- Email: [email protected]
Regulatory Changes Are Upon Us
Practice Management
Regulatory Changes Are Upon Us Gregory M. Worsowicz, MD, MBA, Kristin Harlan, MBA, MHA INTRODUCTION The health care industry has seen many changes since the Patient Protection and Affordable Care Act of 2010. Many of the changes and proposed initiatives have gone from ideas for the future to implementation into today’s practice. When the Affordable Care Act was first signed, physicians may have thought that many of these changes might not occur. Terms such as meaningful use (MU), accountable care organizations (ACO), patient-centered medical homes, quality initiatives, price transparency, and changes in the International Classifications of Diseases (ICD) are now part of how physicians run or will run their practices. These programs and initiatives have been just a few of the catalysts for practice change. As a result, physician practices are in a state of continuous transition. Some of these practice requirements and changes have been ascribed to a decrease in physicians who enter or remain in a private practice. This article reviews a few of the changes and their current status.
MEDICAL SHARED SAVINGS The Centers for Medicare and Medicaid (CMS) established the Medical Shared Savings Program to facilitate accountability for care, coordination of care, and investment in infrastructures and redesign of care processes [1]. Their goal is to improve quality and reduce costs. Since the creation of the Medical Shared Savings Program, CMS has selected multiple organizations to participate as ACOs. Eligible providers, hospitals, and suppliers are able to participate in the shared savings programs by creating and participating in these ACOs. The program has seen a continuous growth in CMS-certified ACOs (Table 1) [2]. Based on this growth, approximately 2.4 million Medicare patients are cared for by an ACO, with an additional 15 million non-Medicare patients who receive care within a practice that is part of a Medicare ACO. There also has been growth of non-Medicare ACOs, which reaches approximately 8-14 million commercially insured patients [3]. Based on these numbers and trends, it appears that this or a similar model of care that involves population health is here to stay. Practices have taken a variety of strategies to prepare for this, which include joining an ACO, becoming involved with a patient-centered medical home, acquiring systems to track patient outcomes and costs, or just taking the wait-and-see approach. The one certainty appears to be that things will change.
MEANINGFUL USE The American Recovery and Reinvestment Act of 2009 introduced the Health Information Technology for Economic and Clinical Health Act [4,5]. This legislation was implemented to spur the adoption of electronic health records (EHR) and quality data reporting. Both of these initiatives had the goal of improving patient care. MU stage I requirements were first published in 2010, and eligibility started in 2011. Since stage I was implemented, there has been an increased adoption of electronic health systems among medical practices. Some surveys report that more than 3 of 4 physicians now use EHRs. Of those who have adopted EHR, 62% say that they have already successfully attested for MU stage I [6]. Through April 2013, more than $8.8 billion has been paid for Medicare EHR programs, and $5.5 billion for Medicaid programs [7]. The clock is ticking to avoid payment penalties. Medicare Eligible Providers (EPs) who demonstrated MU in 2011 or 2012 must demonstrate a full year of MU in 2013 to avoid a PM&R 1934-1482/13/$36.00 Printed in U.S.A.
G.M.W. Physical Medicine and Rehabilitation, University of Missouri, Columbia, MO. Address correspondence to: G.M.W., Department of PM&R, University of Missouri, One Hospital Drive, Columbia, MO 65212; e-mail: [email protected] Disclosure: nothing to disclose K.H. University Physicians, University of Missouri, Columbia, MO Disclosure: nothing to disclose
© 2013 by the American Academy of Physical Medicine and Rehabilitation Vol. 5, 715-717, August 2013 http://dx.doi.org/10.1016/j.pmrj.2013.06.009
715
716
Worsowicz and Harlan
REGULATORY CHANGES ARE UPON US
Table 1. Centers for Medicare and Medicaid Shared Savings Program Date
No. organizations
December 2011 April 2012 July 2012 January 2013
32* 27 87 106
*Pioneer accountable care organizations model.
