Out-of-Network Providers, In-Network Hospitals

Manthan Bhatt

Health plans with high out-of-pocket expenses and narrow insurance networks continue to grow in the Affordable Care Act (ACA) market exchanges. As a result, balance billing for out-of-network providers at in-network hospitals has become a major issue for regulators, the media, and physicians. Insurance regulators, seeking to fix the problem, have created model legislation that will be debated in nearly every state.

Unintended Consequences of CJR

Alexandra E. Page, MD; Mary I. O'Connor, MD

Bundled payments are not only here to stay, they are now being mandated in specific geographic regions, under the Comprehensive Care for Joint Replacement (CJR) program. Although the intent of this payment strategy is to drive value in health care, a likely unintended consequence may be to decrease access to surgical care for certain high-risk patients.

Winning with Payment Reform

"What's important to us is maintaining our independence and our relevance," noted Peter A. Caprise, MD, of the Orthopaedic Center of Central Virginia (OCCV). "So when we look at payment reform, we don't see burdens that are coming down the pike, but opportunities for our practice to shore up our bottom line and ensure our independence." Dr. Caprise shared OCCV's strategy for winning with payment reform at the Fall Meeting of the AAOS Board of Councilors/Board of Specialty Societies.

Is Your Team More than a Group of Individuals?

Matthew M. Tomaino, MD, MBA

The difference between teams and groups of individuals is relevant to every orthopaedic surgeon because it is through teams that patient care is delivered. This is not a new concept, but it reflects a paradigm shift for surgeons indoctrinated to regard the "team" as a mere support system for individual accomplishments. As surgeons, we share an inclination to tightly control processes and to view our teams as vehicles for our individual efforts.

Is a Practice Merger in Your Future?

Amber McGraw Walsh, JD; Scott Downing, JD

Statistics show dramatic trends in the acquisition of medical practices by hospitals, the creation of large practice organizations, and the disappearance of the individual practitioner. For example, in 2014, only 35 percent of physicians described themselves as independent practice owners, according to a study by the Physicians Foundation. Just 6 years earlier, 62 percent of physicians identified themselves as independent practice owners.

The Impact of ICD-10 Implementation

Kyle M. Lee

On Oct. 1, 2015, the 10th revision of the International Classification of Diseases (ICD) code set was implemented in the United States. This was the largest and most far-reaching change since the adoption of ICD-9 in 1979, and was anticipated to have a profound impact on medical practices. Two months after implementation (December 2015), KarenZupko & Associates, Inc. (KZA) conducted a survey to measure that impact.

Healthcare Performance Measures Increase in Importance

Jackie Ryan, MPA

Some say the performance measurement train has left the station. There is no doubt that there is widespread concern from physicians about the financial consequences and regulatory complexity of the Physician Quality Reporting System (PQRS), Meaningful Use, Electronic Health Records (EHR) Incentive Program, and Value Based Modifier.