Healthcare Environment
The healthcare landscape is undergoing rapid transformation. Due to the large-scale changes taking place, it is difficult to predict exactly where the industry is headed. However, one thing is clear: no single voice can navigate these changes alone. Over a decade ago, specialist colleagues recognized this challenge and formed large medical groups to adapt. Now, it is the turn of primary care providers to take a central role in the ongoing transformation of healthcare delivery.
Primary care providers are now recognized as key players in this shift. This pivotal position enables primary care providers to act as coordinators of their patients’ care, managing functions both inside and outside the primary care office. Medicare has acknowledged that traditional evaluation and management codes no longer adequately reimburse for care beyond the office setting. In response, the Centers for Medicare and Medicaid Services (CMS) have introduced several new reimbursable codes, including Chronic Care Management, Transition of Care, End-of-Life Management, and others. These new codes offer the opportunity to expand practice operations beyond their current boundaries and have a profound impact on ancillary services, such as specialists and diagnostic centers.
PrimeHealth Physicians, LLC has proactively positioned itself to lead its members in embracing these updates and opportunities. A prime example of this evolution is the 2015 Medicare Access and Children’s Health Insurance Program (CHIP) Reauthorization Act (MACRA), which will alter the way CMS reimburses physicians. Starting in 2019, physicians must choose one of two paths:
- Merit-based Incentive Payment System (MIPS): This system will adjust fee-for-service payments based on a physician’s performance score, rewarding high performers with bonuses and penalizing lower performers.
- Alternative Payment Models (APMs): Physicians who receive substantial revenue through alternative payment models—such as shared savings programs or Accountable Care Organizations (ACOs)—will be eligible for a 5% annual bonus on fee-for-service payments.
PrimeHealth Physicians has partnered with commercial health plans to implement coordinated and collaborative care delivery models. These partnerships have led to the creation of value-based contracts focused on achieving quality benchmarks and offering cost-effective services. This collaboration has contributed to reducing hospital admissions, emergency room visits, and overall healthcare costs. Ultimately, these efforts benefit not only the health plans and employers but also the patients, who experience better care outcomes and lower healthcare costs.