Challenges facing independent integrated gastroenterology in 2017
The practice of gastroenterology is challenging for community physicians, those employed in multi-specialty clinics or large health care systems and those in academic health centers. Unique challenges confront independent GI practices, and there are mounting regulatory, financial, and operational barriers. Election results of 2016 have thrown us into an even more confusing future. In this month’s Road Ahead column, national GI leaders summarize the major challenges facing independent practices. Each leads (or has led) large GI practices and each has extensive experience with the policies, politics, payers, and pitfalls that impact our specialty. They have written a clear and helpful article for all physicians trying to maintain their independence and patient-focused practices. I have worked in many settings from the VA, to small and then large, independent practice, within a health system and in 2 academic medical centers. There is much to treasure in every type of practice and also many challenges. Physician leaders, both old and young, need to be informed and active in shaping medical policy.
John I. Allen, MD, MBA, AGAF, Editor in Chief
Physicians practicing in independent settings report greater satisfaction with their careers compared with those employed in hospital systems. In a recent survey,1 nearly two-thirds of independent practitioners strongly agreed with the statement, “I like being a physician,” compared with approximately half of those employed by hospital systems. The rapid pace of change in care delivery is forcing all caregivers to modify how they provide care. For physicians practicing in independent settings, understanding, reacting, and adapting to these changes is especially challenging.
It is particularly difficult for physicians and practices to remain abreast and cognizant of the ever-changing rules governing how we deliver care for our patients. The Digestive Health Physicians Association was formed 2 years ago to provide an active voice specifically for independent gastroenterology (GI) practices. The mission of the Digestive Health Physicians Association is to promote and protect the high-quality and cost-efficient care provided in the integrated GI practice model.
In the past decade, meeting the goal of the Triple Aim (improving population health, improving patient experience of care, and reducing the per-capita cost of health care) has become a central tenet of our national health policy strategy, especially since the enactment of the Affordable Care Act. Achieving the goals of the Triple Aim and complying with the changes and new requirements challenges all gastroenterologists, but particularly those working in the independent practice setting, and especially those in small group practices. The Centers for Medicare and Medicaid Services (CMS) recently estimated that under the Merit-Based Incentive Payment System, payment reductions resulting from the first year of reporting in 2017 will occur in 87% of solo practices, in 70% of groups with 2 to 9 physicians, and in 60% of groups with 10 to 24 physicians.2
Preparing yourself and your practice for the changes ahead will require an understanding of the rules, an assessment of your practice’s readiness, and the creation of a plan for compliance to ensure success.
The care model has undergone major changes in the past decade. The development of regional hospital systems has resulted in increasing numbers of employed physicians. Independent gastroenterology practices also have made changes in how they provide care. Vertical integration by independent practices has been a major, positive, and continuing development. As practices have grown more sophisticated with greater areas of specialization, they are increasingly capable of providing services directly to their patients rather than outsourcing them to external providers. Beginning first with endoscopic procedures and now extending to anesthesia, pathology, infusion, and other critical services, increased integration of services across the entire continuum of care has led to improved efficiency and care coordination, benefitting patients with improved outcomes as well as lower costs to our health care system.
The benefits and successes of practice integration, unfortunately, also have made vertically integrated practices a target for regulators and policy makers. Attacks on the integrated delivery model in gastroenterology have at times been supported, if not directly initiated, by our own colleagues in the house of medicine. In this article, we describe some of the threats and challenges confronting independent GI practice.
Anesthesia services
In April 2016, the Florida Society of Anesthesiologists (FSA) made headlines by drawing attention to its role as the relator in a qui tam (whistleblower) lawsuit that it had filed against more than 50 physicians, Ambulatory Surgery Centers, and anesthesia entities. This legal action — which the FSA filed in October 2013 but remained under seal until earlier this year — alleged that the defendants perpetrated Medicare and Medicaid fraud through violations of the federal Anti-Kickback Statute and the False Claims Act. In this lawsuit, the FSA specifically targeted the company model used to provide anesthesia services. Based on publicly available documents, the case currently is in its early stages, although the FSA has made it clear that it views the lawsuit as a blueprint for attacking integrated anesthesia services.
