Changes to reimbursement introduced by the Medicare Access and CHIP Reauthorization Act (MACRA) will affect your Medicare income for 2019.
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.”
