The Journal of the Arkansas Medical Society Issue 11 Vol 114 | Page 9

Wilson was asked how the practice will make decisions and prepare for the VBCI. He responded, “ABCBS is planning to start the program in 2019; however, since the program is using a rolling 12 months of data in order to determine the physician scores, the work that physicians are doing right now will influence their score in the first quarter of 2019. ABCBS has not yet fully rolled out the pro- gram to Arkansas physicians and hospitals; there- fore, physicians are going to be measured on data that was generated before knowing the impact of their decisions or before physicians/hospitals have been able to make changes in processes. Since the program is not yet fully developed, physicians also have not yet received any preliminary data to identify areas of potential improvement. ABCBS has stated they hope to have preliminary ‘shadow’ reports out by Summer 2018. By that point, phy- sicians will be six months into the measurement period for the first quarter of 2019. “ABCBS has talked about adding a ‘Trendline’ to the data starting in 2020; however, this has not yet been defined to my knowledge. ABCBS has stated that there will be some sort of ‘Reasonable Trend’ added to the overall calculation in the future. ABCBS has stated that if physician utilization decreases over time, the addition of this trendline could result in more funds being available than were actually withheld. ABCBS has also stated that if overutiliza- tion were to occur, that could reduce the funds with- held therefore reducing the payout to all physicians. How is this trendline determined? What happens if the “overutilization” is a valid increase in utilization much like we saw this year when flu activity pushed volumes much above normal trends? Will valid fluc- tuations in utilization be taken into account in the trend or will the physicians be taking all of the risk for valid increases in utilization? Based on the trend- line implications and questions above, is ABCBS still taking normal insurance risk or is that being passed along to the physicians/hospitals? Will the ABCBS fee schedules change in future years? How will fee schedule changes or other significant changes (such as the recent pharmacy reimbursement issues) be factored into the trendline?” What are the implications on Ancillary ser- vices? Wilson has a unique perspective on this point. “Many physicians offer in-house lab and x- ray services,” he begins. “Larger clinics may also offer other services such as MRI or CT. Technical reimbursement in most of these areas has been reduced to the point of these services having mar- ginal profitability already. With the further cuts that will come from the VBCI, many of these services may become unprofitable when actual collections are compared to actual expenses. Will it be possible to determine how much of the quarterly payments are allocable to the ancillary services to determine the actual profitability of these services? What if none or only 50% of the bonus pool is earned? Will the ancillary service be profitable? “Practices have to allocate professional and technical payments using different methods. Pro- fessional payments may be allocated directly to the physician generating the service, while technical payments have different rules that must be followed to properly allocate those payments without violating Stark and Anti-Kickback regulations. If the quarterly bonus pool that is paid to a physician includes both professional and technical payments, what steps must a practice take in order to remain compliant with the law? Will the practice be able to determine how much of the payment is professional versus technical? What if the bonus pool is 150% or 200% of the withhold? Does some of the excess need to be allocated as technical to remain compliant?” More Than Healthcare, Correct Care Solutions. WHO WE ARE CCS is a national public healthcare leader caring for underserved patients in correctional settings, psychiatric hospitals and residential treatment facilities. Opportunities for: Physician Locations throughout Arkansas Full-time, part-time and PRN available Comprehensive Benefits • 401K Tuition Reimbursement Competitive Compensation • So Much More... One point upon which both providers and AB- CBS agree is [that there] is the potential to reduce administration costs through the elimination of prior authorization programs. Spaulding is open to the prospect. “ABCBS would rather not maintain prior authorization pro- grams, they are administratively costly and physi- cians do not like them. They are effective in reducing the number of services that do not meet appropri- ateness criteria. Our goal is to be able to eliminate these utilization management programs when we see that other incentives have caused the preva- lence of those services to be well managed, not by the prior authorization process, but in the decisions of those who are providing services. It is quite likely that we will find a way to eliminate that requirement for certain providers who have shown a history of the provision of high value care which would include appropriate use of those services which now require prior authorization. We are working to find a way to do that.” Empathy Compassion CALL TODAY OR APPLY ONLINE Chris Phillips [phone] or email [email protected] ccs.careers CCS IS PROUDLY AN EQUAL OPPORTUNITY EMPLOYER Put your business or service in the hands of 4,500 Arkansas physicians. AMS Executive Vice President David Wroten has received multiple calls from acros s the state with questions about the new program. He feels the Soci- ety and physicians should have greater input into the structure and implementation of VBCI. “We have set up a committee (headed by Dr. Amy Cahill) with the intention of meeting with Ar- kansas Blue Cross and Blue Shield to express our concerns and to offer suggestions that we are hear- ing. We are most concerned with the Bell Curve and how physicians, hospitals, and groups on the back end of the curve will be, in essence, penalized. We are doing our best to advocate for inclusion in the decision-making process.” From any perspective, it seems clear that the winds of change are gathering strength. For more advertising information, contact Penny Henderson at 501.224.8967 or [email protected] NUMBER 11 MAY 2018 • 249