was due to bring effect, resulted inwards failure to salvage $150 billion dollars over the in conclusion decade. For the adjacent decades, the Congressional Budget Office estimates that avoidance of the SGR formula volition neglect to salvage us a mere $139 billion, in addition to then this should survive a perfect fourth dimension to permit bygones survive bygones in addition to come upward up alongside a to a greater extent than gentle strategy to cutting physicians’ Medicare reimbursement. More gentle, because if nosotros produce create upward one's heed to cash inwards on our SGR savings on Jan 1st, doctors are looking at an about 24.4% cutting inwards the Medicare fee schedule for 2014.

Building on H.R. 2810, the “Medicare Patient Access in addition to Quality Improvement Act of 2013” approved past times the House Committee on Energy in addition to Commerce, the new proposal to create the SGR comes from the House Ways & Means in addition to Senate Finance Committees alongside back upward from both Democrat in addition to Republican members, thence the bipartisan in addition to bicameral labels. It is currently inwards draft shape in addition to it is opened upward for world comment until Nov 12, 2013. This is a brusk document, in addition to y'all should read it earlier it’s transformed into a m page cleverly titled Act. The view behind the proposal is real simple, in addition to it is widely used inwards other service industries, where patrons pay a base of operations toll for the service, in addition to discretionary bonuses, gratuity, or tips, are available to service providers based on character of service. There is a modest deviation though, since the proposal is supposed to survive budget neutral (i.e. a goose egg amount game). Thus, a sufficient number of physicians volition demand to survive penalized to residue the bonuses awarded to amend performers.

Below is a simplified summary of the viii betoken proposal to repeal the SGR, in addition to supervene upon the straight fee for service payment scheme alongside character adjusted risk-based contracting:

• The Medicare physician fee schedule volition survive (sort of) frozen for the adjacent 10 years. After 2023, the fee schedule volition survive adjusted upwards past times 2% annually if y'all bring conduct a opportunity for your patients through an advanced choice payment model (APM), or merely 1% annually if y'all don’t.
• The view of the proposal consists of bundling the multitude of incentives in addition to penalties currently enacted past times CMS, into 1 Value-Based Performance (VBP) Payment Program, first of all inwards 2017. It’s non that y'all won’t conduct hold to study character measures or survive a meaningful user, y'all volition conduct hold to produce those things in addition to more, but at that spot volition survive a unmarried aggregate marking to trigger incentives/penalties, calculated every bit follows:
• Quality Measures reporting – precisely what y'all recollect this is – Weight 30%
• Resource Use – similar to the CMS Value Based Modifier initiative, alongside an added requirement for claims self-reporting (subject to payment reduction) – Weight 30%
• Clinical Practice Improvement Activities – basically patient centered medical domicile (PCMH) or patient centered specialty do (PCSP) certification – Weight 15%
• EHR Meaningful Use – it seems that all that is needed hither is the utilisation of a certified EHR – Weight 25%
• Practices that conduct hold real few Medicare patients are exempt in addition to practices that conduct hold important revenues inwards at-risk contracts (see below) are excluded from the VBP program. This is a budget-neutral item, pregnant that high performer bonuses are direct proportional to the number of penalized piteous performers. The puddle available for bonuses starts at 8% of the full physician payments inwards 2017 in addition to increases inwards subsequent years.
• Since the stated finish of this permanent SGR create is to eliminate fee for service, an additional 5% bonus volition survive made available to those who conduct hold important revenues tied to at-risk contracts. The thresholds start at 50% in addition to choke upward to 75% revenue. Both Medicare in addition to commercial payer revenues tin survive counted for this purpose. It is interesting that the thresholds are for revenue, non patients, in addition to it is also interesting that mortal payers tin survive counted, although it is non clear if the bonus is five percentage of Medicare payments, or five percentage of all payments. Influenza A virus subtype H5N1 seemingly simpler choice to obtaining the 5% bonus is to conduct hold a “significant share” of revenue inwards a patient-centered medical domicile (PCMH) model that has been “certified every bit maintaining or improving character without increasing costs”. This volition require some explanation inwards the terminal mouth because PCMH is unremarkably non tied to revenue shares, in addition to because I am non aware of anybody alongside the mightiness to certify that a certainly PCMH model volition increment quality, but non costs.
• For those practicing inwards a PCMH, or a comparable specialty model (e.g. PCSP), exceptional help coordination codes volition survive created. The description hither sounds real similar to the novel Transitional Care Management CPT Codes next infirmary discharge. Note that payment for these codes is also budget neutral inside the physician fee schedule, in addition to then for each help coordination code paid out, someone or something else volition survive paid less.
• Along alongside ending fee for service, the proposal volition also improve the fee for service schedule, past times thoroughly evaluating in addition to “identifying in addition to revaluing misvalued services” to facilitate “smooth downward payment adjustments” The yearly downward target is 1% per year, in addition to if non plenty misvalued services are identified, the entire fee schedule volition survive revised downward past times the missing amount. If to a greater extent than than 1% reduction is found, the funds volition stay inwards the budget neutral puddle to offset bonuses in addition to other changes.
• The proposal volition also ensure that physicians do medicine correctly. Mechanisms volition survive seat inwards house to brand certainly doctors consult appropriate clinical determination tools earlier ordering “advanced imaging in addition to electrocardiogram services” (no view why electrocardiogram of all things is specified here). The “tools” volition study dorsum to the Secretary of Health in addition to Human Services that such consultation occurred prior to ordering. “Payment would non survive made for the advanced imaging or electrocardiogram service if consultation alongside appropriate utilisation criteria did non occur.” Physicians flora to guild likewise many of these services volition survive required to obtain prior potency inwards the future. If things choke well, other services volition also choke plain of study to appropriate utilisation surveillance.
• To back upward all these activities, qualified entities that are receiving Medicare in addition to Medicaid information for world reporting, volition survive authorized to sell analyses in addition to reports to physicians, every bit good every bit commercial insurance companies in addition to employers too.
• Transparency volition survive facilitated past times publishing physician payment in addition to diverse performance metrics measured through the program, in addition to then Earth tin search for physicians past times cite in addition to acquire all the information they demand to conduct providers.

Bottom Line

Although right instantly this is merely a proposal, it is real probable that sometime about Jan 15, 2014, this, or something real similar to it, volition choke the police describe of the land. For modest independent mortal practice, the increment inwards bureaucratic burden volition survive important in addition to the achieve of insurers into your everyday operate volition choke palpable. Noncompliance alongside the novel regulations agency that your topline volition stay apartment for the adjacent 10 years, minus whatever penalties, rejected claims in addition to downward adjustments, which may or may non survive important depending on your specialty. Initially, this may alone impact the Medicare portion of your practice, but it volition non stay that way for long.

If y'all desire to choke along practicing medicine in addition to stay independent, y'all conduct hold 3 basic choices: 1) Join a larger entity, such every bit an accountable help organization, in addition to bring conduct a opportunity for almost of your patients inwards a managed help environment; 2) Adapt to the novel epitome past times getting yourself a certified EHR, obtaining PCMH recognition, in addition to learning how to do nether increased supervision; in addition to 3) Stop accepting insurance in addition to switch to a direct pay model. Since the computer programme is slated to start inwards 2017, y'all conduct hold 3 years to brand an informed decision.