negative payment adjustment in 2015. EPs first demonstrating MU in 2014 must meet the 90-day attestation requirement by October 3, 2014, to avoid a negative payment adjustment in 2015 (Table 2). Stage II will use a core and menu structure for objectives. Medicare Eligible Providers must meet 17 core and 3 menu objectives for a total of 20 core objectives [8]. This is just one of the requirements for meeting stage II.
upcoming change [15]. As with any transition, physician practices will be affected. CMS recognizes this and recommends that providers’ budgets should account for software upgrades, software license costs, hardware procurement, staff training costs, revision of work form, work flow changes during and after implementation, and risk mitigation [16]. Physicians will need to be aware of the specificity of data required for accurate ICD-10 coding because, if not documented, coders may have to contact their physicians for additional information, which results in time-consuming rework. Paul Weygandt, MD, JD, MPH, MBA, CCS, CPE, vice president of Physician Services at J.A. Thomas & Associates, a Nuance Company, recommends a 3-phase approach, including physician awareness, subspecialty or specialty training, and identifying a physician champion [17]. The time is now to either initiate this strategy, look to outsource this function, or roll the dice that there will be yet another delay in the October 2014 implementation date.
PRICE TRANSPARENCY Private insurers provide beneficiaries ways to be aware of medical costs. These plans offer patient portals to both cost compare and provide individual cost estimators [9,10]. This may even become of greater interest to patients as they move from low out-of-pocket deductible programs to higher, consumer-driven policies. Although private payers previously provided this information, it has not been until recently that CMS also has started to publish hospital and outpatient charges. In May 2013, CMS posted information that compared the charges and services of the 100 most common Medicare inpatient stays [11]. As a follow-up to this, new data were released on a county level as well as selected data on hospital outpatient charges that included estimates for the average charges of 30 types of hospital outpatient procedures, such as clinic visits, echocardiograms, and endoscopies, from across the country [12]. This information has been picked up by the mainstream press when comparing discrepancies for local and regional charges [13,14]. It is only a matter of time until individual physician charges are published with your quality data. Therefore, someone in your practice needs to monitor what is being reported (eg, charges, contractual adjustments, actual payments) and its accuracy. Your practice may be impacted by patient “price shopping” in the future, if not already occurring.
ICD, 10TH REVISION The original implementation date for the ICD, 10th Revision (ICD-10) was scheduled for October 1, 2013. This is not just a Medicare change because everyone is mandated by the Health Insurance Portability Accountability Act to use ICD10. However, due to various organizations’ concern, the date was delayed until October 1, 2014. This delay is expected to assist small organizations, in particular, to prepare for the
PHYSICIAN PRACTICE Physicians in all groups continue to face increased overhead costs for information technology, administrative support, and looming ICD-10 implementation. Some physicians feel the push to leave privately owned practices to join either large physician groups or hospital employment. Articles in The New York Times [18] and The Washington Times [19] have begun to document this migration of physicians from private practice into some form of large group employment. Physicians who reported being in a private practice independently was down from 57% in 2000 to 39% in 2009. A Jackson Healthcare Study showed that, in 2012, 40% of hospitals acquired one or more physician practices, with 52% planning to do so in 2013 [20]. This trend of physicians leaving private practice due to the burden of regulatory and practice costs has been well documented [20,21]. Your choice of practice setting (private or employed) may vary by region and market, and will include ACOs, medical homes, large medical groups, or hospital employment. In each of these cases, physicians may forfeit some of their independence and not feel the direct responsibility for capital, technical, administrative, and staffing resources. Is it time for you or your practice to consider this? If not, are you prepared for all the continuous change?
