What GIs Need to Know About Value-Based Reimbursement

September 06, 2013

By David Weinberg, MD, MSc, AGAF, chair, department of medicine, Fox Chase Cancer Center. Dr. Weinberg is also the chair of the AGA Institute Clinical Practice and Quality Management Committee. 

As you may have heard, Medicare recently released a draft rule outlining plans to accelerate the shift to value-based reimbursement. Under the Affordable Care Act, approximately 500,000 physicians working in group practices will begin receiving bonuses or penalties, known as the physician value-based modifier, based on performance by 2017. AGA recently released an analysis of how the physician value-based modifier will impact gastroenterologists, and I encourage you to read this important commentary. You can also view a sample gastroenterologist report from CMS.

The draft rule would affect your physician groups differently, depending on your group size:

  • Large groups consisting of 100 or more health-care professionals would earn or lose up to one percent of their pay beginning in 2015.
  • Physician groups with 10 to 99 professionals would move into the program in 2016. They will be eligible for benefits, but protected from penalties for the first year they are enrolled in the program.
  • Small physician groups, those with nine or fewer health-care professionals, would be added in 2017.

The bonuses or penalties received by clinicians are calculated based on quality measures that are specific to each specialty. Medicare plans to compare physicians against others in their specialties. Those physician groups whose patients are the least costly to Medicare are eligible for larger bonuses and fewer penalties.

To stay ahead in this quality-driven era, I encourage you to take advantage of AGA's Roadmap to the Future of GI. Through the roadmap, you will find resources and tools to help you deliver high-quality, cost-efficient care, including clinical service lines, clinical guidelines, quality measures and regonition platforms. 

Please reach out to AGA directly with any thoughts or feedback on these resources. We look forward to helping you understand and confront the mounting challenges under health-care reform.

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