Physicians often say they feel like the rules, standards and policies regarding the way they practice medicine change all too frequently. In 2016, there are several key issues physicians should keep their eyes on as they continue to develop, ranging from value-based payment models to mega-mergers to Supreme Court verdicts.
Here are eight physician pressure points in 2016, according to an issue brief from Navigant.
1. Medicare reimbursements and value-based payments. Following the 2015 agreement to replace the sustainable growth rate, this spring CMS will release a draft of the Medicare Access and CHIP Reauthorization Act, which includes two tracks: the Merit-Based Incentive Payment System and the Alternative Payment Model. MIPS will include a combination of various value-based programs with up to 9 percent adjustments or penalties on Medicare payments to physicians by 2022. CMS will also clarify new payment policies for APM participants outlining how to qualify for 5 percent incentive payments and to be excluded from MIPS.
2. Medicare policy changes. Medicare has adjusted several payment policies that will have a marked impact on physicians and their patients. The two-midnight rule was relaxed to allow shorter inpatient stays, though each case will be reviewed for medical appropriateness. Additionally, Medicare will cover advanced care planning for physicians to discuss end-of-life preferences with beneficiaries, and the agency has expanded its list of reimbursable telehealth services, according to the report.
3. Business relationships. Medicare Shared Savings Program participants received a formal waver from CMS and the Office of the Inspector General that mollifies fraud and abuse regulations for accountable care organizations and several modifications relaxing the Stark Law.
4. Meaningful use. There are several recent and pending changes to the Medicare EHR Incentive Programs. In 2016, physicians must either apply for a hardship exception by July 1 or submit attestation data showing they have attested to meeting 10 new objectives for any continuous 90 days. While meeting existing MU requirements, physicians should note that CMS is changing the program to shift from "measuring clicks to focusing on care," according to the report.
5. ICD-10. Following the relatively disruption-free transition to ICD-10 in October, 2016 will be a year of education as clinical teams gain a better sense of medical necessity requirements and common coding nuances, according to the report. Additionally, the claims auditing and quality reporting flexibility Medicare and some private payers offer will expire in October, so providers and revenue cycle teams have a short period of time to finish learning the 69,823 diagnostic codes and 71,924 procedural codes, according to the report.
6. Mega mergers. Everyone will be watching to see if Aetna's proposed $37 billion acquisition of Humana and Anthem's proposed $54 billion bid for Cigna will be approved. The Department of Justice and Federal Trade Commission will perform a national level antitrust review and announce the results in the middle or second half of 2016, according to the report. Physicians should know there is greater opportunity to contribute viewpoints with public hearings and advocacy coalitions at the state level. Not to be overlooked is the FTC's intervention in large hospital system mergers across the country.
7. Patient engagement. As more patients are on the hook for a greater share of their healthcare costs through high-deductible health plans, physicians will be tasked with designing sustainable treatment plans to meet patients' needs while also accommodating restricted budgets.
8. Supreme Court cases. There are several significant court cases the physician community should watch, according to the report. The Supreme Court's ruling in Gobeille v. Liberty Mutual Insurance Company decided self-funded Employee Retirement Income and Security Act plans are not required to report to a state's all-payer claims database, limiting the claims and reimbursement data made transparent by 16 states' all payer claims databases. In Universal Health Services v. U.S. ex rel., the court will decide whether providers are violating the False Claims Act when they submit claims without complying with all Medicare and Medicaid regulations.