Table 2. Meaningful dates for eligible providers (EP) 2011 2014 2014 2015
First year able to attest stage I First year eligible to attest stage II October 3, 2014: Date that first-time EPs must successfully attest to avoid penalty Medicare payment negative adjustment
PM&R
Vol. 5, Iss. 8, 2013
CONCLUSION Running a medical practice has changed and will continue to change. Regardless of your practice type, setting, or payer mix, the issues touched on in this article should motivate all health care providers to evaluate the changing requirements for their practices. Many of these issues are no longer happening in the future but are occurring today. You should be prepared for today and anticipate the changes that your practice will need for tomorrow.
REFERENCES 1. Centers for Medicare & Medicaid Services. Shared Savings Program. Available at http://www.cms.gov/Medicare/Medicare-Fee-for-ServicePayment/sharedsavingsprogram/index.html. Accessed June 1, 2013. 2. Centers for Medicare & Medicaid Services. Accountable Care Organizations (ACO). Available at http://www.cms.gov/Medicare/MedicareFee-for-Service-Payment/ACO/index.html?redirect⫽/aco/. Accessed June 3, 2013. 3. Weil R, Gandhi N. The ACO surprise: There’s a common belief that Medicare’s ACO Programs have had little impact but a new survey of the field reveals a very different story. Oliver Wyman’s Health and Life Sciences. Available at http://www.oliverwyman.com/media/OW_ENG_ HLS_PUBL_The_ACO_Surprise.pdf. Accessed June 3, 2013. 4. Using electronic health records to improve health care in your practice and community. Available at http://www.healthit.gov/providersprofessionals/ehr-incentive-payment-timeline. Accessed April 12, 2011. 5. Available at https://www.cms.gov/EHRIncentivePrograms/01_overview. asp. Accessed April 2, 2011. 6. HIT Consultant. Survey: Meaningful use incentives fuels EHR adoption to all-time high. Available at http://www.hitconsultant.net/2013/05/31/ survey-meaningful-use-incentives-fuels-ehr-adoption-to-all-time-high/. Accessed June 7, 2013. 7. Centers for Medicare & Medicaid Services. Data and program reports. Available at http://www.cms.gov/Regulations-and-Guidance/Legislation/ EHRIncentivePrograms/DataAndReports.html. Accessed June 3, 2013. 8. Centers for Medicare & Medicaid Services. Fact sheets. Details for: CMS proposes definition of stage 2 meaningful use of certified electronic health records (HER) technology. Available at https://www.cms.gov/ apps/media/press/factsheet.asp?Counter⫽4286&intNumPerPage⫽10 &checkDate⫽&checkKey⫽&srchType⫽1&numDays⫽3500&srchOpt⫽ 0&srchData⫽&keywordType⫽All&chkNewsType⫽6&intPage⫽&show All⫽&pYear⫽&year⫽&desc⫽&cboOrder⫽date. Accessed June 6, 2013. 9. Anthem Blue Cross. Plan and comparison tool. Available at http:// www.anthem.com/wps/portal/ca/group?name⫽uc&content_path⫽
10.
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12.
