This Week – May 21, 2016

This Week in Washington, D.C.

From ACG Board Member, Caroll D. Koscheski, MD, FACG

ICD-10 Transition, “No Big Deal”…..but is it over? 

The much publicized and anticipated International Statistical Classification of Diseases and Related Health Problems 10th Revision (ICD-10) transition has come and gone with very few problems, but have we heard the last of this?

If you recall, the implementation process was somewhat turbulent — the initial transition date was delayed, re-announced, and finally enacted one year later.  Understandably, there were a lot of anticipated concerns with this major overhaul of the ICD-10 coding system.  At first glance, once the dust settled, it seemed that there were very few complications that were being reported.  However, if you take a closer look, you will realize that some principal factors of ICD-10 are being transitioned by allowing a one year grace period on the usage of ICD-9, as opposed to the highly specified coding that is in fact a critical part of ICD-10.  This one year grace period granted by CMS will come to an end this October, which may result in problems on varying levels, depending on your group.  Private insurance companies will determine their own deadlines.

To learn more how ACG can help you, please read the full blog post here.



Is MACRA the Death Knell for
Small and Independent GI Practices?

In the upcoming days, ACG will focus on certain segments of this newly proposed Medicare payment system, delving more into the specifics, but in piecemeal and in brief summaries.  This way, we hope the busy GI clinician is not overloaded with lengthy explanations, complicated flow charts, and more acronyms all at the same time.

Many in the health policy circles keep asking whether MACRA will force solo and small independent GI practices into alternative payment models (APMs) or consolidation.  Indeed, CMS even estimates that only 13% of solo practitioners and 35% of groups with 2-9 providers would be eligible for a bonus under the MIPS program.  Is this by design? After all, CMS did announce that its goal is to have 50% of Medicare payments through alternative payment models by 2018.   What’s more, APM participants will receive higher annual updates from 2019-2024 (5% annually).

The decision to merge or join an APM should go beyond simply looking at MACRA.  It also may not be a foregone conclusion when considering the following:

  • The estimates: CMS did clarify that these estimate are based off of 2014 data, when many solo practitioners and small physician practices were not participating in Medicare quality reporting programs. So while alarming, the data may also be somewhat misleading.  However, if one uses these CMS dire estimates to predict the end of solo and small practices, then please also note that CMS further estimates that only 55% of larger practices (25-99 providers) are also likely to receive a MIPS bonus payment.  Does this mean that roughly one-half of larger practices are doomed, too?
  • Old vs. New: As far as Medicare Part B fee for service payment penalties go, independent GI practices who do absolutely nothing in 2017 appear to be worse off under the “old SGR system” than under the modified fee for service under MACRA. Plus, the annual updates in 2025 and beyond are comparable for both MIPS and APM participants.  If you could make it under the old system, could you make it under the new system as well?
  • MIPS Could be the Lesser of the Evils for Smaller GI Practices:
    • Participation in an APM under MACRA still requires providers to report quality measures and invest in health IT, in addition to other APM start-up costs. At least 50% of APM participants must use certified health IT in the first year.  This requirement is increased to 75% after the first year.  Certain APMs can penalize participants for not using certified EHRs.  Will the GI practice have a choice in deciding which certified EHR to invest in, and preferably one that is suitable to the needs of the GI practice?
    • APM participants all share the risk for certain financial losses in excess of targeted costs. APM participants also agree to see a certain percentage of Medicare Part B patient volume each year.  This may hurt practice management flexibility and patient-mix budgeting.  The irony: Can small practices afford to join an APM?
    • APM participants operate as a group, yet the desire for many independent practices is autonomy, and to remain independent (to the extent possible). Conversely, since APMs are largely based off of primary care services, do APMs even want an “expensive” specialty care provider when trying to meet cost-savings targets?
    • CMS reassured providers that the MIPS offers flexibility and support for small practices. While still under construction, CMS will also offer “virtual groups” for MIPS reporting.  This may help achieve efficiencies without losing some autonomy.  Will this be a viable option?

Many factors and elements must be considered.  It does require the independent practice to look beyond these proposed MACRA requirements before making this decision.

How Can ACG Help?

Check out ACG’s “Making $ense of MACRA” summary for more analysis of MIPS and APMS.

The 2016 ACG Annual Scientific Meeting and Postgraduate Course will also delve into the details of these changes, as well as offer strategies and insight on how to adequately prepare your practice for these upcoming changes and reimbursement landscape.