THE OFFICIAL NEWS SOURCE OF ACR CONVERGENCE 2022 • NOVEMBER 10-14



MACRA has arrived, and now it counts

Angus Worthing, MD
Angus Worthing, MD

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

“Rheumatologists generally know that MACRA is up and running,” said Angus Worthing, MD, 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 & Thrive in the New Era of MACRA, MIPS & APMs from 8:30 – 10:00 am Sunday in Room 6 D. MACRA affects only Medicare reimbursements, but all payers are moving to similar quality- and value-based systems.

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 practices depends on many factors. The most important is the patient and payer mix. Those with few Medicare patients will feel little effect.

Ed Herzig, MD
Ed Herzig, MD

“But suppose you are receiving $500,000 a year in Medicare Part B reimbursement,” said Ed Herzig, MD, Chair of Mercy Health Select in Fairfield, OH. “You stand to lose four percent 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.”

That four percent 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 four percent bonus. Those who fall below the median will be penalized four percent. The penalty rises to nine percent over the next few years.

The overhead for most rheumatology practices is between 70 and 80 percent, Dr. Worthing said. Losing nine percent could be a major blow when gross margins are only 20 to 30 percent.

“MIPS is a zero-sum game,” said 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.”

Kwas Huston, MD
Kwas Huston, MD

Another important calculation is how much it will cost to collect and report the data required under MIPS.

“CMS has said they will mitigate smaller practices, likely those that have fewer than 100 patients and bill less than $90,000, and some rural practices,” Dr. Herzig said. “But every rheumatologist is being measured. Just who will be included in the program has yet to be finally determined.”

Rheumatologists who participate in RISE, the Rheumatology Informatics System for Effectiveness Registry created by the ACR, automatically meet some of the MIPS measurement criteria.

“RISE sits on top of your electronic medical record and extracts needed data for you,” Dr. Herzig said. “We are encouraging all rheumatologists to be part of RISE, even those who are part of larger healthcare systems.”

MIPS is not the only evaluation system available under MACRA. Alternative Payment Models (APMs) provide the other path, but few APMs have been approved by CMS to date and there are no APMs in rheumatology. For now, most rheumatologists will continue to be evaluated under MIPS.

That will change. An ACR working group chaired by Drs. Herzig and Huston is developing a rheumatology-specific APM. The APM will focus on the most common rheumatologic disease, rheumatoid arthritis, but once approved, the model can be adapted to other diseases.

“We have a draft APM, but work remains to be done,” Dr. Huston said. “We are working hard to develop a rheumatology APM for the future, but we all need a plan for what we will be doing this year and how we will deal with MIPS over the next two or three years. MIPS is where we are now, but MIPS, in its current form, is not a long-term sustainable plan for rheumatologists. The APM is on the way.”