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member/f0/s0/t0/pw_e182176.htm&label⫽Plan%20and%20Comparison% 20Tool. Accessed June 6, 2013. United Healthcare. myHealthcare Cost Estimator. Available at http:// www.uhc.com/individuals_families/member_tools/myhealthcare_cost_ estimator.htm. Accessed June 6, 2013. U.S. Department of Health and Human Services. Administration offers consumers an unprecedented look at hospital charges. Available at http://www.hhs.gov/news/press/2013pres/05/20130508a.html. Accessed June 7, 2013. U.S. Department of Health and Human Services. Secure health data helping patients, doctors improve care and health. Available at http:// www.dhhs.gov/news/press/2013pres/06/20130603b.html. Accessed June 7, 2013. Rosenthal E. The $2.7 trillion medical bill: Colonoscopies explain why U.S. leads the world in health expenditures. The New York Times. June 1, 2013. Available at http://www.nytimes.com/2013/06/02/health/ colonoscopies-explain-why-us-leads-the-world-in-health-expenditures. html?pagewanted⫽all&_r⫽0. Accessed June 3, 2013. Health: A Bitter Pill to Swallow. Time. Available at http://www.time. com/time/magazine/article/0,9171,969453,00.html. Accessed June 6, 2013. McKinney M. One-year delay on ICD-10 to October 2014 finalized. Modern Healthcare. Available at: http://passportmedia.wordpress.com/ 2012/08/24/. Accessed June 7, 2013. Centers for Medicare & Medicaid Services. FAQs: ICD-10 Transition Basics. Available at http://www.cms.gov/Medicare/Coding/ICD10/ Downloads/ICD10FAQs2013.pdf. Accessed June 6, 2013. Bresnick J. ICD-10 delay a “disservice,” but there’s still time to prepare. EHR Intelligence. April 25, 2013. Available at http://ehrintelligence. com/2013/04/25/icd-10-delay-a-%E2%80%9Cdisservice%E2%80%9Dbut-there%E2%80%99s-still-time-to-prepare/. Accessed June 7, 2013. Harris G. More doctors giving up private practices. The New York Times. March 26, 2010:B1. Available at http://www.nytimes.com/2010/03/ 26/health/policy/26docs.html?pagewanted⫽all&_r⫽1&. Accessed June 3, 2013. Devaney T. Paperwork, costs push doctors out of practices. The Washington Times. July 23, 2012. Available at http://www.washingtontimes.com/ news/2012/jul/23/doctors-are-leaving-their-small-private-practices-/?page⫽ all. Accessed June 3, 2013. Jackson Healthcare. Trend watch: Physician practice acquisitions: Tracking which physician practices hospitals are acquiring. Available at http:// www.jacksonhealthcare.com/media/182032/practiceacquisitionreport_ ebook0213.pdf. Accessed June 7, 2013. ERH Intelligence. Solo physicians and accountable care: Is it time to sell out? Available at http://ehrintelligence.com/2013/04/25/solo-physiciansand-accountable-care-is-it-time-to-sell-out/. Accessed June 3, 2013.
Regulatory Changes Are Upon Us Gregory M. Worsowicz, MD, MBA, Kristin Harlan, MBA, MHA INTRODUCTION The health care industry has seen many changes since the Patient Protection and Affordable Care Act of 2010. Many of the changes and proposed initiatives have gone from ideas for the future to implementation into today’s practice. When the Affordable Care Act was first signed, physicians may have thought that many of these changes might not occur. Terms such as meaningful use (MU), accountable care organizations (ACO), patient-centered medical homes, quality initiatives, price transparency, and changes in the International Classifications of Diseases (ICD) are now part of how physicians run or will run their practices. These programs and initiatives have been just a few of the catalysts for practice change. As a result, physician practices are in a state of continuous transition. Some of these practice requirements and changes have been ascribed to a decrease in physicians who enter or remain in a private practice. This article reviews a few of the changes and their current status.
MEDICAL SHARED SAVINGS The Centers for Medicare and Medicaid (CMS) established the Medical Shared Savings Program to facilitate accountability for care, coordination of care, and investment in infrastructures and redesign of care processes [1]. Their goal is to improve quality and reduce costs. Since the creation of the Medical Shared Savings Program, CMS has selected multiple organizations to participate as ACOs. Eligible providers, hospitals, and suppliers are able to participate in the shared savings programs by creating and participating in these ACOs. The program has seen a continuous growth in CMS-certified ACOs (Table 1) [2]. Based on this growth, approximately 2.4 million Medicare patients are cared for by an ACO, with an additional 15 million non-Medicare patients who receive care within a practice that is part of a Medicare ACO. There also has been growth of non-Medicare ACOs, which reaches approximately 8-14 million commercially insured patients [3]. Based on these numbers and trends, it appears that this or a similar model of care that involves population health is here to stay. Practices have taken a variety of strategies to prepare for this, which include joining an ACO, becoming involved with a patient-centered medical home, acquiring systems to track patient outcomes and costs, or just taking the wait-and-see approach. The one certainty appears to be that things will change.
