In Dr. Fogel’s own words, “I am a dinosaur.” Ron is a community gastroenterologist in a small (one physician; his partner recently left to join a large group practice) GI practice near Detroit. He also was one of two Community Practice Councillors who sat on the Governing Board of the AGA and has been a powerful voice for a private practice model that is under enormous pressure as health care reform marches on. He has unique experiences, having graduated from McGill University, Montreal (Canadian Health system); worked in California (an advanced managed care state); at Henry Ford (Academic Medical Center) Verona, Wisc.; and finally, in a community under enormous financial pressure (Detroit) that is dominated by organizations that demand population health management. (Michigan Unions have been on the forefront of pushing population health solutions.) In this article, Dr. Fogel shares his challenges and solutions as he continues to celebrate the satisfactions that come from independent, small group practice–based patient care.
- John I. Allen, MD, MBA, AGAF, Special Section Editor
The year 2014 has been a transformative one for my clinical practice. Marked on the calendar were the following: March – deadline for 2013 Patient Quality Reporting System (PQRS) report; July – Meaningful Use Part 2; October – transition to International Classification of Diseases, 10th revision.1, 2, 3
I have not included the hospital (Henry Ford Macomb) switching to EPIC (Verona, WI) in May or the decisions regarding maintenance of certification. In this article, I review some of the challenges that we face from new regulations and uncertainties regarding access to patients. The Roadmap to the Future of Gastroenterology provides direction to address some of these issues.4, 5, 6
Dr. Ronald Fogel
For other topics, I present my analysis. I hope that this information will be helpful for other small practices as they navigate into the new health care system.
The changing regulatory environment is the immediate result of the Patient Protection and Affordable Care Act of 2010; however, changes were being developed before passage of this legislation. The overarching aim of the legislation was to improve access to care and increase the value of care by improving the efficiency and the quality while reducing the cost. Medicare is evolving from a “passive payer of health care costs to an active purchaser of services,”4, 5 and, similar to any business, wants to buy only high-quality products that meet predefined specifications.
The effects of these changes on the small clinical practice are predictable. Despite government credits, such as those for electronic health records (EHR), the cost of change often exceeds the monies received. Moreover, many of the mandated changes do not come with any government financial support. Often, there is a temporary decrease in practice revenue because fewer patients are seen while new processes are implemented. Practices may have expenses related to staff training and purchase of hardware and/or software. As a result, small practices have to analyze the cost/benefit of each new regulation. Failure to implement the changes also is associated with costs that could reach 4% of Medicare fee-for-service reimbursement if a physician is not a participant in the Patient Quality Reporting System and Meaningful Use.
In this article, I present the potential impact of the new requirements on my practice and the resources that were used to satisfy the regulations.
Patient Quality Reporting System
The immediate goal of the PQRS, a voluntary reporting program, is to submit quality data for review. At present, PQRS represents pay for reporting. Reporting in the 2013 PQRS program was necessary to qualify for an incentive payment of 0.5% of the total estimated part B allowed charges during the reporting period and to prevent a penalty in 2015. A 1.5% reduction in payment would result from nonparticipation in the 2013 quality program and a 2% reduction in 2016 for nonparticipation during 2014.
AGA resources
The American Gastroenterological Association (AGA) website provides performance measures for hepatitis C, inflammatory bowel disease, and colonoscopy. Although this information can be found on government websites, the AGA has organized the material in a style that is easily understood. There are two methods to report quality data: by claims or by a registry with a measures group. Claims-based submissions present a number of difficulties. The quality codes must be added to each billing claim. Claims-based reporting requires information from 50% of Medicare fee-for-service patients. In addition, there is no feedback that the quality information has been processed and submitted to Centers for Medicaid & Medicare Services.
Using the Registry is preferred over claims reporting because it is necessary to report only a 25-patient sample (if reporting measures group). The Digestive Health Recognition Program is the platform in which to organize the data that AGA submits to CMS. Submission of data is acknowledged, closing the loop for the year. It was readily evident that joining the registry is the most efficient and least expensive approach to satisfy this regulation.
