Health care reform, economic and business uncertainty, increased regulatory burdens and scrutiny, and declining reimbursement from Medicare and other managed care payers are pushing a realignment of physician practices and providing new incentives for integration, consolidation, and other practice structures.
In a recent Medical Economics poll, 4 out of 5 physicians found it challenging to maintain their dual roles as doctor and businessperson, and 76% thought it was only going to get worse.
New and Complicated Regulations, like the following:
- New enrollment, disclosure , and compliance requirements under the Affordable Care Act
- Transition to ICD-10 Coding and version 5010 HIPAA transaction standards
- Regulatory and Advisory Organizations are expected to impact care and reimbursement –
- Patient-Centered Outcomes Research Institute (identifies research priorities and conducts research on the clinical effectiveness of medical treatments)
- Independent Payment Advisory Board (makes recommendations to reduce the per capita rate of growth in Medicare spending)
- Physician Quality Reporting Initiative
Increased Regulatory Oversight, like the following:
- Stark, Anti-kickback, HIPAA, False Claims Act, and similar Florida laws are being vigorously enforced (e.g., HEAT)
- The Affordable Care Act has made health care fraud much more dangerous –
- A physician no longer must have direct knowledge that his or her actions constituted a violation to be prosecuted.
- Activities of staff may be more easily attributed to the physician
- There is new liability for making a false statement or material error on provider applications
- Keeping an overpayment for longer than 60 days after discovery is now a violation of the False Claims Act
- Physicians providing diagnostic services like MRI, PET and CT scans must provide information to patients in writing about the other area providers
- Whistleblower and Qui Tam actions by former employees
- Increased scrutiny of valuations
Reimbursement issues, like the following:
- Decrease in government reimbursement – slower, less reliable
- Increase in number of Medicaid funded patients with lower payments (an average Medicaid payment is 56% of private payment, Medicare is 81%)
- Affordable Care Act raises the Medicaid rate for primary care physicians to 100% of Medicare in 2013 and 2014, but no guarantee long term
- Payment is shifting from traditional fee for service to “results delivered,” and segmented approaches to care are being replaced by accountability and responsibility for a patient’s health
- Thus, changes in payment methodologies — bundled payments (combined payments across multiple sectors), and new delivery models (e.g., Accountable Care Organizations and Medical Homes)
In subsequent posts, I will outline the following and discuss how they fit into evolving physician practice structures:
- Different Physician-Health System Integration Models
- ACOs, IPAs, and PHOs
- Physician Practice Consolidations
- Changing Levels of Medicare Participation
- Concierge Practice.