MEANINGFUL USE The American Recovery and Reinvestment Act of 2009 introduced the Health Information Technology for Economic and Clinical Health Act [4,5]. This legislation was implemented to spur the adoption of electronic health records (EHR) and quality data reporting. Both of these initiatives had the goal of improving patient care. MU stage I requirements were first published in 2010, and eligibility started in 2011. Since stage I was implemented, there has been an increased adoption of electronic health systems among medical practices. Some surveys report that more than 3 of 4 physicians now use EHRs. Of those who have adopted EHR, 62% say that they have already successfully attested for MU stage I [6]. Through April 2013, more than $8.8 billion has been paid for Medicare EHR programs, and $5.5 billion for Medicaid programs [7]. The clock is ticking to avoid payment penalties. Medicare Eligible Providers (EPs) who demonstrated MU in 2011 or 2012 must demonstrate a full year of MU in 2013 to avoid a PM&R 1934-1482/13/$36.00 Printed in U.S.A.
G.M.W. Physical Medicine and Rehabilitation, University of Missouri, Columbia, MO. Address correspondence to: G.M.W., Department of PM&R, University of Missouri, One Hospital Drive, Columbia, MO 65212; e-mail: [email protected] Disclosure: nothing to disclose K.H. University Physicians, University of Missouri, Columbia, MO Disclosure: nothing to disclose
© 2013 by the American Academy of Physical Medicine and Rehabilitation Vol. 5, 715-717, August 2013 http://dx.doi.org/10.1016/j.pmrj.2013.06.009
715
716
Worsowicz and Harlan
REGULATORY CHANGES ARE UPON US
Table 1. Centers for Medicare and Medicaid Shared Savings Program Date
No. organizations
December 2011 April 2012 July 2012 January 2013
32* 27 87 106
*Pioneer accountable care organizations model.
negative payment adjustment in 2015. EPs first demonstrating MU in 2014 must meet the 90-day attestation requirement by October 3, 2014, to avoid a negative payment adjustment in 2015 (Table 2). Stage II will use a core and menu structure for objectives. Medicare Eligible Providers must meet 17 core and 3 menu objectives for a total of 20 core objectives [8]. This is just one of the requirements for meeting stage II.
upcoming change [15]. As with any transition, physician practices will be affected. CMS recognizes this and recommends that providers’ budgets should account for software upgrades, software license costs, hardware procurement, staff training costs, revision of work form, work flow changes during and after implementation, and risk mitigation [16]. Physicians will need to be aware of the specificity of data required for accurate ICD-10 coding because, if not documented, coders may have to contact their physicians for additional information, which results in time-consuming rework. Paul Weygandt, MD, JD, MPH, MBA, CCS, CPE, vice president of Physician Services at J.A. Thomas & Associates, a Nuance Company, recommends a 3-phase approach, including physician awareness, subspecialty or specialty training, and identifying a physician champion [17]. The time is now to either initiate this strategy, look to outsource this function, or roll the dice that there will be yet another delay in the October 2014 implementation date.
PRICE TRANSPARENCY Private insurers provide beneficiaries ways to be aware of medical costs. These plans offer patient portals to both cost compare and provide individual cost estimators [9,10]. This may even become of greater interest to patients as they move from low out-of-pocket deductible programs to higher, consumer-driven policies. Although private payers previously provided this information, it has not been until recently that CMS also has started to publish hospital and outpatient charges. In May 2013, CMS posted information that compared the charges and services of the 100 most common Medicare inpatient stays [11]. As a follow-up to this, new data were released on a county level as well as selected data on hospital outpatient charges that included estimates for the average charges of 30 types of hospital outpatient procedures, such as clinic visits, echocardiograms, and endoscopies, from across the country [12]. This information has been picked up by the mainstream press when comparing discrepancies for local and regional charges [13,14]. It is only a matter of time until individual physician charges are published with your quality data. Therefore, someone in your practice needs to monitor what is being reported (eg, charges, contractual adjustments, actual payments) and its accuracy. Your practice may be impacted by patient “price shopping” in the future, if not already occurring.
