Flashback

Flashback to 2013 and the attempt to repeal the SGR formula

Publish date: June 21, 2017
By
Larry Kosinski, MD, MBA, AGAF, FACG

 

This month, our “Flashback” article highlights Congress’s long-term attempt to repeal the Sustainable Growth Rate formula for physician reimbursement and base our payments on patient health outcomes. Although the Medicare Access and Quality Improvement Act of 2013 (highlighted in our 2013 article) sponsored by Rep. Michael Burgess and passed unanimously in the House of Representatives did not become law, it did set the stage for the passage of H.R.2 – the Medicare Access and CHIP Reauthorization Act of 2015 (MACRA). Also sponsored by Rep. Burgess and passed with bipartisan support, MACRA has now become the foundation for our transition from fee-for-service reimbursement to value-based care.

In just 2 short years, we have all become familiar with terms like MIPS (Merit-based Incentive Payment System) and APMs (Alternative Payment Models). These two methods of reimbursement will become the backbone of a growing percentage of our revenue going forward. Gastroenterologists should embrace these programs and work to find our unique position in the health care value chain.

A less well-known component of the MACRA, the Physician Focused Payment Model (PFPM), allows physicians to develop unique value-based payment models that can then be deployed by the Centers for Medicare & Medicaid (CMS) as APMs. Project Sonar, an intensive medical home for patients with inflammatory bowel disease, was recently approved as the first PFPM, which may represent an opportunity for gastroenterologists to participate in APMs in 2018.

Do not reject the transition to value. Medicine is no different from most other industries in which value for the consumer is the major driver of business model change. Although physicians pride themselves on practicing quality medicine, quality cannot be our only focus. The cost of the services we provide must also be considered. Together, higher quality and lower cost drive value.

Our focus on cost should not only be directed at the specific services we ourselves provide, but should also be aimed at the total cost of care for the population of patients we are serving. We must be able to demonstrate to those who are taking the risk for payment that the real value of our services lies in improving the health and lowering the overall cost of care for a population of patients.

Larry R. Kosinski, MD, MBA, AGAF, FACG, is a managing partner of Illinois Gastroenterology Group, the Clinical Private Practice Councillor for the AGA, and serves on its Governing Board. He is president and chief medical officer of Project Sonar and an Associate Editor of GI & Hepatology News.

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Challenges facing independent integrated gastroenterology in 2017