Global Payments – OWNED by the Surgeon!
Under the current fee-for-service (FFS) payment system, specialists developed practice styles and business models that flourished by maximizing the delivery of highly reimbursed services. Specialists today, however, are likely to be concerned about forthcoming global payment models that are designed to reduce the inexorable increase in health care expenditures by promoting high-value services, eliminating low-value services, and improving care coordination and integration. For many specialists, this new world of global payments is slowly evolving from an amorphous concern to a potential threat to their livelihoods.nnThis disruption to the current norms of specialty practice, and both the concerns and opportunities presented by global payments, are evident in discussions occurring throughout the country, although likely with greater urgency in physician organizations already transitioning to global payment systems such as those participating in the Medicare accountable care organization programs. As this transition accelerates, even though much of the clinical revenue from specialists will continue to be generated from standard FFS payments, increasing numbers of patients will be covered under global budgets, even if in many cases another care system is “at risk.”nnNationwide, specialists likely are considering potential innovations to better manage patients under global risk arrangements.For instance, specialists in some areas can envision designing aggressive team-based programs aimed at reducing hospitalizations for high-risk cases of diabetes or chronic obstructive pulmonary disease with the assistance of a nurse or case manager. Others might note the opportunity for improved coordination with primary care. While currently specialists might be seeing patients with chronic medical conditions such as asthma or kidney disease 3 or 4 times per year (often with diagnostic testing that provides additional revenue, but little new information), they may recognize that many of these cases could easily be sent back to primary care physicians for the majority of their care, which would free up specialists’ schedules so that they could offer more timely access to those who truly needed their specialized knowledge and consultative services.Yet current incentives and financial models are not in place to support these innovations, which would all result in decreased FFS revenue. Additionally,and perhaps more importantly, there currently are financial disincentives to innovate, to hire practice extenders, or to offer additional consultative services, by phone or e-mail. Neither in the current FFS payment model nor in most global payment models with incentives targeted solely for primary care practitioners are there mechanisms to support such innovations in care delivery.nnThe current systemic constraints and contradicting incentives beg the question, how should the delivery of and compensation for specialty services be structured under global payments? Specialists ideally would be motivated to not only provide optimized patient care and enhanced consultative services to their primary care colleagues but also be actively involved in redesigning practices, coordinating care, reducing unnecessary care, and improving efficiency. To achieve these goals, however, specialists must be incentivized to provide timely, thoughtful,and value-added care,even if it means changing the way that care is delivered. Such change will require overcoming years, if not decades, of deeply ingrained (and currently lucrative) behaviors that have evolved under the current FFS system.nnFor both patients and primary care practitioners, a key need is to obtain appropriate specialty input, but that input need not be in the form of face-to-face visits.The medium for this message may vary widely ranging from telephone consultations to e-mail or other messaging platforms, as well as asynchronous web- or video-based interactions. Traditional visits likely will remain the norm, but increasingly interactions may involve such non–visit based encounters. Thus,under these models,job descriptions and the day-to-day activities of many specialists will change markedly, and specialist compensation methods must account for these new activities. Several likely outcomes may result, although the extent to which each of these becomes common in individual practices, organizations, and markets will vary considerably.nnFirst, in more integrated delivery markets with prior experience with risk contracting, there is likely to be resurgence of risk-based models of specialty compensation wherein groups of specialists receive a fixed per-member-per-month fee to provide specialty care.These fees (or budgets) can be based on an entire enrolled population or can be triggered when a patient first sees a specialist. Specialist physicians may continue to receive FFS payments with intermittent reconciliation, or they might shift to mixed compensation models with salary or specific remuneration for currently uncompensated activities. Under such models, specialists will have more freedom to allocate their fixed resources to providing higher-value services and will have less incentive to see patients more frequently or perform procedures. Organizations,however, will need to put systems in place to ensure continued clinical productivity.nnSecond,when used,the current FFS system compensation models will need to be adapted to cover unreimbursed activities that may be valuable. Compensating physicians for services such as e-mail,telephone,and