PRACTICE MANAGEMENT: THE ROAD AHEAD John I. Allen, Section Editor
The Small Gastroenterology Practice: How to Survive in a Changing World. Perspectives of a Practicing Clinician Ronald Fogel Digestive Health Center of Michigan, Chesterfield Township, Michigan
In Dr Fogel’s own words, “I am a dinosaur”. Ron is a community gastroenterologist in a small (2 physician) GI practice near Detroit. He also is one of two Community Practice Councillors that sit on the Governing Board of the AGA and has been a powerful voice for a private practice model that is under enormous pressure as health care reform marches on. He has unique experiences, having graduated from McGill University (Canadian Health system), worked in California (an advanced managed care state), at Henry Ford (Academic Medical Center), and finally in a community under enormous financial pressure (Detroit) that is dominated by organizations that demand population health management (Michigan Unions have been on the forefront of pushing population health solutions). In this article, Ron shares his challenges and solutions as he continues to celebrate the satisfactions that come from independent, small group practice-based patient care. John I. Allen, MD, MBA, AGAF Special Section Editor he year 2014 has been a transformative one for my clinical practice. Marked on the calendar were the following: March: deadline for 2013 Patient Quality Reporting System (PQRS) report; July: Meaningful Use Part 2; October: transition to International Classification of Diseases, 10th revision.1–3 I have not included the hospital (Henry Ford Macomb) switching to EPIC (Verona, WI) in May or the decisions regarding Maintenance of Certification. In this article, I review some of the challenges that we face from new regulations and
T
Resources for Practical Application To view additional online resources about this topic and to access our Coding Corner, visit www.cghjournal.org/content/ practice_management.
uncertainties regarding access to patients. The Roadmap to the Future of Gastroenterology provides direction to address some of these issues.4–6 For other topics, I present my analysis. I hope that this information will be helpful for other small practices as they navigate into the new health care system. The changing regulatory environment is the immediate result of the Patient Protection and Affordable Care Act of 2010, however, changes were being developed before passage of this legislation. The overarching aim of the legislation was to improve access to care and increase the value of care by improving the efficiency and the quality while reducing the cost. Medicare is evolving from a “passive payer of health care costs to an active purchaser of services,”4,5 and, similar to any business, wants to buy only high-quality products that meet predefined specifications. The effects of these changes on the small clinical practice are predictable. Despite government credits, such as those for electronic health records (EHR), the cost of change often exceeds the monies received. Moreover, many of the mandated changes do not come with any government financial support. Often, there is a temporary decrease in practice revenue because fewer patients are seen while new processes are implemented. Practices may have expenses related to staff training and purchase of hardware and/or software. As a result, small practices have to analyze the cost/ benefit of each new regulation. Failure to implement the changes also is associated with costs that could reach 4% of Medicare fee-for-service reimbursement if a physician is not a participant in PQRS and Meaningful Use. In this article, I present the potential impact of the new requirements on my practice and the resources that were used to satisfy the regulations. Abbreviations used in this paper: AGA, American Gastroenterological Association; CMS, Centers for Medicaid and Medicare Services; EHR, electronic health records; GI, gastrointestinal; PQRS, Patient Quality Reporting System. © 2015 by the AGA Institute 1542-3565/$36.00 http://dx.doi.org/10.1016/j.cgh.2014.12.003
Clinical Gastroenterology and Hepatology 2015;13:419–421
PRACTICE MANAGEMENT: THE ROAD AHEAD, continued Patient Quality Reporting System The immediate goal of the PQRS, a voluntary reporting program, is to submit quality data for review. At present, PQRS represents pay for reporting. Reporting in the 2013 PQRS program was necessary to qualify for an incentive payment of 0.5% of the total estimated part B allowed charges during the reporting period and to prevent a penalty in 2015. A 1.5% reduction in payment would result from nonparticipation in the 2013 quality program and a 2% reduction in 2016 for nonparticipation during 2014.
American Gastroenterological Association Resources The American Gastroenterological Association (AGA) website provides performance measures for hepatitis C, inflammatory bowel disease, and colonoscopy. Although this information can be found on government web sites, the AGA has organized the material in a style that is easily understood. The 2 methods to report quality data are by claims or by a registry with a measures group. Claims-based submissions have a number of difficulties. The quality codes must be added to each billing claim. Claims-based reporting requires information from 50% of Medicare fee-for-service patients. In addition, there is no feedback that the quality information has been processed and submitted to Centers for Medicaid and Medicare Services (CMS). Use of the Registry is preferred over claims reporting because it is only necessary to report a 25-patient sample (if reporting measures group). The AGA Digestive Health Recognition Program is the platform to organize the data that are submitted to CMS by the AGA. Submission of data is acknowledged, closing the loop for the year. It was readily evident that joining the registry was the most efficient and least expensive approach to satisfy this regulation. Participation in PQRS lead to a review of AGA guidelines and to changes in documentation and practice that improved patient care. In this instance, participation in the Quality Reporting System improved quality of care for a subset of patients.
