In response to the required changes in reimbursement from fee for service to value-based payment under the Medicare Access and CHIP Reauthorization Act (MACRA) of 2015, the ACR is exploring development of a rheumatology-specific alternative payment model (APM) for rheumatologists and practices, which would provide an additional option for payment other than the Merit-Based Incentive Payment System (MIPS).
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APMs to Outlast MIPS
Under MACRA, physicians and practices who take Medicare patients can opt to participate in one of two different systems of value-based reimbursement: the Merit-Based Incentive Payment System (MIPS) or an Alternative Payment Model (APM). Although all physicians who accept Medicare will automatically be enrolled in MIPS unless they meet exemption requirements, it is anticipated that APMs will be increasingly adopted.
“The MIPS program was not designed to be sustainable for practices in the long run,” says Kwas Huston, MD, the Center for Rheumatic Disease, Kansas City, Mo., saying that inherent pressures within MIPs are pushing physicians toward APMs.
Creating an RA-Specific APM
Dr. Huston, along with Edward Herzig, MD, is co-chair of an ACR working group that is working toward a potential APM that would focus on rheumatoid arthritis (RA). The working group consists of ACR members in a variety of practice settings and geographic areas. Dr. Huston emphasizes that the ACR believes rheumatologists will be better served if a rheumatology-specific APM is developed by the ACR rather than an outside group, such as the Centers for Medicare & Medicaid Services (CMS).
However, he underscores that the goal of the APM is to help rheumatology practices thrive and improve their financial performance. “We hope an APM will work better for patients and physicians by eliminating some of the impediments to care, such as prior authorization; paying for non-face-to-face interactions with patients; and providing steady and predictable revenue for patient care,” he says.
Current APM Status
The ACR is working with an expert consultant on this project and has sought input from a wide variety of stakeholder groups to make sure that a potential payment model is feasible and can be incorporated into practice.
To date, the working group has developed a working draft proposal and is in the midst of refining various elements.
According to Drs. Herzig and Huston, once the draft proposal is refined, it will be presented to the ACR Committee on Rheumatologic Care (CORC) and the ACR Board of Directors. The end goal will be to present a model to the U.S. Government Accountability Office’s Payment Model Technical Advisory Committee (PTAC) so that it could be recommended to and approved by the CMS as an APM that can be used by rheumatologists, if desired.
“Eventually, we would hope to expand the RA model to other rheumatic diseases,” says Dr. Huston. “The APM model will be flexible enough that it could be applied to any rheumatology practice, whether independent, employed, single- or multi-specialty, or academic,” he says.
Mary Beth Nierengarten is a freelance medical journalist based in Minneapolis.