curbside consultations will need to be paired with new metrics documenting the value of these services. In addition, specialists also will need to be responsible for and incentivized to improve population-based care (eg, endocrinologists responsible for reducing an entire population’s mean hemoglobin A1C) with active outreach,peer practice review,and physician education on how to determine when, whom, and why to refer to specialty care.nnThird, it is likely that increasing numbers of specialists will become salaried employees of hospitals or health systems and that compensation will become less linked to actual FFS revenue generated by direct physician services. For instance, “cognitive” specialists, such as infectious disease physicians, are crucial to hospitals’ functioning; yet these physicians receive lower pay than many other specialties. Thus, to ensure the availability of infectious disease consultants, hospitals may need to supplement their pay beyond the level of typical FFS payments.nnFourth, as care becomes more tightly managed, certain specialists may see substantial decreases in the demand for their services. Low value services will diminish or be eliminated and peer education will allow for care that does not require specialty input to be provided by primary caregivers, possibly leading to less frequent initial and follow-up consultation sand fewer procedures in some specialties. Practice style evolution as described above (eg, e-mail/telephone consults, enhanced disease management, incorporation of mid-level providers such as nurse practitioners or physician assistants,and care managers) will also put downward pressure on demand.nnFifth, specialists also should be prepared to see a reduction in income, particularly when compared with primary care and cognitive specialties that have been under reimbursed in the current FFS system. Current relative payment levels have been codified in the fee schedule used by Medicare that also serves as a model for FFS payment by most private health plans. Even capitated systems that do not use FFS reimbursementmust pay market-level salaries to attract qualified specialists.Many health policy experts have long noted the current inequities,and current Medicare Payment Advisory Commission (MedPAC) recommendations call for a rebalancing of primary care and specialty pay to address these inequities. 1-3 Combined with the likely decreased demand noted above, it is difficult to envision a future in which both payment levels and pay relative to primary care are not adjusted down for many specialties.nnThe coming tide of payment reform as well as continued, if not escalating, cost pressures as the Affordable Care Act is implemented and an additional 30 million individuals obtain some form of health insurance present great opportunities for innovations in how health care services are organized and delivered. For the first time in US history, more patients and physicians will operate in a system in which there are defined boundaries for costs. There may be substantial shifts in how resources are spent, whether shifting from specialists to primary care physicians or from inpatient to outpatient settings. These changes will have dramatic effects on specialist practice, with implications both for how specialists practice as well as for the forms and levels of their compensation. Although changes in specialist roles and responsibilities will better align specialists with the goals of integrated care systems, with likely benefit to the health care system overall, these changes are also likely to result in substantial changes in specialist pay and number.n
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nSource: www.jama.jamanetwork.com; Thomas Jefferson University — Michael Barr; July 23, 2013.
S61.452A — Open bite of left hand, initial encounter.nnW55.21XA — Bitten by cow, initial encounter.nnY93.K2 — Activity, milking an animal.nnY92.73 — Farm field as the place of occurrence of the external cause.nn nnIn preparation for the upcoming deadline for ICD-10 implementation, Welter Healthcare Partners presents weekly ICD-10 Codes of the Week! Our goal is to familiarize you with the new and expanded code set and the additional clinical documentation needed from your providers to comply with ICD-10 coding, and more importantly, for accurate and clean claims submission to keep your revenue stream flowing! We are to help YOU prepare for the October 1, 2014 implementation date. Please don’t hesitate to 
S93.431A — Sprain of tibiofibular ligament of right ankle, initial encounternnW03.XXXA — Other fall on same level due to collision with another person, initial encounternnY93.41 — Activity, dancingnnY92.252 — Music hall as the place of occurrence of the external causenn nnIn preparation for the upcoming deadline for ICD-10 implementation, Welter Healthcare Partners presents weekly ICD-10 Codes of the Week! Our goal is to familiarize you with the new and expanded code set and the additional clinical documentation needed from your providers to comply with ICD-10 coding, and more importantly, for accurate and clean claims submission to keep your revenue stream flowing! We are to help YOU prepare for the October 1, 2014 implementation date. Please don’t hesitate to 