Meaningful Use Part 2 Stage 2 of Meaningful Use requires that physicians provide clinical summaries after each office visit, develop a portal that allows patients the ability to view or transmit their health information, and use secure 420
electronic messaging to communicate with patients on relevant health information. Recently, the implementation of stage 2 was delayed for 1 year. Although our EHR has been certified for stage 2, we chose not to purchase the additional software or to develop the patient portal as necessary to meet stage 2. The software upgrades were not expensive, but the cost of maintaining a portal represented an open-ended expense. Patients have ready access to their results and to a physician via telephone call. Because it was not evident that patients would benefit from the practice meeting Meaningful Use Part 2 and because there is a 1-year grace period, I chose not to invest in the Stage 2 upgrades at this time.
International Classification of Diseases, 10th Revision The ICD-10 was scheduled to start in the United States on October 1, 2014. Countries that already use the ICD-10 include Canada, Australia, United Kingdom, France, Germany, Belgium, Italy, Japan, and the Nordic countries. The new system has many more codes, allowing for better specificity of the diagnosis, resulting in more precise tracking and surveillance of important gastrointestinal (GI) diseases. The responsibility of the practice during the transition to the ICD-10 will be accuracy of coding. Physician and staff training will be needed. Additional costs may include new claims software and information technology changes. Other changes resulting from the ICD-10 are not controlled by the practice. Specifically, our billing service has to establish end-to-end testing so that our claims could be sent and processed by payors and that payment could be returned to us. Similar to most small practices, we are checking our clearing house to ensure that they will be prepared for the start of the ICD-10.
American Gastroenterological Association Resource The AGA developed a translation guide from the ICD, 9th revision, to the ICD-10 for the 50 most common GI diagnoses. Practicing with this resource showed that the ICD-10 implementation would not represent a major disruption of our practice.
Health Care Exchanges The exchanges are marketplaces from which consumers can purchase health insurance. Qualified health
PRACTICE MANAGEMENT: THE ROAD AHEAD, continued plans must meet organizational criteria and provide essential health benefits as designated by United States Department of Health and Human Services. Consumers purchasing these plans may be eligible for financial assistance. In Michigan, 272,000 patients enrolled for health care through the exchanges.7 Of this number, 237,000 received some financial assistance. Participation in exchanges brings new patients to the practice. Many of these individuals have been without health insurance for several years. Some patients only require a screening colonoscopy. Other patients have complicated health problems that require ongoing care. Participation in the exchanges required much preparatory time to review contracts and be credentialed by the plans with which we chose to participate. A major ongoing administrative hurdle is the need to confirm that the patient still is enrolled and paying the insurance premiums at each visit. On several occasions, insurers refused to pay for services because the patient did not pay the insurance premium that month. It is too early to determine the impact of exchanges on the practice, but even now it is evident that the numbers of patients requesting appointments has increased. However, insurers will need to improve communication with the small practice regarding patient benefits. Eventually, we will withdraw from those plans that have the greatest administrative burden.
information is easily accessible so that it is not necessary to collect the same information at multiple visits. However, many physicians still are learning how to use the EHR effectively. For example, physicians will type the note during the patient interview. Looking at the keyboard and not at the patient can influence the openness and willingness of patients to discuss symptoms and health concerns. Patients may perceive a lack of interest and focus by the physician, leading to dissatisfaction with the entire medical experience. Data entry into the health record after the visit, by typing or using voice recognition software, increases the workday or reduces the number of patients who can be seen. More time is needed to learn how to optimize the value of the EHR. Although small medical practices can adapt to change, it is not certain that small practices will survive. The regulatory burden is becoming more expensive and the reimbursement is decreasing. Reduction in upper endoscopy codes in 2014 is one example of decreased revenue. Most new graduates of GI training programs are looking at hired positions in hospital programs or in large groups. As physician-owners retire, small practices will close or merge into larger groups, depriving patients of a practice style predicated on the personal relationship with the physician, an approach that cannot always be provided by large groups or multispecialty practices.
