Conference Coverage

MACRA’s near and potential long-term future outlined for rheumatology



– Now that implementation of the Medicare Access and CHIP Reauthorization Act is on rheumatologists’ doorsteps, figuring out what is required in 2017 is imperative to avoid future penalties and maximize the chance of earning a bonus.

Recent announcements from the Centers for Medicare & Medicaid Services (CMS) on performance thresholds and how to meet them in 2017 give rheumatologists a great shot at not getting penalized when payment adjustments begin in 2019.

Dr. William F. Harvey

Dr. William F. Harvey

Of the two quality reporting pathways that CMS has established for physician participation in 2017 and beyond – the Merit-based Incentive Payment System (MIPS) and Advanced Alternative Payment Models (APMs) – most rheumatology practices will probably choose MIPS because most will not qualify to participate in an APM, William F. Harvey, MD, said at the annual meeting of the American College of Rheumatology.

However, efforts by the ACR to create new rheumatology-focused APMs could play a major role in changing that, said Dr. Harvey, clinical director of the Arthritis Treatment Center at Tufts Medical Center, Boston, and former chair of the ACR’s Committee on Government Affairs.

The MIPS option in MACRA is “a repackaging” of old programs, including Meaningful Use (which is now called Advancing Care Information), value-based modifiers, and the Physician Quality Reporting System (PQRS). “One silver lining to this massive piece of legislation is that it’s actually less downside risk than if you had continued with Meaningful Use, PQRS, and value-based modifier,” Dr. Harvey said.

MIPS is onerous by design, in Dr. Harvey’s opinion. “CMS does not want to continue the fee-for-service arrangement and MIPS is basically fee-for-service with a bit of pay-for-performance bolted on top of it. They’ve already stated that they want to push every provider into alternative payment model–type reimbursements going forward.”

Rheumatologists aren’t eligible for MIPS if they see fewer than 100 Medicare patients per year or if they bill less than $30,000 in Medicare fees. For MIPS-eligible physicians, adjustments to Medicare payments begin in 2019 based on 2017 quality reporting data. Physicians will still receive yearly 0.5% increases in Medicare pay in 2017-2019 and 0% each year through 2025 before any adjustments are made based on the MIPS score. Participation in the MIPS pathway gives the potential for payment adjustments starting at plus or minus 4% in 2019, plus or minus 5% in 2020, plus or minus 7% in 2021, and plus or minus 9% in 2022 and beyond, based on how rheumatologists compare against their peers.

Targets for 2017 and adjustments beyond 2017

Each year in November, CMS will announce the base performance threshold goal that physicians will need to reach in the following year in order to avoid negative Medicare payment adjustments 2 years later.

Each year’s threshold will be based on the data collected from the prior year. For the year starting Jan. 1, 2017, in order to avoid a 4% cut in their Medicare Part B base rate payment in 2019, rheumatologists will need to meet a base performance threshold score of just 3 out of 100.

“Basically, if you participate in a program in any way whatsoever, you can hit this target,” Dr. Harvey said.

In 2017, getting a score of 70 or more out of 100 puts rheumatologists into a high performance category that makes them eligible for a piece of the $500 million pool of positive payment adjustments that will be available in each of the first 6 years of MIPS.

Providers who score less than 3 out of 100 will get the maximum penalty – a 4% cut in their 2019 Medicare payment rate. Further, in 2017, only 90 days of reporting is required to qualify for positive adjustments in 2019.

The base performance threshold will certainly go up for 2018 to “probably 30, 40, 50; something like that,” Dr. Harvey said.

Knowing the threshold in advance should help rheumatologists to predict by the middle of each year whether they are going to make it, but how much of any increase (or decrease) in payment adjustment they will have 2 years hence will be very difficult to know, he said, because each year the adjustment must be budget neutral and is dependent on how many physicians are above and below the threshold.

