The APM pathway is more individualized, but requires physicians to share in risk and reward. Many initially assumed Accountable Care Organizations (ACOs) would meet the criteria for APMs, but CMS recently made it clear that achieving APM status would be more challenging.
What it will take for independent rheumatologists to qualify for an APM is still largely undecided, Dr. White says.
“CMS’s intention is to move physicians from MIPS into APMs, and we [the ACR] expect the vast majority of physicians will participate in MIPS in the first year, but it’s clearly designed to be unsustainable and difficult,” Dr. White says. “Long term, the question might not be whether to be in MIPS or an APM, it might be, ‘When should I become an APM, and what kind should I try to become?’”
Participants in APMs will receive lump-sum incentive payments of 5% from 2019 through 2024, and the CMS says next-generation ACOs and the comprehensive primary care plus model will qualify, as will some demonstrations in oncology and kidney failure.2
However, the fundamental challenge for rheumatologists and other subspecialists, Dr. White says, is that many of these models require large numbers of patients. Many physicians may find that it’s not financially feasible to tolerate the risk under their current practice structure.
The Promise of RISE
“I think MACRA presents some incredible challenges to the majority of rheumatologists in this country who are in small practices,” says Dr. Adams, who is also a consultant for the Alabama Society of Rheumatic Diseases. “Rheumatologists in small practices are going to have to find a way to affiliate with larger entities and participate in registries like RISE (Rheumatology Informatics System for Effectiveness). I don’t know how any doctor is going to survive without that after 2019.”
Indeed, Dr. Herzig notes that among roughly 5,200 practicing rheumatologists in the U.S., the largest group he’s aware of comprises 18 physicians. This is why the ACR encourages members to take advantage of RISE, he says, which is a Qualified Clinical Data Registry (QCDR) available for free to the ACR’s members.
Currently, 300 rheumatologists participate in RISE, according to Salahuddin “Dino” Kazi, MD, chair of the ACR Registries and Health Information Technology Committee, and there are an additional 300 in the pipeline. ACR created RISE well before MACRA was on the horizon, but now that it’s here, Dr. Kazi says it’s time for it to adapt.
At present, “three out of the four [MIPS categories] can be achieved by RISE,” says Dr. Kazi, also a rheumatologist at the University of Texas Southwestern Medical Center. “It can facilitate population management and figure out who the patients are that are neediest or most expensive; eventually, it can be used for resource utilization and practice improvement activities. … We would grow it if the membership demands it. The vendors are ready to manage the demand.”
