Rheumatology Can Use MACRA to Drive Healthcare Improvements

We have entered the second year of the Medicare Access and CHIP (Children’s Health Insurance Program) Reauthorization Act (MACRA) of 2015. It’s no secret that the costs of medical care—17.1% of the U.S. gross national product compared with 9.8% in Great Britain, 10.7% in Canada and 11.6% in France—have become an overwhelming driver for change. Further, outcomes in the U.S. appear no better and frequently poorer in many categories than in most advanced societies. The U.S. healthcare system must become more efficient and cost effective.

Physicians and other health professionals have expressed frustration, anger and despair about MACRA, feeling that we have no input or control. Certainly, this is no time to be a Pollyanna. However, MACRA could function as a springboard for changes that address fundamental financial and care activity problems that we experience in rheumatology. We need to focus on what we aspire to do best: Provide the highest quality care to our patients in the most efficient, cost-effective way possible. MACRA is the current requirement, which we can try to use as a tool to improve patient outcomes.

What It Is

MACRA quite simply is the legislation that defines the formula by which 400,000 healthcare professionals are paid for services provided to Medicare beneficiaries. It replaces Congress’ 1997 Balanced Budget Act, which determined the budget for Medicare Part B to ensure that yearly increases did not exceed the growth in gross domestic product. Implementation of that Act included a yearly Sustainable Growth Rate (SGR) adjustment to provide for formula variations, the so-called doc fix, in order to maintain adequate reimbursement to providers. However, by 2014, the SGR adjustment would have resulted in a 24% cut in Medicare reimbursement for physicians, which might have led many physicians to leave the program and was not actually sustainable. Hence, MACRA was passed with strong bipartisan support.

MACRA is not part of the Affordable Care Act; although there may be changes, it is the current policy of the Centers for Medicare and Medicaid Services (CMS) for reimbursement. We must do our best to adapt.

MACRA mandates a dramatic departure from SGR to a system that is value-driven by quality and is determined by patient care measures. The MACRA model, called the Quality Payment Program, assigns each participating healthcare professional a numerical score based on a formula of measures provided by the CMS, which include healthcare expenditures (costs) that are directly attributed to that professional’s services.

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.

With MACRA as the impetus, we should move quickly to address and adopt other changes in RA care, including examining and redefining healthcare professionals’ roles to promote a more patient-centric care model and to address the two major concerns of our patients: pain and functional impairment.

A measure of physical function distinguishes active from control treatments as effectively as formal joint counts or laboratory tests, and is more significant than abnormal laboratory tests or radiographic scores in the prognosis of most severe long-term outcomes of RA, such as work disability, costs, joint replacement surgery and premature death. While measurement of physical function by U.S. rheumatologists in routine care has increased over the years to 36%, the only quantitative data in routine care medical records remain laboratory tests and bone densitometry.

Rheumatologists may provide as much benefit to patients as any other type of doctor. However, that benefit cannot be documented effectively only with laboratory tests and imaging tests. Quantitative scores for physical function and pain obtained on patient self-report questionnaires are needed. Availability of these relevant scores could lead to the reduction of more expensive traditional measures, thus improving the physician’s MACRA profile. Collection of self-report data is feasible in the waiting area; the patient performs most of the work and saves time for the doctor, while improving documentation and doctor-patient communication.

All rheumatology healthcare professionals must incorporate quantitative measurement to best serve our patients’ needs and document effectiveness. Now that healthcare professionals are being held directly accountable for expenditures of healthcare dollars as part of the formula that determines our Medicare payments, we must become more directly engaged in costs using such strategies as bundling of services for disease states, including RA and SLE.

Examples of RA issues that we must steward include disease-modifying regimens for specific patients and at different stages of disease and how these treatments are monitored and modified. These are questions that remain controversial despite more than 20 years of drug availability.

The time is now. MACRA is here. Let us meet the challenge head-on and improve care for patients while improving the activities of our profession.

Terence Starz, MD, is a clinical professor of medicine in the Division of Rheumatology at the University of Pittsburgh School of Medicine and is in practice at Arthritis and Internal Medicine Associates–UPMC in the Western Pennsylvania area.

Theodore Pincus, MD, is affiliated with Rush University Medical Center in Chicago.

Janet Bahr, NP, is a certified adult nurse practitioner at Gundersen Health System in Onalaska, Wis.