The MIPS score is based on four categories that total up to 100 points:

Quality (60% of 2017 score)

The quality category is determined by six measures that are worth 10 points each. All of the quality domains from PQRS are gone, and out of those six measures providers must have one cross-cutting measure and one outcome measure, or just one high-priority measure. Since rheumatology does not yet have any designated outcome measures, rheumatologists will need to report other designated measures. For each of these six required measures, a provider would earn 3 points for reaching the benchmark, and then the score could be increased to 4-10 points per measure based on a decile system that determines the provider’s performance against others who have met the benchmark for that measure.

Of the 13 quality metrics that are in the rheumatology quality measure set, 7 are not specific to rheumatology (advanced directive documentation, body mass index screening and follow-up, taking a comprehensive medication list, tobacco screening in adolescents, tobacco screening in adults, hypertension screening and follow-up, and sending consult note to referring doctor), whereas 6 are (TB screening within 6 months of starting a biologic, yearly TB screening on biologics, measuring rheumatoid arthritis [RA] disease activity, measuring RA functional assessment, documenting RA prognosis, and RA steroid management).

The quality category will account for 50% of the MIPS score in 2018.

Resource use (0% of 2017 score)

“The fact that the resource use part of the equation has been set to 0% for the 2017 performance year is a really good thing for rheumatologists because we use some of the most expensive drugs around,” Dr. Harvey said. “Part of the reason that CMS did this is that they are having trouble accounting for the fact that they have easy access to Part B cost data – infusion cost data – but they don’t have very good access to Part D self-injectable drug cost data.”

“We are going to make it a key advocacy point that they appropriately take into account cost in future years,” he added.

While the resource use category of MIPS contributes nothing to the 2017 MIPS score, it will increase to 10% in 2018 and by 2021 it’s anticipated to be 30% of the MIPS score, while the quality category is anticipated to drop to 30%.

Clinical practice improvement activities (15% of 2017 score)

This part includes more than 90 proposed activities to count toward the category’s score, including patient engagement activities, care coordination, extended office hours, and participation in a qualified clinical data registry (QCDR), such as the ACR’s RISE Registry, which is already a certified QCDR. A total of 40 points in this category gives full credit for the 15 percentage point value given to it for 2017.

All of the proposed activities for 2017 are weighted as medium (10 points) or high weight (20 points). For example, 40 points could be earned by meeting two medium-weight measures and one high-weight measure.

The clinical practice improvement activities category will stay at 15% of the MIPS score in 2018.

Advancing care information (25% of 2017 score)

“This is another one that gets complicated, but there’s one key take-home message: This is way easier than Meaningful Use has ever been,” Dr. Harvey said. There are 100 points needed in the advancing care information category in order to get the full 25 percentage points that it accounts for in the 2017 MIPS score.

For reporting on five required measures (electronic health record [EHR] security analysis, e-prescribing, patient access to an EHR, and being able to send and accept summary of care documents), a provider will earn 50 points.

Another 90 performance points are available for reporting certain information, and this is based on a decile system just like the quality category in which a rheumatologist’s performance is measured against other rheumatologists who have met the benchmark for each particular measure. These optional measures include providing patient-specific educational information; patients being able to view, download, and transmit their own medical records; secure messaging; acceptance of patient-generated health data; medication reconciliation; and submitting data to a state immunization registry.

Another 15 bonus points are available for additional public health reporting and reporting to CMS using a certified EHR or QCDR.

All these measures together give providers the potential to earn 155 points toward the 100-point threshold.

“If you’re already doing Meaningful Use, chances are you’re going to do really well in this area,” he said.

The advancing care information category will stay at 25% of the MIPS score in 2018.

Problems with current APMs

Under MACRA, participation in an APM means that the physician is exempt from MIPS and will receive a 5% lump sum bonus per year in 2019-2024, a higher annual increase in fee-for-service revenues, and the general benefits of participating in an APM. However, few rheumatologists will qualify for the APM pathway, and there are no rheumatology-specific APMs in existence.

