Changes to reimbursement introduced by the Medicare Access and CHIP Reauthorization Act (MACRA) will affect your Medicare income for 2019.
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Angus Worthing
“Rheumatologists generally know that MACRA is up and running,” says Angus Worthing, MD, FACR, FACP, clinical assistant professor of rheumatology at Georgetown University Medical Center and chair of the ACR’s Government Affairs Committee. “Virtually every rheumatologist and rheumatology professional and rheumatology practice is being affected by MACRA. MACRA will affect everybody’s bottom line.” Dr. Worthing will take part in a highly practical symposium, Holy MACRA: How to Survive and Thrive in the New Era of MACRA, MIPS and APMs, from 8:30–10:00 a.m. on Sunday, Nov. 5. MACRA affects only Medicare reimbursements, but all payers are moving to similar quality- and value-based systems.
Lag Time & How It Will Affect You
MACRA has a two-year lag between reporting quality measures to the Centers for Medicare and Medicaid
Services (CMS) and changes in Medicare reimbursement. Data for 2017 will affect reimbursement in 2019. Precisely how MACRA affects individual providers and practicesdepends on many factors. The most important is the patient and payer mix. Those with few Medicare patients will feel little effect.
“But suppose you are receiving $500,000 a year in Medicare Part B reimbursement,” says Ed Herzig, MD, chair of Mercy Health Select in Fairfield, Ohio. “You stand to lose 4% of that in 2019, $20,000, if you do not report data for 2017. Can you afford to lose $20,000? That is one of the calculations we all have to make.”
Ed Herzig
Where MIPS Fits In
That 4% figure comes from MIPS, or the Merit-Based Incentive Payment System, that is MACRA’s default evaluation. Under MIPS, each provider is assessed annually using a combination of quality, improvement, cost and value measures. Those who score in the top half of providers will receive a 4% bonus. Those who fall below the median will be penalized 4%. The penalty rises to 9% over the next few years.
The overhead for most rheumatology practices is between 70 and 80%, Dr. Worthing says. Losing 9% could be a major blow when gross margins are only 20–30%.
“MIPS is a zero-sum game,” says Kwas Huston, MD, clinical assistant professor of rheumatology at the University of Missouri-Kansas City School of Medicine. “There are winners and losers every year, and the bar is effectively raised every year. People who fail to score in the top half will either become part of larger organizations or they will drop out as penalties become more extreme.”
Kwas Huston
The Cost Factor
Another important calculation is how much it will cost to collect and report the data required under MIPS.
“CMS has said it will mitigate smaller practices, likely those that have fewer than 100 patients and bill less than $90,000, and some rural practices,” Dr. Herzig says. “But every rheumatologist is being measured. Just who will be included in the program has yet to be finally determined.”
Rheumatologists who participate in RISE, the Rheumatology Informatics System for Effectiveness Registry, created by the ACR, automatically meet some of the MIPS measurement criteria.
“RISE sits on top of your electronic medical record and extracts needed data for you,” Dr. Herzig says. “We are encouraging all rheumatologists to be part of RISE, even those who are part of larger healthcare systems.”
The APM Path
MIPS is not the only evaluation system available under MACRA. Alternative Payment Models (APMs) provide the other path, but few APMs have been approved by the CMS to date, and there are no APMs in rheumatology. For now, most rheumatologists will continue to be evaluated under MIPS. That will change. An ACR working group chaired by Drs. Herzig and Huston is developing a rheumatology-specific APM. The APM will focus on the most common rheumatologic disease, rheumatoid arthritis, but once approved, the model can be adapted to other diseases.
“We have a draft APM, but work remains to be done,” Dr. Huston says. “We are working hard to develop a rheumatology APM for the future, but we all need a plan for what we will be doing this year and how we will deal with MIPS over the next two or three years. MIPS is where we are now, but MIPS, in its current form, is not a long-term, sustainable plan for rheumatologists. The APM is on the way.”
Don’t Miss It!
Don’t miss this session, Holy MACRA: How to Survive and Thrive in the New Era of MACRA, MIPS and APMs, Sunday, Nov. 5, from 8:30–10:00 a.m. in Room 6D.