WASHINGTON — In another setback for President Obama’s health care initiative, the administration has delayed until 2015 a significant consumer protection in the law that limits how much people may have to spend on their own health care.nnThe limit on out-of-pocket costs, including deductibles and co-payments, was not supposed to exceed $6,350 for an individual and $12,700 for a family. But under a little-noticed ruling, federal officials have granted a one-year grace period to some insurers, allowing them to set higher limits, or no limit at all on some costs, in 2014.nnThe grace period has been outlined on the Labor Department’s Web site since February, but was obscured in a maze of legal and bureaucratic language that went largely unnoticed. When asked in recent days about the language — which appeared as an answer to one of 137 
Health plans are free to set out-of-pocket limits lower than the levels allowed by the administration. But many employers and health plans sought the grace period, saying they needed time to upgrade their computer systems. “Benefit managers using different computer systems often cannot keep track of all the out-of-pocket costs incurred by a particular individual,” said Kathryn Wilber, a lawyer at the American Benefits Council, which represents many Fortune 500 companies that provide coverage to employees.nnLast month the White House announced a one-year delay in enforcement of another major provision of the law, which requires larger employers to offer health coverage to full-time employees. Valerie Jarrett, Mr. Obama’s senior adviser, said that the delay of the employer mandate showed “we are listening” to businesses, which had complained about the complexity of federal reporting requirements.nnAlthough the two delays are unrelated, together they underscore the difficulties the Obama administration is facing as it rolls out the health care law.nnAdvocates for people with chronic illnesses said they were dismayed by the policy decision on out-of-pocket costs.nn“The government’s unexpected interpretation of the law will disproportionately harm people with complex chronic conditions and disabilities,” said Myrl Weinberg, the chief executive of the National Health Council, which speaks for more than 50 groups representing patients.nnFor people with serious illnesses like cancer and multiple sclerosis, Ms. Weinberg said, out-of-pocket costs can total tens of thousands of dollars a year.nnDespite the delay, consumers in 2014 will still have many new protections. They cannot be denied health insurance or charged higher premiums because of pre-existing conditions, and many will qualify for subsidies intended to lower their costs.nnIn promoting his health care plan in 2009, Mr. Obama cited the limit on out-of-pocket costs as one of its chief virtues. “We will place a limit on how much you can be charged for out-of-pocket expenses, because in the United States of America, no one should go broke because they get sick,” Mr. Obama told a joint session of Congress in September 2009.nnAdvocates for patients said the promise of the law was being deferred. “We have wonderful new drugs, the biologics, to treat rheumatoid arthritis, but they are extremely expensive,” said Dr. Patience H. White, a vice president of the Arthritis Foundation. “In the past, patients had to live in constant pain, often became disabled and had to leave their jobs. The new drugs can make a huge difference, and we were hoping that the cap on out-of-pocket costs would make them affordable. But now many patients will have to wait another year.”nn
The American Cancer Society shares the concern and noted that some new cancer drugs cost $100,000 a year or more.nn“If a prescription drug plan does not currently have a limit, then it will not have to have one in 2014,” said Molly Daniels, deputy president of the lobbying arm of the American Cancer Society. “Patients who require expensive drugs could continue to have enormous financial exposure, despite the clear intent of the law to limit a patient’s total out-of-pocket exposure.”nnFederal officials said they were offering transition relief to certain health plans in 2014. But, they said, by 2015, health plans must comply with the law and must have an overall limit on out-of-pocket costs for medical, drug and other benefits combined.nnTheodore M. Thompson, a vice president of the National Multiple Sclerosis Society, said: “The promise of out-of-pocket limits was one of the main reasons we supported health care reform. So we are disappointed that some plans will be allowed to have multiple out-of-pocket limits in 2014.”nnThe law also requires coverage of dental care for children, but these benefits can be offered in a separate health plan with its own limit on out-of-pocket costs.nnFederal rules say that a free-standing dental plan must have “a reasonable annual limitation on cost-sharing.” In states where the new health insurance marketplace will be run by the federal government, the limit on out-of-pocket costs for pediatric dental benefits can be no more than $700 for coverage of one child and $1,400 for a plan covering two or more children in the same family.n
S00.83XA — Contusion of other part of head, initial encounter.nnY93.82 — Activity, spectator at an eventnnW21.03XA — Struck by baseball, initial encounter.nnY92.320 — Baseball field as the place of occurrence of the external cause.nn nnIn preparation for the upcoming deadline for ICD-10 implementation, Welter Healthcare Partners presents weekly ICD-10 Codes of the Week! Our goal is to familiarize you with the new and expanded code set and the additional clinical documentation needed from your providers to comply with ICD-10 coding, and more importantly, for accurate and clean claims submission to keep your revenue stream flowing! We are to help YOU prepare for the October 1, 2014 implementation date. Please don’t hesitate to