MACRA Challenges Lead to New ACR Alternative Payment Model

A panel discussion, titled, "Holy MACRA! How to Survive and Thrive in the New Era of MACRA, MIPS and APMs," was presented on Sunday at the 2017 American College of Rheumatology’s (ACR) Annual Meeting in San Diego, California. The session provided practice managers with key information about keeping pace with the Medicare Access and CHIP Reauthorization Act of 2015 (MACRA), and also provided ACR with a prime opportunity to reveal the initial draft of its new, Medicare Access and CHIP Reauthorization Act-, or MACRA, compliant alternative payment model (APM) for rheumatoid arthritis (RA).

Challenges With MIPS

The panel began with moderator Angus Worthing, MD, FACR, FACP, providing an overview of the challenges that the merit-based incentive payment system (MIPS) poses for clinicians. Under the 2017 structure for MIPS, the categories of quality (60%), resource use (0%), clinical practice improvement activities (15%), and advancing care information (25%) are combined to create a composite score that determines a practice’s annual adjustment from CMS.

Worthing pointed out 3 key downsides to MIPS:

• The annual adjustment in reimbursement set to reach ±9% in 2022; Worthing noted that most practices have overheads of around 70%, resulting in a physician taking home 30 cents per dollar. Thus, a downward adjustment of —9% would be felt keenly: “If that gets cut from 100 down to 91 cents, you’re taking home 21 cents.”
• MIPS is “a budget-neutral system” in which high-performing practices benefit financially at the expense of low performers. “It’s a zero-sum game,” said Worthing. “The losers pay for the winners.”
• CMS’ final rule, announced last week, includes Medicare Part B drug costs—including the cost of expensive biologic therapies—in adjustments beginning in 2020. If a practice is reimbursed for biologics at a 4% margin, then sustains a —9% adjustment, “you’re underwater,” said Worthing. “This will stop infusion therapy or injection therapy” given in the physician’s office, he predicted, because no practice will be willing to take such a financial risk.

Succeeding With MACRA

Ed Herzig MD, FACP, MACR, gave practical advice to rheumatologists looking ahead to the first adjustment period in 2019. Activities that practices may already be undertaking can be reported as quality performance activities, and Herzig encouraged practitioners to report activities such as documenting current medications in patient records, conducting osteoporosis management in women with fractures, conducting glucocorticoid management in patients with RA, and evaluating RA functional status.

Herzig also offered global tips for success with MACRA:

• Ensure that the practice’s electronic health record system is certified
• Use ACR’s Rheumatology Informatics System for Effectiveness registry as a way to reduce administrative burden in reporting
• Establish a point person within the practice to monitor patients who are counted in MIPS populations
• Review data monthly (or quarterly at a minimum)
• Decide whether to report data for 90 days of this year or to report a full year of data
• Pick a pace to achieve full compliance with MACRA
• Join a network in order to reduce the burden of practice change

An APM for RA

Last to speak was Kwas Huston, MD, who unveiled ACR’s draft of a new APM for the treatment of patients with RA. The organization hopes to eventually expand the model to other diseases if it is approved by the Physician-Focused Payment Model Technical Advisory Committee (PTAC) and CMS.

The APM creates a standard approach to RA treatment based on ACR guidelines, requires the use of methotrexate and disease-modifying anti-rheumatic drugs (DMARDs) before the use of biologics, specifies the frequency and type of monitoring for patients, and will be updated regularly by ACR. A 75% adherence rate for reporting will, said Huston, provide flexibility to provide care to patients whose circumstances require deviation from the standard approach.

The model recognizes 4 phases of RA care:

• Diagnosis and treatment planning. This stage will trigger a 1-time payment to cover evaluation, testing, diagnosis, and treatment planning, inclusive of lab testing, imaging, communication with other physicians, and shared decision making.
• Support for primary care physicians (PCP) in evaluating joint symptoms. Communication with a PCP who has an agreement with a rheumatology network to work collaboratively triggers 1 payment for discussion regarding a specific patient (including discussion of pre-referral testing and expediting the referral of high-risk patients).
• Initial treatment of RA. When a patient agrees to a treatment plan, a monthly payment is triggered for 6 months, which allows flexibility for non-face-to-face communication and advanced services for those who need them. Payments are stratified based on patient characteristics.
• Continued care of RA. Continued care will trigger monthly payments, not tied to office visits, again with stratified payments.

For accountability, clinicians must meet face-to-face with patients at least once every 6 months, document disease activity using a validated scale, maintain a written RA treatment plan consistent with the ACR pathway, follow-up within 2 weeks of a medication change, complete a functional assessment, conduct a tuberculosis screening, and create a steroid plan.

Practitioners who follow the treatment pathway 75% of the time will be exempt from penalties. Those who fall short of 75% compliance will be subject to adjustments from —2% to –8%.

The pathway, said Huston, provides adequate payment for high-value services, avoids MIPS penalties, reduces documentation, keeps physicians from being responsible for the high cost of drugs, and gives clinicians more control over performance measures.