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

WASHINGTON – 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.

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.