Rheumatology Can Use MACRA to Drive Healthcare Improvements

Two reimbursement structures are offered: the Merit-Based Incentive Payment model (MIPS) and the Alternative Payment Model (APM). Most physicians and other healthcare professionals are using MIPS, which includes four connected elements that determine Medicare reimbursement: quality; clinical practice improvement activities; certified electronic health record technology; and resource utilization (cost). MIPS combines parts of the Physician Quality Reporting System, Value-Based Payment Modifier and the Medicare Electronic Health Record incentive programs. These are modifications of past Medicare requirements, but direct participation in utilization and reporting by healthcare professionals other than some physicians was minimal.

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MACRA is mandated by law to be budget neutral, meaning there can be no adjustments to the Medicare Part B monies allocated in the annual national budget. MIPS scores of individual healthcare professionals are compared directly with their peers. There will be “winners and losers” based on these scores, with annual adjustments starting in 2019 at up to +/–4% and increasing to up to +/–9% in 2022 for the total payments made to individuals for the services they provided.

A second payment method involves APMs—a new method of provider compensation for care provided to Medicare beneficiaries. APM development for such disease states as rheumatoid arthritis (RA) and osteoarthritis appears costly and time consuming, and after submission, the proposals undergo a cumbersome multilayered review process. APMs require physicians to participate in patient-centric medical homes or assume a more than nominal risk for financial losses.

Implementation of MACRA activities may require significant changes in operations, communications, personnel allocation, outcome measurement and record keeping. Each rheumatologist must have an approved vehicle to submit data to CMS, which may be met by the ACR RISE registry and additional data management systems. The rheumatology community will have a significant opportunity to direct creation of new care models with additional approaches to MACRA implementation.

A unique strength is that we, the arthritis healthcare professionals, are the key navigators for our patients’ care. The Institute of Medicine’s six domains of quality healthcare (safe, patient centered, efficient, effective, timely and equitable) provide a starting point for instituting change. In addition, these domains are endorsed by the Agency on Healthcare Research and Policy and focus directly on the patient as the driving force.

An RA APM

The ACR is working to develop an RA APM based on both the 2010 ACR/EULAR RA classification criteria and the 2015 ACR guideline for the treatment of RA. It is now clear that once the disease has been present for more than three months, aggressive management, including initiation of disease-modifying agents, can have a major impact on the disease course and consequences. This change in management approach has occurred over the past 10 years, and without much controversy. Why it had taken so long for the rheuma­tology community to fully endorse this more aggressive approach to RA management remains unknown.