Independent GI Practice to Meet Federal and Commercial Requirements?

‘How do you move a glacier?” posed Lawrence Kosinski, MD, MBA, AGAF, FACG, managing partner of Illinois Gastroenterology Group (IGG) at the 2015 AGA Clinical Congress of Gastroenterology and Hepatology.

Offering potential solutions like pretending it’s not there, waiting for climate change, or even chipping away at it in small increments, Kosinski expressed a parallel link, conveying the latest trending topic of reimbursement issues and the transition to value.

According to Kosinski, “Reimbursement is incrementally moving from Fee For Service to Value Based Payments (VBP). Reimbursement will be driven by the measurement of quality, outcomes, and cost containments, and the future lies in cooperation, transparency, and voluntary reporting.”

Regarding Value-Base Payment Modifiers (VM), Affordable Care Act (ACA) section 3007 mandated that, by 2015, CMS begin applying a value modifier under the Medicare Physician Fee Schedule (MPFS). Both cost and quality data are to be included in calculating payments for physician.

An established platform for clinicians to demonstrate and be recognized for superior care in irritable bowel disease (IBD) and colorectal cancer (CRC), the AGA Digestive Health Recognition Program (DHRP), was designed to provide “quality reporting already familiar to the payers”.

Kosinski addressed the foundation of clinical integration (CI) programs on the horizon: to maintain a structured collaboration between a physician group and a health system designed to improve efficiency and joint contracting with managed care organizations.

These CI programs would primarily serve to identify initiatives with high impact for employers such as chronic disease conditions, pharmaceutical enterprises, as well as benefits’ costs, absenteeism, and presenteeism. Additionally, payers would reimburse physicians at negotiated rates possibly determined by individual level performance or PHO performance.

Kosinski noted CI examples specific to gastrointestinal conditions: formulary adherence to PPIs, Bowel Preparations, Mesalamines, Immune Modulators, and Biologics. Also Clinical Decision Support tools provided a dashboard for Crohn’s disease (CD) assessment and treatment, particularly allowed for reporting in Project Sonar, which is a patient engagement tool using a portal through which CD patients can send status reports of their condition and stay in touch with the physicians charged with their care.

Aptly stated, "In many ways technology will improve patient engagement and this will be key to our ability to manage risk."

Furthermore, the CDS tool enabled a vehicle for reporting IBD measures to PQRS, which would also qualify the physician for potential AGA DHRP.

New research had indicated the industry revenue would be increasingly driven by VBP. Kosinski succinctly concluded, “VBP is here to stay, encounter based reporting is gone, and VM reporting is here and will be the driver of the future.”