The year 2015 brought an end to the much-maligned Sustainable Growth Rate (SGR), sometimes known as the “doc fix.” The SGR established limits on Medicare reimbursement for physicians, and each year, physicians and those lobbying on their behalf were forced to stave off drastic cuts to their payments.
“The SGR was Congress’s attempt to control the rise of Medicare costs. It established a flawed formula that, if carried out, would have reduced reimbursements severely,” says Ed Herzig, MD, FACP, MACR, immediate past chair of RheumPAC, political action committee of ACR, and a rheumatologist at Mercy Health in Cincinnati. “We had to go to Congress every year, sometimes twice a year, and use our advocacy skills to get them not to [implement] it.”
Now, rheumatologists and others are working to understand and prepare for its replacement, the Medicare Access and CHIP Reauthorization Act of 2015 (MACRA), which was passed on April 16, 2015. MACRA orients reimbursement toward paying for value over volume and relies on many of the quality initiatives CMS has pushed in recent years.
However, details on MACRA were lacking until April 27, 2016, when the Centers for Medicare & Medicaid Services (CMS) issued a Notice of Proposed Rulemaking.
At First Glance
“Initial review of the proposed rule suggests that CMS has been listening to the rheumatology community’s concerns about developing a value-based payment system that works to assist, not hinder, the ability of rheumatologists to deliver high-quality care to Medicare patients living with rheumatic diseases,” ACR President Joan Von Feldt, MD, MSEd, said in a statement following the CMS announcement.1
However, because MACRA fundamentally alters the way physicians are paid for the work they do, many remain uncertain of the impact it will have on the practice of medicine, particularly for rheumatologists.
“The stated purpose [of MACRA] is to improve quality and reduce cost,” Dr. Herzig says. “Improving quality is only theoretical, but what isn’t theoretical is reducing cost. CMS is taking a carrot-and-stick approach to cost savings. If practitioners reach certain defined goals [by the CMS], whether they are ‘quality’ or cost, then doctors will be rewarded.”
This perspective is echoed by Christopher D. Adams, MD, chief of rheumatology at East Alabama Medical Center in Auburn/Opelika, Ala., and a member of the ACR’s Government Affairs Committee, who says MACRA “is based on some good ideas, and the really good idea is that we should pay for quality and effective outcomes in medicine. The problem with MACRA is that it’s a one-size-fits-all mentality, and rheumatologists have argued for years that what we do is different from everyone else.”
What Is MACRA?
MACRA restructures physician reimbursement by creating the Quality Payment Program, a framework with two pathways: the Merit-Based Incentive Payment System (MIPS) and the Advanced Alternative Payment Models (APMs).
Through Jan. 1, 2019, doctors will see an annual baseline Medicare payment increase of 0.5%. These automatic increases end on that date, when MACRA begins and physicians must choose to seek reimbursement through MIPS or through an APM. However, it’s important to remember that benchmarking begins much sooner.
“Even though reimbursement in the MACRA system starts in 2019, your practice is being measured beginning in January 2017,” says rheumatologist Doug White, MD, chair of ACR’s Committee on Rheumatologic Care. “Time is of the essence.”
MIPS consolidates quality measurements into a single payment adjustment. Physicians receive a composite quality score for each reporting period that is used to determine reimbursement rates, based on four performance categories—quality, advancing care information, clinical improvement activities and cost.
In Year 1, 50% of the score is based on quality, which CMS says hinges on six measures from a range of options tailored to specialties. Advancing care information makes up 25% of the score and takes into account how clinicians use technology in their practice, with an emphasis, the CMS says, on interoperability and information exchange. Care coordination efforts are included among the clinical practice improvement activities that define 15% percent of the MIPS score, and cost makes up the remaining 10%, which is based not on physician reporting, but on billing claims.
Dr. Herzig believes “the whole goal is to make doctors responsible for the costs of the system.” That is the basis for concern among some rheumatologists. “When you think about the costs of care, in rheumatology, the best drugs are biologic agents, and they are very expensive,” he says. “If those drugs are rolled into the costs of care and, at some point in time, we are responsible for the costs of those drugs, too, that would be impossible. We have to see what CMS includes in resource use.”
Although MIPS does not require physicians to assume risk, it is budget neutral and by 2022, payment adjustments will range by plus or minus 9%. It is based on every physician working under a single tax identification number.
“For every person above, there is someone below,” says Dr. Herzig. “You are measured against all of your peers, so in my opinion, it’s a zero-sum game. You can be in the upper half and make money, but you’re still competing against your colleagues and all others being measured.”
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. The 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.”
As a QCDR, RISE taps into electronic health records and captures the entirety of a practice’s patient population; thus, physicians using it don’t need to take extra steps for reporting through the MIPS pathway. RISE is valuable because rheumatologists are too small a market for information technology vendors to create additional carve-outs, says Dr. Adams.
