Perspectives on Physician Pressure Points in 2016

Guidehouse recently released the "8 Physician Pressure Points in 2016" issue brief to outline the facts behind what matters most to doctors today. Read more about Guidehouse's perspectives and insights on each of the pressure points changing the game for physicians.


Medicare Reimbursements and Value–Based Payments
Medicare reimbursement and value–based alternative payment models are no longer the alternative. They're the only option. The MACRA payment rules to be finalized this year will only solidify degrees on the margin of that fate. So physicians who aren't involved in value–based arrangements of some sort today, are years behind. Their Medicare reimbursements will start to mirror Medicaid rates in no time. Physicians who are paid for value must be bearing risk for 25% of your Medicare business by January 1, 2017 – which is only a few months away. And looking ahead, Medicare is rapidly increasing the risk requirement to an aggressive 75% for a performance year just five years from now. That's quite a stretch since 87% of Medicare ACOs aren’t even accepting any risk today.1


Medicare Policy Changes
After years of battling the Two–Midnight rule, physicians can expect a "lighter touch" from this Medicare statute. Clinical easements for inpatient cases and advanced care planning are countered with the first steps into site neutral payments. Just when some clinical headaches are reduced, Medicare starts closing the window on the most attractive path for many private practice physicians, shifting administrative burdens to hospitals.


Business Relationships
It shouldn't come as a surprise that Medicare is tinkering with the Stark Law to legalize business relationships that are fundamental to alternative payment arrangements – which HHS has crowned as the future of healthcare. Finalizing these measures is long overdue. But it remains to be seen how fraud and abuse enforcement will occur in light of these accommodations, especially for non–ACO arrangements and with commercial ventures.


Meaningful Use
It's time for the 26% of doctors who haven't adopted a certified EHR – and the 51% that are only using basic EHR functionality – to pull their heads out of the sand.2 Gone are the days of incentive payment carrots. We are emerging to the days of sticks. The Feds will coalesce ever–changing EHR requirements in this year's MACRA regulations, and not to be overlooked are state efforts. New York's e–prescribing requirements are a prime example that it's not just the Feds sharpening their EHR sticks.


In about six months Medicare and private payers will sunset their year–long ICD–10 flexibilities, heightening their scrutiny of claims and quality reporting. If you're a physician, this should be keeping you up at night. You shouldn't be pulling any punches when it comes to evaluating your in–house team's capabilities. It's more than just delayed reimbursements. It's your livelihood and your license. At the extreme, it's prison time. We outsource so much of our personal lives – from financial advisors and housekeepers to Uber drivers. Why wouldn't you outsource your revenue cycle to a firm that specializes in it?


It's time to face the fact here. The Aetna–Humana and Anthem–Cigna mergers will be approved. Yes, there will be accommodations, but only in certain markets. This means tougher times are ahead for physicians. Narrow networks are here to stay, and they're going to bleed from the individual to employer markets. So expect tougher network negotiations and heightened quality requirements. If you're not as efficient, or prescribing treatments that may have the air of defensive medicine, you'll watch your patient population dwindle while your peers in the physician group or hospital see greater volumes.


Patient Engagement
Patients are on the financial hook more and more every day (deductibles are up 67% from 2010 to 2015 for employer–sponsored coverage3) so the pressure is mounting for physicians to help patients weigh the cost–benefit of treatment options. More importantly, physicians may need to stress the impact of foregoing treatment altogether. Insurers aren't in the room for these conversations, so physicians bear the brunt of blame, uncertainty, and angst for cost and coverage. As patients seek lower cost and alternative treatment options, the pressure builds for physicians to expand care coordination with a vast set of untraditional actors.


SCOTUS & Federal Court Cases
The boundaries of the False Claims Act requirements are up for revision by the Supreme Court and a few federal courts. These are not to be missed by physicians, however the biggest case of the year for those practicing medicine is the Teladoc case in Texas. It's a high noon showdown between a new actor with the Silicon Valley approach to existing laws and regulations versus institutions that have served the American public for decades by setting the guidelines of patient protections.



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