How doctors can overcome payment obstacles in 2017
The old ways of practicing medicine are gone—at least if physicians want to get paid in a value-based world.
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Changes to Medicare reimbursement continue to bewilder and intimidate smaller practices while the effect on private payers remains unknown. Physicians already deal with patients angry at having to pay high deductibles for the same level of care, while fighting to maintain leverage with payers and getting paid for all the work they do to improve the well-being of patients. The “unknowns” about 2017—from how payments will progress to what will transpire under a new administration in Washington, D.C.—has many concerned.
“I think 2017 will be a little more challenging because the focus on quality is putting reimbursement at risk,” says Jeffrey Kagan, MD, a Newington, Connecticut-based internist and member of the Medical Economics Editorial Advisory Board. “The other unknown is what is going to happen to Obamacare,” Kagan adds. “I have a business with a budget based on income not falling. If income falls and affects our budget for the year, we’ll have to figure out where to cut back.”
Only by understanding the biggest risks to their revenue this year can physicians maximize their reimbursements.
Maximizing revenue in a MACRA-driven world
The requirements for the Medicare Access and CHIP Reauthorization Act (MACRA) reflect a larger shift in the industry, and physicians need to be proactive in how they approach the new law this year to maximize revenue potential in 2019 and beyond.
“This is the beginning of the transformation of the healthcare system,” says Randy Buchnowski, MHA, FACHE, network executive for Halley Consulting Group, a healthcare consulting firm. “I see this as a movement toward value-based care that is going to go well beyond Medicare.
Practices that fail to adopt value-based models jeopardize their future revenue, says Katie Fellin, MHSA, a senior manager at ECG Management Consultants and a specialist in working with small physician groups and independent practices. “Although the ACA introduced ‘accountable care’ into the healthcare lexicon, commercial payers have run with the concept and show no signs of backing away,” Fellin says in an email.
Fellin points to two surveys as evidence: a 2016 survey from the Health Care Transformation Task Force in which 38% of payers who responded had value-based payment models with providers at the end of 2015, and a 2016 Commonwealth Fund study showing that more than 800 accountable care organizations (ACOs), both commercial and Medicare, cover an estimated 28 million patients.
Aetna, as of early last year, had nearly 6.2 million members receiving care from physicians in value-based arrangements, accounting for 40% of Aetna’s payments for medical care, she adds.
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Taking a long-term approach is the key to maximizing reimbursement and creating a thriving practice, says Laura Wooster, MPH, interim senior vice president of public policy for the American Osteopathic Association.
No matter where a practice is in preparing for MACRA and value-based care, physicians should look to take the next step, whether it’s finally getting an electronic health record (EHR) system or moving from Medicare shared savings track one to track two, because those investments can pay off over time.
“I think there are business opportunities here in terms of practices being able to do well,” says Wooster. “It will require a good amount of planning and an upfront investment of time and resources, but in the end, this can be looked at as a positive business opportunity.”
To get started, Fellin suggests providers do the following:
- Report at least the minimum amount of data required for MACRA in 2017 to avoid the financial penalty;
- Select the quality measures they can track, report and perform well on; and
- Adopt a care delivery model that supports the transition to value-based care, such as an ACO or a patient-centered medical home.
Success under MACRA and value-based care doesn’t have to be complicated, says Joseph Schlecht, DO, a Jenks, Oklahoma-based primary care physician. Schlecht started practicing value-based care more than a decade ago after realizing he wasn’t taking as good care of his diabetic patients as he could. Today, he’s set to reap the financial rewards for quality care through MACRA and from private payers.
“Doctors want to practice the way they’ve done for 40 years, but that’s not the way it’s going to go,” Schlecht says. “We have to shift to quality reports.”
His solution is to create patient registries for diabetes and other chronic conditions. Once set up, the registries are combined with a severity index so he can identify his most at-risk patients. His staff has access to the information and is trained on how to handle these patients.
Higher-risk patients get scheduling priority, and the combination of registries and severity index allows him to regularly schedule eye and foot exams, for example, which also drive additional revenue. Patients receive better care management while the practice benefits from higher patient satisfaction scores and increased profitability.
Schlecht created his first registries with the help of a receptionist, two medical assistants and an office manager, who put it together in about 30 hours of overtime work.
This same data and outcome tracking has positioned him to perform well under MACRA. “Everyone says they are better than the next guy,” says Schlecht. “The payers are now saying, ‘Show me.’ Without registries and data, you can’t show or prove anything.”