“You can measure the quality of your work across many clinical quality measures and compare your performance against your practice partners and regional and national peers,” says Dr. Kazi, who adds that, in terms of MACRA, “We have a recipe for this, but we haven’t cooked the meal yet. We have patient numbers, ZIP codes, practice size, insurance information, all of which can provide elements needed to benchmark the cost of episodes of care each year.”
And RISE presents rheumatologists the chance to chart their own course on the MACRA sea.
“We really need to demonstrate the value of rheumatology by having our own information, so we’re not dependent on others defining what’s important,” Dr. Kazi says. “If we do it ourselves, it gives us a voice we don’t otherwise have, backed by data and numbers.”
Other Opportunities
In addition to adapting RISE, Dr. White says the ACR is exploring other opportunities for rheumatologists in a new reimbursement environment. For example, although the Bundled Payments for Care Improvement Initiative (BPCI) is not currently a qualified APM, Dr. White says he suspects “the concept behind it will drive emerging APMs as we move forward, especially in subspecialty diseases.”
For example, a rheumatologist may receive a fixed sum to care for a patient in their first year following a rheumatoid arthritis diagnosis. “But we need a lot more information before we can figure out what’s tenable and what’s not,” Dr. White adds.
Or rheumatologists may consider a specialized medical home model, which could potentially be considered by CMS as an APM. Rheumatologists would need to assume accountability for patient-level outcomes and spending, since rheumatology patients have chronic, lifelong illness and “rheumatologists function as primary care physicians” for many of them, Dr. White says.
“We’ll see what emerges,” he adds.
ACR representatives recently met with Congressional staff to share concerns and ideas, and Dr. Adams says the feedback they received was “encouraging.”
However, the cost to rheumatologists, particularly those in small or solo practices, must be taken into account, Drs. Herzig and Adams both say.
“Some doctors will look at their Medicare income, see what percentage of Medicare they have in their practice and decide whether a 4% cut is worth it or not,” Dr. Herzig says. “What doctors need to know is they need to have real control of their budget. If they know what their budget is and look at what percentage of Medicare is their budget, they can figure out what that means to them.”
For example, starting in 2019, if a practitioner receives $300,000 a year in Medicare reimbursements, a 4% loss is $12,000. “That cost might be absorbed,” Dr. Herzig says. “However, the penalty rises each year.
“Doctors have to get moving now,” he adds. “There is no time to waste.”
Looking Forward
In addition to knowing their budget, rheumatologists should look for ways to work together, Drs. Adams, Herzig, White and Kazi all say.
“We’re not going to survive as lone rangers, independently putting out every brush fire that comes along,” Dr. Adams says. “This movement toward quality and cost control in medicine is too big for any one doctor or small group of doctors to deal with. I think the ACR’s efforts are vitally important, and members really need to support and contribute to it in terms of leadership.”
On June 24, 2016, the ACR submitted a letter to the CMS lauding the promise of MACRA while also expressing deep concerns over some aspects of the reimbursement overhaul.3 The comments reflect many of those shared by Drs. Adams, Herzig, White and Kazi. In particular, the ACR believes the benchmark timeline for MACRA measurement to be “daunting,” and would like to see additional exceptions and consideration made for small and solo practices.
The key issues, the ACR wrote to the CMS, concern timing and complexity of the requirements, the lack of APMs for which rheumatologists appear to be qualified and the exclusion of Part D medication costs from resource use calculations.
“We are pleased to provide comments on a number of the complex issues raised within the rule,” wrote Dr. Von Feldt in the letter to the CMS. “As a general principle, we encourage CMS to be mindful of our ability to treat and care for patients with chronic and rheumatic diseases.”
To help prepare for MACRA, the ACR has created resources, including educational tools and online content specifically for MACRA, to prepare rheumatologists for the changing landscape.
“ACR members should learn about MACRA and learn what the ACR is doing to be proactive,” Dr. Adams says. “They should also consider participation in RISE.”
He adds, “In order to survive as rheumatologists, we are going to have to figure out how to swim in the great, big MACRA ocean without being eaten.”
Editor’s note: The letter to CMS is available on the ACR website at www.rheumatology.org/MACRA.
References
- Von Feldt J. Rheumatology community responds to MACRA proposed rule. American College of Rheumatology. 2016 Apr 28. http://www.rheumatology.org/About-Us/Newsroom/Press-Releases/ID/741/Rheumatology-Community-Responds.
- Clough JD, McClellan M. Implementing MACRA: Implications for physicians and for physician leadership. JAMA. 2016 Jun 14;315(22):2397–2398.
- American College of Rheumatology. Commenting on Medicare Program; Merit-Based Incentive Payment System (MIPS) and Alternative Payment Model (APM) Incentive under the Physician Fee Schedule, and Criteria for Physician-Focused Payment Models. 2016 Jun 24. http://www.rheumatology.org/Portals/0/Files/ACR%20MACRA%20Proposed%20Rule%20Comments.pdf.
Kelly April Tyrrell writes about health, science and health policy. She lives in Madison, Wis.
