There is no denying that the past few years have been a time of immense change in healthcare. Sweeping pieces of legislation have fundamentally altered the way we practice medicine. This is absolutely the case when it comes to the Medicare Access and CHIP Reauthorization Act of 2015 (MACRA, for short). MACRA is an enormous piece of legislation signed into law in April 2015. The bill gained immediate notoriety because it killed the Medicare sustainable growth rate (SGR) formula—an oft-criticized, nearly 20-year-old system used to calculate physician payment reductions. Congress’ rare act of bipartisanship was a victory for rheumatologists; lawmakers not only eradicated a proposed double-digit pay cut, they also opened up new roads to long-term financial stability for physicians.
However, the so-called permanent doc fix is anything but simple. From my perspective, MACRA is actually a bigger change to the overall healthcare landscape than even the Affordable Care Act. This is because the legislation largely reworks how doctors are reimbursed by Medicare. It also demands new, active engagement and decision making on the part of providers. For this reason, MACRA must be on every rheumatologist’s radar. It certainly is on the radar of our leadership team at the American College of Rheumatology and, as such, we will take an active role in assisting member rheumatologists in the transition to a new era of physician payments.
Before delving into the details of MACRA—as well as the choices that lie ahead for rheumatologists—I want to clearly establish what I hope readers will take away from this column.
First, time is of the essence: There is a very real deadline on Jan. 1, 2017. This is the date that data from your practice will start counting for Medicare reimbursement in 2019. This means that the time to start thinking about MACRA is right now.
Second, all providers will have to choose one of two payment tracks: Merit-Based Incentive Payment System (MIPS) or Alternative Payment Models (APMs).
Third, the ACR and its electronic patient-data reporting system, Rheumatology Informatics System for Effectiveness (RISE) Registry, will be an increasingly important resource in the months ahead, especially for those who select the MIPS track. And finally, it is imperative that the rheumatology community understand the impending long-term effects of MACRA and engage in strategic thought about the best option for their practice. I want to remind you that the ACR will be there, providing up-to-date information and support for its members.
Choose Your Own Adventure: MIPS vs. APMs
MACRA not only eliminated SGR, it also replaced it with an alternative set of predictable, annual, baseline payment increases and two potential payment tracks from which all providers must choose. Both payment models fit into the Centers for Medicare and Medicaid Services’ (CMS’s) larger goal of paying for value, rather than fee for service. What exactly does this mean? Well, all the way through 2019, there will be an annual baseline payment increase of 0.5%. From that point on, annual automatic increases come to an end, and physicians will have to choose their own adventure when it comes to Medicare reimbursement. Almost without exception, every Medicare provider in the country will be forced into one of these two pathways.
One pathway is MIPS. Under MIPS, elements of the Physician Quality Reporting System, the Value-Based Payment Modifier, and the Meaningful Use program will be consolidated into a single program with four weighted performance categories on which eligible professionals will be assessed for reimbursement: 1) Quality; 2) Resource Use; 3) Clinical Practice Improvement Activities; and 4) Meaningful Use of Certified EHR Technology. For physicians who select the MIPS track, a methodology will be used to assess the physician’s performance provided for Medicare beneficiaries, and each MIPS eligible physician will receive a composite quality score for each performance period.
The other pathway is one of many alternative payment models (APMs) (e.g., Accountable Care Organizations). MACRA provides incentives for providers to participate in certain APMs. From 2019 through 2024, qualifying APM participants will receive a lump sum incentive payment of 5%. Qualifying APM participants will not be subject to MIPS adjustments; however, many components of MIPS, including electronic health records (EHRs), are also requirements of APMs.
At the moment, there is a lot to learn about both MIPS and APMs because many of the rules about MIPS and APMs are yet to be written. The specific benefits and drawbacks will become clear over time, as CMS continues to determine how it will put these two tracks into operation. The ACR is actively engaged with CMS administrators to make sure that the rules and quality measures defining each track are fair, feasible and logical for rheumatologists.
To strengthen the collective effort, the ACR has contracted with regulatory lobbyists who have expertise and relationships in this area, complementing the ACR’s lobbying efforts in the legislative arena. Over the coming year, the ACR will be launching an informational campaign that will give members access to up-to-date MACRA information and analysis throughout CMS’s decision-making process.
Navigating the MIPS Pathway
Method of Attribution: For those practitioners considering the MIPS pathway, the method of attribution is important—that is, the process by which patients get assigned to a particular doctor for cost and quality measures. Under MIPS, rheumatologists will be judged as a group based on every doctor who is a part of a single Tax Identification Number (TIN). Hence, if a patient with a complex condition sees many different doctors, cost and quality measurements will be aggregated for all doctors in the TIN. Under the APM track, the method of attribution will be by the physician’s National Practitioner Identifier (NPI), in a more precise, individualized manner. The takeaway here: If you work with people of high-quality care and low cost, MIPS will make sense for you. That said, knowing who is in your TIN will be an important consideration for those considering the MIPS pathway.
Rheumatology Informatics System for Effectiveness (RISE) Registry: RISE plus MIPS equals survival. The RISE Registry—a database developed and managed by the ACR and available to and free for all members—will be key to success in the MIPS pathway. The database is a robust tool for quality improvement reporting that pulls data on demographics, medications, lab data, disease activity, functional status and other metrics directly from your practice’s EHR system. Importantly, RISE has been designated as a qualified clinical data registry (QCDR) by CMS, meaning that rheumatologists who wish to use RISE for MIPS quality reporting will be able to do so automatically.
Although we are excited about the role RISE can play in helping rheumatologists successfully navigate the MIPS track, it is also important to note that MIPS may not end up being the final CMS payment pathway. From what we know about CMS’s current thinking, the agency seems to see MIPS as a temporary solution to ease the transition to the new value-based payment structure. We believe CMS will eventually phase out the MIPS pathway and transition all providers into APMs in the future. Because this could have significant implications for small private practices, the ACR will continue to actively engage with CMS on this issue and provide additional updates as we know more about the agency’s long-term plans for physician reimbursement.
There is no doubt that MACRA alters the reimbursement landscape and presents important, ongoing decisions for practicing rheumatologists. However, I am confident the rheumatology community will adapt and prosper in the face of these changes and that the ACR will be there along the way with up-to-date information and support. Information will be our most important tool in getting ahead of the curve and succeeding in this rapidly changing environment. I encourage all members to grasp the opportunity to get their practice ready for changes coming down the pike, thinking strategically. And I encourage members to consider micro-volunteering opportunities especially in advocacy on these issues, in order to Advance Rheumatology!
Joan M. Von Feldt, MD, MSEd, FACR, FACP, is the president of the ACR, professor of medicine at the Perelman School of Medicine at the University of Pennsylvania. She is also staff physician at the Philadelphia VA Medical Center.