The ACR is taking steps to clarify a proposed rule from the Centers for Medicare and Medicaid Services (CMS) that, as currently written, would consider the cost of Part B drugs when calculating physician reimbursement under the Merit-Based Incentive Payment System (MIPS).
“The ACR is concerned about this, because large cuts to reimbursement for pass-through items, such as Part B drugs, would severely limit the viability of our members’ practices,” says Angus Worthing, MD, FACR, FACP, chair of the ACR’s Government Affairs Committee (GAC).
What It Means for You
MIPS is one of two reimbursement pathways established by the Medicare Access and CHIP Reauthorization Act of 2015 (MACRA), bipartisan legislation that replaced the Sustainable Growth Rate and consolidated such reporting programs as Meaningful Use and the Physician Quality Reporting System.
Beginning in 2019, provider payments will be subject to a 4% positive or negative adjustment depending on scores across several performance categories, increasing to plus or minus 9% by 2022. MIPS is budget neutral, which means half of providers realize bonuses while the other half see penalties.
In the 2018 Quality Payment Program Proposed Rule issued by the CMS in June 2017, the agency indicates that “items and services” furnished by MIPS-eligible providers, including the cost of Part B drugs, would be subject to adjustment.1
“Receiving a minus 4 to minus 9% payment based on Part B drug costs could be catastrophic to a rheumatology practice, forcing rheumatologists to no longer infuse drugs in-office, or it could bankrupt a practice,” says Kayla Amodeo, PhD, ACR Regulatory Affairs director.
For example, professional charges for seeing a patient with rheumatoid arthritis in-office four times a year are $433.52, Dr. Worthing told Inside Health Policy in September. A one-year course of Remicade at a starting dose costs a physician practice $11,328.85. The MIPS penalty or bonus, then, would be applied to the $11,762.37 per patient charge, rather than the $433.52 alone.2
In fact, a resolution introduced in the American Medical Association House of Delegates by the American Society of Clinical Oncology and the ACR estimates the median financial impact for some specialties could range from 16–19%.3
Rheumatologists are among the most active providers of Part B drugs, Dr. Worthing says. “If rheumatologists close their doors, their patients would lose access to critical treatments.”
A Shift in Policy
In a letter to the Department of Health and Human Services written by Reps. Erik Paulsen (R-Minn.) and Leonard Lance (R-NJ), on which they were joined by over two dozen colleagues in the U.S. House of Representatives, the lawmakers wrote that the proposed rule represents a shift in policy for the CMS, given that the reporting programs it replaced did not factor Part B costs into reimbursement.4
The group also wrote that the move would “significantly and adversely exaggerate the magnitude of the bonuses and penalties provided under MIPS for medical specialties that routinely administer prescription drugs by infusion or injection,” and break from the intention of MACRA to give physicians greater control of quality care delivery. The ACR was active in educating lawmakers about the letter and asking that they sign on.
Indeed, the CMS rule could lead to perverse incentives, says Dr. Amodeo. “If physicians know they will be penalized, this could result in access problems for patients needing expensive drugs, whereas for physicians getting the bonus, there would be the potential for substantial bonuses if they prescribe or treat patients with expensive Part B drugs.”
All Hands on Deck
The CMS is expected to release its final rule on Nov. 1, Dr. Worthing says, adding that if Part B costs remain a factor considered in payment adjustments, “then it will be critical for rheumatologists and rheumatology health professionals to tell their members of Congress to fix this problem.”
Already, the ACR has taken several significant steps to clarify or reverse the proposed rule, including submitting comments to the CMS and to the House Ways and Means Committee, signing on to a letter with the AMA and with the American Academy of Ophthalmology,5 and meeting with staff from the Ways and Means Committee and Senate Finance Committee.
“We’ve got all hands on deck, as they say,” says Dr. Worthing. “The ACR is doing everything it can to get this done. We’ve written letters, met with Congress, formed coalitions with other specialties, and we’ve generated coverage from important inside-the-beltway press that key leaders read. We also hope the AMA will help take up our cause in its November interim meeting.”
What You Can Do
Individual rheumatologists and rheumatology providers and practices should also communicate with their elected officials, Dr. Amodeo said, noting that the rule may require a statutory fix and without hearing from constituents “Congress seems very unwilling to open MACRA back up.”
Unsure how to achieve this?
“This can be as easy as sending an email through the ACR’s Legislative Action Center, sending a tweet tagging one’s representative or even setting up a meeting in the member’s district office,” says Dr. Worthing. “The ACR Executive Committee has already met with key Congressional committees that realize the importance of this problem, but input from their constituents will be critical to help break the gridlock in Washington, D.C.”
Kelly April Tyrrell writes about health, science and health policy. She lives in Madison, Wis.
- Centers for Medicare and Medicaid Services. Medicare Program; CY 2018 updates to the Quality Payment Program. Federal Register. 2017 Jun 30;82(125). https://www.federalregister.gov/documents/2017/06/30/2017-13010/medicare-program-cy-2018-updates-to-the-quality-payment-program.
- Specialists lobby to exclude drug costs from doctor pay calculations. Inside Health Policy. 2017 Sep 27;20(39). https://insidehealthpolicy.com/daily-news/specialists-lobby-congress-exclude-drug-costs-doctor-pay-calculations.
- American Society of Clinical Oncology and American College of Rheumatology. Oppose inclusion of Medicare Part B drugs in QPP/MIPS payment adjustment. American Medical Association House of Delegates Resolution I-17. 2017. https://www.ama-assn.org/sites/default/files/media-browser/public/hod/i17-225.pdf.
- Paulsen E. [Letter to Congressional colleagues, including an attached letter to Health and Human Services Secretary Tom Price.] 2017 Aug 25.
- American Academy of Ophthalmology. Submissions to the Committee on Ways and Means Subcommittee on Health Regarding Statutory and Regulatory Burdens on Optimized Efficiency and Patient Care [letter]. 2017 Aug 1.