References
Value-Based Modifier The goal of this program is to reward practitioners who provide quality care and to penalize those who provide low-value care. At present, the value-based payment modifiers are being rolled out to groups of more than 100 physicians. However, this year and next year, the CMS will provide Quality and Resource Use Reports to small groups (
The Small Gastroenterology Practice: How to Survive in a Changing World. Perspectives of a Practicing Clinician Ronald Fogel Digestive Health Center of Michigan, Chesterfield Township, Michigan
In Dr Fogel’s own words, “I am a dinosaur”. Ron is a community gastroenterologist in a small (2 physician) GI practice near Detroit. He also is one of two Community Practice Councillors that sit on the Governing Board of the AGA and has been a powerful voice for a private practice model that is under enormous pressure as health care reform marches on. He has unique experiences, having graduated from McGill University (Canadian Health system), worked in California (an advanced managed care state), at Henry Ford (Academic Medical Center), and finally in a community under enormous financial pressure (Detroit) that is dominated by organizations that demand population health management (Michigan Unions have been on the forefront of pushing population health solutions). In this article, Ron shares his challenges and solutions as he continues to celebrate the satisfactions that come from independent, small group practice-based patient care. John I. Allen, MD, MBA, AGAF Special Section Editor he year 2014 has been a transformative one for my clinical practice. Marked on the calendar were the following: March: deadline for 2013 Patient Quality Reporting System (PQRS) report; July: Meaningful Use Part 2; October: transition to International Classification of Diseases, 10th revision.1–3 I have not included the hospital (Henry Ford Macomb) switching to EPIC (Verona, WI) in May or the decisions regarding Maintenance of Certification. In this article, I review some of the challenges that we face from new regulations and
T
Resources for Practical Application To view additional online resources about this topic and to access our Coding Corner, visit www.cghjournal.org/content/ practice_management.
uncertainties regarding access to patients. The Roadmap to the Future of Gastroenterology provides direction to address some of these issues.4–6 For other topics, I present my analysis. I hope that this information will be helpful for other small practices as they navigate into the new health care system. The changing regulatory environment is the immediate result of the Patient Protection and Affordable Care Act of 2010, however, changes were being developed before passage of this legislation. The overarching aim of the legislation was to improve access to care and increase the value of care by improving the efficiency and the quality while reducing the cost. Medicare is evolving from a “passive payer of health care costs to an active purchaser of services,”4,5 and, similar to any business, wants to buy only high-quality products that meet predefined specifications. The effects of these changes on the small clinical practice are predictable. Despite government credits, such as those for electronic health records (EHR), the cost of change often exceeds the monies received. Moreover, many of the mandated changes do not come with any government financial support. Often, there is a temporary decrease in practice revenue because fewer patients are seen while new processes are implemented. Practices may have expenses related to staff training and purchase of hardware and/or software. As a result, small practices have to analyze the cost/ benefit of each new regulation. Failure to implement the changes also is associated with costs that could reach 4% of Medicare fee-for-service reimbursement if a physician is not a participant in PQRS and Meaningful Use. In this article, I present the potential impact of the new requirements on my practice and the resources that were used to satisfy the regulations. Abbreviations used in this paper: AGA, American Gastroenterological Association; CMS, Centers for Medicaid and Medicare Services; EHR, electronic health records; GI, gastrointestinal; PQRS, Patient Quality Reporting System. © 2015 by the AGA Institute 1542-3565/$36.00 http://dx.doi.org/10.1016/j.cgh.2014.12.003
Clinical Gastroenterology and Hepatology 2015;13:419–421
PRACTICE MANAGEMENT: THE ROAD AHEAD, continued Patient Quality Reporting System The immediate goal of the PQRS, a voluntary reporting program, is to submit quality data for review. At present, PQRS represents pay for reporting. Reporting in the 2013 PQRS program was necessary to qualify for an incentive payment of 0.5% of the total estimated part B allowed charges during the reporting period and to prevent a penalty in 2015. A 1.5% reduction in payment would result from nonparticipation in the 2013 quality program and a 2% reduction in 2016 for nonparticipation during 2014.
American Gastroenterological Association Resources The American Gastroenterological Association (AGA) website provides performance measures for hepatitis C, inflammatory bowel disease, and colonoscopy. Although this information can be found on government web sites, the AGA has organized the material in a style that is easily understood. The 2 methods to report quality data are by claims or by a registry with a measures group. Claims-based submissions have a number of difficulties. The quality codes must be added to each billing claim. Claims-based reporting requires information from 50% of Medicare fee-for-service patients. In addition, there is no feedback that the quality information has been processed and submitted to Centers for Medicaid and Medicare Services (CMS). Use of the Registry is preferred over claims reporting because it is only necessary to report a 25-patient sample (if reporting measures group). The AGA Digestive Health Recognition Program is the platform to organize the data that are submitted to CMS by the AGA. Submission of data is acknowledged, closing the loop for the year. It was readily evident that joining the registry was the most efficient and least expensive approach to satisfy this regulation. Participation in PQRS lead to a review of AGA guidelines and to changes in documentation and practice that improved patient care. In this instance, participation in the Quality Reporting System improved quality of care for a subset of patients.