ICD, 10TH REVISION The original implementation date for the ICD, 10th Revision (ICD-10) was scheduled for October 1, 2013. This is not just a Medicare change because everyone is mandated by the Health Insurance Portability Accountability Act to use ICD10. However, due to various organizations’ concern, the date was delayed until October 1, 2014. This delay is expected to assist small organizations, in particular, to prepare for the
PHYSICIAN PRACTICE Physicians in all groups continue to face increased overhead costs for information technology, administrative support, and looming ICD-10 implementation. Some physicians feel the push to leave privately owned practices to join either large physician groups or hospital employment. Articles in The New York Times [18] and The Washington Times [19] have begun to document this migration of physicians from private practice into some form of large group employment. Physicians who reported being in a private practice independently was down from 57% in 2000 to 39% in 2009. A Jackson Healthcare Study showed that, in 2012, 40% of hospitals acquired one or more physician practices, with 52% planning to do so in 2013 [20]. This trend of physicians leaving private practice due to the burden of regulatory and practice costs has been well documented [20,21]. Your choice of practice setting (private or employed) may vary by region and market, and will include ACOs, medical homes, large medical groups, or hospital employment. In each of these cases, physicians may forfeit some of their independence and not feel the direct responsibility for capital, technical, administrative, and staffing resources. Is it time for you or your practice to consider this? If not, are you prepared for all the continuous change?
Table 2. Meaningful dates for eligible providers (EP) 2011 2014 2014 2015
First year able to attest stage I First year eligible to attest stage II October 3, 2014: Date that first-time EPs must successfully attest to avoid penalty Medicare payment negative adjustment
PM&R
Vol. 5, Iss. 8, 2013
CONCLUSION Running a medical practice has changed and will continue to change. Regardless of your practice type, setting, or payer mix, the issues touched on in this article should motivate all health care providers to evaluate the changing requirements for their practices. Many of these issues are no longer happening in the future but are occurring today. You should be prepared for today and anticipate the changes that your practice will need for tomorrow.
REFERENCES 1. Centers for Medicare & Medicaid Services. Shared Savings Program. Available at http://www.cms.gov/Medicare/Medicare-Fee-for-ServicePayment/sharedsavingsprogram/index.html. Accessed June 1, 2013. 2. Centers for Medicare & Medicaid Services. Accountable Care Organizations (ACO). Available at http://www.cms.gov/Medicare/MedicareFee-for-Service-Payment/ACO/index.html?redirect⫽/aco/. Accessed June 3, 2013. 3. Weil R, Gandhi N. The ACO surprise: There’s a common belief that Medicare’s ACO Programs have had little impact but a new survey of the field reveals a very different story. Oliver Wyman’s Health and Life Sciences. Available at http://www.oliverwyman.com/media/OW_ENG_ HLS_PUBL_The_ACO_Surprise.pdf. Accessed June 3, 2013. 4. Using electronic health records to improve health care in your practice and community. Available at http://www.healthit.gov/providersprofessionals/ehr-incentive-payment-timeline. Accessed April 12, 2011. 5. Available at https://www.cms.gov/EHRIncentivePrograms/01_overview. asp. Accessed April 2, 2011. 