The ACR and a number of other physician medical associations are lobbying for an immediate legislative fix to a piece of the MACRA law that factors high-cost Part B drugs into a rheumatology practice’s Medicare reimbursement rate through the Merit-Based Incentive Payment System (MIPS). This change, which goes into effect immediately, will impact practices in 2019 when the first MIPS bonuses and penalties occur and would force many rheumatologists to stop prescribing Part B drugs that are very important to patients with chronic rheumatologic conditions.
Explore this issueFebruary 2018
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How It Will Work
“The way the new system is set up, doctors will be informed about the magnitude of their payment adjustment for a given year before the year starts, and those who are told that their upcoming fees will be reduced by up to 4% (or 9% in future years) are basically being told to avoid incurring any high drug costs with thin profit margins—and that is exactly what Part B drugs are,” explains Angus Worthing, MD, FACP, FACR, chair of the ACR’s Government Affairs Committee.
He gives the example of the change in rate of calculated reimbursement with Part B drug costs included for a patient with rheumatoid arthritis. Currently, the rate is calculated based on professional charges for seeing the patient. So it would cost approximately $433 to see the patient in the office four times per year. With the shift to include Part B drug costs, the course of a Part B drug, such as infliximab, at $11,328 for one year at a starting dose would be added to the professional charges. This means the CMS would use $433 plus the drug cost, or $11,761, rather than $433 to assess a penalty or bonus.
How It Will Affect You & Your Patients
Patients with autoimmune diseases are commonly prescribed Part B drugs, such as infliximab (Remicade, Inflectra, Remsima), abatacept (Orencia), rituximab (Rituxan), certolizumab (Cimzia), golimumab (Simponi Aria) and belimumab (Benlysta), and osteoporosis drugs, such as zoledronic acid (Recast) and denosumab (Prolia). If this rule is not changed as soon as possible, rheumatologists who provide Part B drugs could see big variations in reimbursement, with the possibility of very large reimbursement cuts from the CMS, which would force providers to stop providing Part B therapies to patients or risk the operational viability of their practice, Dr. Worthing says.
“This rule is an extreme disincentive for doctors to provide Part B drugs in the office. All the patients in such a practice would risk being told to obtain their medicines elsewhere—likely at less convenient, more expensive locations that have a different profit/loss margin.”