The healthcare environment is undergoing rapid transformation. Because of such large scale changes, it is difficult to predict where things are headed. It is clear, however, that no one can be heard as a single voice. Our specialist colleagues realized this more than a decade ago by forming large medical groups. Now, it is our time. Primary care providers are once again considered as key players in the current transformation of the delivery of health care. This key position allows the primary care providers to act as the coordinator of each individual patient’s care functions inside and outside the primary care office. Medicare has recognized that simple evaluation and management codes did not pay for care beyond the office. Hence, CMS has implemented several new reimbursable codes, including chronic care management codes, transition of care codes, end of life management codes, and much more. Such new CMS procedure codes and reimbursements do require the providers to expand the operations of their offices beyond their current walls and offer an opportunity to significantly impact other ancillary services, such as specialists and diagnostic centers.
PrimeHealth Physicians, LLC has positioned itself to proactively engage and lead its members faced with the most up to date changes and opportunities in the marketplace. Most recently, the 2015 Medicare Access and Children’s Health Insurance Program (CHIP) Reauthorization Act (MACRA) will alter the way in which the Centers for Medicare and Medicaid Services will reimburse physicians. In 2019 and each year after that, physicians will have to choose one or two paths: 1) Merit-based Incentive Payment System (MIPS), where fee-for-service payments will be adjusted either with bonuses or penalties, depending on a physician’s score on a new to-be-determined reporting program; or 2) Alternative Payment Models (APMs), where physicians will receive a five percent annual bonus to fee-for-service payments if they can prove they receive substantial revenue through alternative payment models, such as shared savings programs, accountable care organizations, etc. PrimeHealth Physicians has partnered with commercial health plans to implement coordinated and collaborative care delivery models. Commercial health plans and PrimeHealth Physicians have implemented value-based contracts that address quality benchmarks and cost-effective services that are reducing hospital admissions and use of emergency rooms. These examples and many others are creating savings for the health plans, the employers, and ultimately the patient.