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Evolving Physician Reimbursement Structures: Moving the Medical Group to Value-Based Success

Posted by Matthew Smith on May 19, 2016 10:17:08 AM

By Cami Hawkins, MHA, Manager, GE Healthcare Camden Group (originally published in Journal of Healthcare Management, May-June, 2016)

Now that the Medicare Sustainable Growth Rate ("SGR") formula has been repealed, physicians and other providers must prepare for the Merit-Based Incentive Payment System ("MIPS"). This article addresses several important questions about evolving physician reimbursement structures and provides guidance on how to succeed under the new programs.

With the passage of the Medicare Access and CHIP Reauthorization Act, what changes can physicians expect with regard to payment incentive models?

Repeal the Medicare SGR formula and passage of the Medicare Access and CHIP Reauthorization Act of 2015 (MACRA) are bringing about significant changes to the Medicare physician fee schedule and reimbursement methodology (Centers for Medicare and Medicaid Services ("CMS"), 2015). MACRA established annual positive or flat fee updates for ten years and implemented a two-track fee update thereafter. In addition, MACRA created MIPS and consolidated the current Medicare fee-for-service incentive initiatives. The law also provides a mechanism for physicians to participate in alternative payment methods, including the patient-centered medical home model and others to be defined. In repealing the SGR and passing the MACRA, Congress's intent was to move away from the fee-for-service payment methodology and toward a value-based payment system.

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Value-Based Success


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Ms. Hawkins is a manager with GE Healthcare Camden Group and has more than 20 years of experience in the healthcare provider sector as a management consultant. She specializes in the areas of practice operations, contract negotiations, benefits administration, reimbursement management, and market development. Ms. Hawkins assists a wide range of provider organizations, healthcare systems, and independent and employed physician groups with addressing issues impacting their overall performance and competitive positioning. Her key areas of expertise include strategic planning, population health strategy, and hospital/physician integrations. She may be reached at [email protected].

Topics: CMS, MACRA, Value-Based Payments, Cami Hawkins, MIPS, Physician Reimursement, Value-Based Success

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