Harold D. Miller

Harold D. Miller

APMs arose because of barriers in the fee-for-service system that prevent physicians from delivering higher-quality care at lower costs, and these barriers are not always appreciated, said Harold D. Miller, president and CEO of the Center for Healthcare Quality and Payment Reform. He is also a member of the Physician-Focused Payment Model Technical Advisory Committee. These include no payment or inadequate payment for high-value services and the loss of revenue that occurs when patients can be treated with low-cost services.

Most current APMs are “shared savings” programs where if the physician or health system can reduce spending below the expected levels, then the provider receives a share of the payer’s savings. However, these shared-savings APMs all still use a fee-for-service structure, which makes them just a different form of pay for performance, according to Mr. Miller.

Physicians still don’t get paid for unfunded or underfunded services, and physicians who are already efficient receive little or no additional revenue and may be forced out of business, while physicians who have been practicing inefficiently or inappropriately are paid more than conservative physicians. There’s also the potential for rewarding the denial of needed care. Physicians in shared-savings APMs are also placed at risk for costs they cannot control and for random variations in spending. And most of all, the shared savings bonuses are temporary and when there are no more savings to be generated, physicians are underpaid, Mr. Miller said.

During 2013-2015, 46%-48% of Medicare shared-savings accountable care organizations (ACOs) increased their Medicare spending rather than reduced it, and only 24%-30% of the ACOs received shared-savings payments. In each year, Medicare spent more than it saved, with net losses ranging from $50 million to $216 million. This happened because physicians in the programs still got paid with fee-for-service payments, Mr. Miller said.

Creating rheumatology-focused APMs

MACRA designated the development of the Physician-Focused Payment Model Technical Advisory Committee, of which Mr. Miller is a member, to solicit and review physician-focused payment models and make recommendations to CMS about which ones to implement.

Physician-focused payment models got their start through pioneering work by physicians who obtained data from insurers to find ways to reach out proactively to patients to address problems before patients are hospitalized. Through these efforts, they have reduced cost and increased patient satisfaction while also increasing payment to physicians by supporting “medical home” services, according to Dr. Miller.

These efforts to create APMs that support high-quality, physician-directed care begin by identifying avoidable spending that varies from specialty to specialty and from condition to condition. Then they address barriers in the current fee-for-service system – such as no payment for many high-value services and insufficient revenue to cover costs when using fewer or low-cost services – by providing flexible, adequate payment while requiring physicians to take responsibility for the things they said could be avoidable when paid in that way. However, this responsibility must be focused on what a particular physician can influence, Mr. Miller noted.

Rheumatologists could be helped by these physician-focused payment models because they receive less than 10% of the total Medicare health care spending per patient whose care was directed by a rheumatologist. In that case, finding ways to drop total spending per patient by 5% could at the same time give rheumatologists a 25% increase in payment while also saving Medicare 3% overall, he said.

Rheumatologists are best set up to take condition-based payments that are geared to keep patients out of the hospital, rather than the hospital episode–based payments that have dominated APMs in existence so far. Central to this condition-based model is getting the right diagnosis at the start, so payment for getting the correct diagnosis would be critical.

APMs designed for rheumatologists could take into account the diseases often seen by a rheumatologist, such as RA, and then identify opportunities to improve care and reduce costs while identifying barriers in the current payment system for achieving those goals, Mr. Miller said. These opportunities and barriers would vary from condition to condition. In some cases, particularly for low-frequency conditions, there may not need to be a new payment model established and it could be done through fee-for-service.

Ideally, these condition-based payment models for specialists such as rheumatologists would exist within the “medical neighborhood” of primary care physicians who could refer to them when necessary. Specialists would be accountable for the aspects of care that they can control, such as avoiding unnecessary tests and procedures and avoiding infections and complications.

“That’s building the ACO from the bottom up, rather than what Medicare is trying to do, which is to create it from the top down,” Mr. Miller said.

Mr. Miller noted that it will be important for specialties such as rheumatology to define the cost data it needs in order to develop condition-based payment models.

Dr. Harvey had no relevant disclosures. Mr. Miller has no financial relationships with any commercial interests.

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