Meaningful Use Part 2 Stage 2 of Meaningful Use requires that physicians provide clinical summaries after each office visit, develop a portal that allows patients the ability to view or transmit their health information, and use secure 420
electronic messaging to communicate with patients on relevant health information. Recently, the implementation of stage 2 was delayed for 1 year. Although our EHR has been certified for stage 2, we chose not to purchase the additional software or to develop the patient portal as necessary to meet stage 2. The software upgrades were not expensive, but the cost of maintaining a portal represented an open-ended expense. Patients have ready access to their results and to a physician via telephone call. Because it was not evident that patients would benefit from the practice meeting Meaningful Use Part 2 and because there is a 1-year grace period, I chose not to invest in the Stage 2 upgrades at this time.
International Classification of Diseases, 10th Revision The ICD-10 was scheduled to start in the United States on October 1, 2014. Countries that already use the ICD-10 include Canada, Australia, United Kingdom, France, Germany, Belgium, Italy, Japan, and the Nordic countries. The new system has many more codes, allowing for better specificity of the diagnosis, resulting in more precise tracking and surveillance of important gastrointestinal (GI) diseases. The responsibility of the practice during the transition to the ICD-10 will be accuracy of coding. Physician and staff training will be needed. Additional costs may include new claims software and information technology changes. Other changes resulting from the ICD-10 are not controlled by the practice. Specifically, our billing service has to establish end-to-end testing so that our claims could be sent and processed by payors and that payment could be returned to us. Similar to most small practices, we are checking our clearing house to ensure that they will be prepared for the start of the ICD-10.
American Gastroenterological Association Resource The AGA developed a translation guide from the ICD, 9th revision, to the ICD-10 for the 50 most common GI diagnoses. Practicing with this resource showed that the ICD-10 implementation would not represent a major disruption of our practice.
Health Care Exchanges The exchanges are marketplaces from which consumers can purchase health insurance. Qualified health
PRACTICE MANAGEMENT: THE ROAD AHEAD, continued plans must meet organizational criteria and provide essential health benefits as designated by United States Department of Health and Human Services. Consumers purchasing these plans may be eligible for financial assistance. In Michigan, 272,000 patients enrolled for health care through the exchanges.7 Of this number, 237,000 received some financial assistance. Participation in exchanges brings new patients to the practice. Many of these individuals have been without health insurance for several years. Some patients only require a screening colonoscopy. Other patients have complicated health problems that require ongoing care. Participation in the exchanges required much preparatory time to review contracts and be credentialed by the plans with which we chose to participate. A major ongoing administrative hurdle is the need to confirm that the patient still is enrolled and paying the insurance premiums at each visit. On several occasions, insurers refused to pay for services because the patient did not pay the insurance premium that month. It is too early to determine the impact of exchanges on the practice, but even now it is evident that the numbers of patients requesting appointments has increased. However, insurers will need to improve communication with the small practice regarding patient benefits. Eventually, we will withdraw from those plans that have the greatest administrative burden.
information is easily accessible so that it is not necessary to collect the same information at multiple visits. However, many physicians still are learning how to use the EHR effectively. For example, physicians will type the note during the patient interview. Looking at the keyboard and not at the patient can influence the openness and willingness of patients to discuss symptoms and health concerns. Patients may perceive a lack of interest and focus by the physician, leading to dissatisfaction with the entire medical experience. Data entry into the health record after the visit, by typing or using voice recognition software, increases the workday or reduces the number of patients who can be seen. More time is needed to learn how to optimize the value of the EHR. Although small medical practices can adapt to change, it is not certain that small practices will survive. The regulatory burden is becoming more expensive and the reimbursement is decreasing. Reduction in upper endoscopy codes in 2014 is one example of decreased revenue. Most new graduates of GI training programs are looking at hired positions in hospital programs or in large groups. As physician-owners retire, small practices will close or merge into larger groups, depriving patients of a practice style predicated on the personal relationship with the physician, an approach that cannot always be provided by large groups or multispecialty practices.
References
Value-Based Modifier The goal of this program is to reward practitioners who provide quality care and to penalize those who provide low-value care. At present, the value-based payment modifiers are being rolled out to groups of more than 100 physicians. However, this year and next year, the CMS will provide Quality and Resource Use Reports to small groups (