6. HIT Consultant. Survey: Meaningful use incentives fuels EHR adoption to all-time high. Available at http://www.hitconsultant.net/2013/05/31/ survey-meaningful-use-incentives-fuels-ehr-adoption-to-all-time-high/. Accessed June 7, 2013. 7. Centers for Medicare & Medicaid Services. Data and program reports. Available at http://www.cms.gov/Regulations-and-Guidance/Legislation/ EHRIncentivePrograms/DataAndReports.html. Accessed June 3, 2013. 8. Centers for Medicare & Medicaid Services. Fact sheets. Details for: CMS proposes definition of stage 2 meaningful use of certified electronic health records (HER) technology. Available at https://www.cms.gov/ apps/media/press/factsheet.asp?Counter⫽4286&intNumPerPage⫽10 &checkDate⫽&checkKey⫽&srchType⫽1&numDays⫽3500&srchOpt⫽ 0&srchData⫽&keywordType⫽All&chkNewsType⫽6&intPage⫽&show All⫽&pYear⫽&year⫽&desc⫽&cboOrder⫽date. Accessed June 6, 2013. 9. Anthem Blue Cross. Plan and comparison tool. Available at http:// www.anthem.com/wps/portal/ca/group?name⫽uc&content_path⫽
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member/f0/s0/t0/pw_e182176.htm&label⫽Plan%20and%20Comparison% 20Tool. Accessed June 6, 2013. United Healthcare. myHealthcare Cost Estimator. Available at http:// www.uhc.com/individuals_families/member_tools/myhealthcare_cost_ estimator.htm. Accessed June 6, 2013. U.S. Department of Health and Human Services. Administration offers consumers an unprecedented look at hospital charges. Available at http://www.hhs.gov/news/press/2013pres/05/20130508a.html. Accessed June 7, 2013. U.S. Department of Health and Human Services. Secure health data helping patients, doctors improve care and health. Available at http:// www.dhhs.gov/news/press/2013pres/06/20130603b.html. Accessed June 7, 2013. Rosenthal E. The $2.7 trillion medical bill: Colonoscopies explain why U.S. leads the world in health expenditures. The New York Times. June 1, 2013. Available at http://www.nytimes.com/2013/06/02/health/ colonoscopies-explain-why-us-leads-the-world-in-health-expenditures. html?pagewanted⫽all&_r⫽0. Accessed June 3, 2013. Health: A Bitter Pill to Swallow. Time. Available at http://www.time. com/time/magazine/article/0,9171,969453,00.html. Accessed June 6, 2013. McKinney M. One-year delay on ICD-10 to October 2014 finalized. Modern Healthcare. Available at: http://passportmedia.wordpress.com/ 2012/08/24/. Accessed June 7, 2013. Centers for Medicare & Medicaid Services. FAQs: ICD-10 Transition Basics. Available at http://www.cms.gov/Medicare/Coding/ICD10/ Downloads/ICD10FAQs2013.pdf. Accessed June 6, 2013. Bresnick J. ICD-10 delay a “disservice,” but there’s still time to prepare. EHR Intelligence. April 25, 2013. Available at http://ehrintelligence. com/2013/04/25/icd-10-delay-a-%E2%80%9Cdisservice%E2%80%9Dbut-there%E2%80%99s-still-time-to-prepare/. Accessed June 7, 2013. Harris G. More doctors giving up private practices. The New York Times. March 26, 2010:B1. Available at http://www.nytimes.com/2010/03/ 26/health/policy/26docs.html?pagewanted⫽all&_r⫽1&. Accessed June 3, 2013. Devaney T. Paperwork, costs push doctors out of practices. The Washington Times. July 23, 2012. Available at http://www.washingtontimes.com/ news/2012/jul/23/doctors-are-leaving-their-small-private-practices-/?page⫽ all. Accessed June 3, 2013. Jackson Healthcare. Trend watch: Physician practice acquisitions: Tracking which physician practices hospitals are acquiring. Available at http:// www.jacksonhealthcare.com/media/182032/practiceacquisitionreport_ ebook0213.pdf. Accessed June 7, 2013. ERH Intelligence. Solo physicians and accountable care: Is it time to sell out? Available at http://ehrintelligence.com/2013/04/25/solo-physiciansand-accountable-care-is-it-time-to-sell-out/. Accessed June 3, 2013.