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

Of the 13 quality metrics that are in the rheumatology quality measure set, 7 are not specific to rheumatology (advanced directive documentation, body mass index screening and follow-up, taking a comprehensive medication list, tobacco screening in adolescents, tobacco screening in adults, hypertension screening and follow-up, and sending consult note to referring doctor), whereas 6 are (TB screening within 6 months of starting a biologic, yearly TB screening on biologics, measuring rheumatoid arthritis [RA] disease activity, measuring RA functional assessment, documenting RA prognosis, and RA steroid management).

The quality category will account for 50% of the MIPS score in 2018.

Resource use (0% of 2017 score)

“The fact that the resource use part of the equation has been set to 0% for the 2017 performance year is a really good thing for rheumatologists because we use some of the most expensive drugs around,” Dr. Harvey said. “Part of the reason that CMS did this is that they are having trouble accounting for the fact that they have easy access to Part B cost data – infusion cost data – but they don’t have very good access to Part D self-injectable drug cost data.”

“We are going to make it a key advocacy point that they appropriately take into account cost in future years,” he added.

While the resource use category of MIPS contributes nothing to the 2017 MIPS score, it will increase to 10% in 2018 and by 2021 it’s anticipated to be 30% of the MIPS score, while the quality category is anticipated to drop to 30%.

Clinical practice improvement activities (15% of 2017 score)

This part includes more than 90 proposed activities to count toward the category’s score, including patient engagement activities, care coordination, extended office hours, and participation in a qualified clinical data registry (QCDR), such as the ACR’s RISE Registry, which is already a certified QCDR. A total of 40 points in this category gives full credit for the 15 percentage point value given to it for 2017.

All of the proposed activities for 2017 are weighted as medium (10 points) or high weight (20 points). For example, 40 points could be earned by meeting two medium-weight measures and one high-weight measure.

The clinical practice improvement activities category will stay at 15% of the MIPS score in 2018.

Advancing care information (25% of 2017 score)

“This is another one that gets complicated, but there’s one key take-home message: This is way easier than Meaningful Use has ever been,” Dr. Harvey said. There are 100 points needed in the advancing care information category in order to get the full 25 percentage points that it accounts for in the 2017 MIPS score.

For reporting on five required measures (electronic health record [EHR] security analysis, e-prescribing, patient access to an EHR, and being able to send and accept summary of care documents), a provider will earn 50 points.

Another 90 performance points are available for reporting certain information, and this is based on a decile system just like the quality category in which a rheumatologist’s performance is measured against other rheumatologists who have met the benchmark for each particular measure. These optional measures include providing patient-specific educational information; patients being able to view, download, and transmit their own medical records; secure messaging; acceptance of patient-generated health data; medication reconciliation; and submitting data to a state immunization registry.

Another 15 bonus points are available for additional public health reporting and reporting to CMS using a certified EHR or QCDR.

All these measures together give providers the potential to earn 155 points toward the 100-point threshold.

“If you’re already doing Meaningful Use, chances are you’re going to do really well in this area,” he said.

The advancing care information category will stay at 25% of the MIPS score in 2018.

Problems with current APMs

Under MACRA, participation in an APM means that the physician is exempt from MIPS and will receive a 5% lump sum bonus per year in 2019-2024, a higher annual increase in fee-for-service revenues, and the general benefits of participating in an APM. However, few rheumatologists will qualify for the APM pathway, and there are no rheumatology-specific APMs in existence.

Most current APMs are “shared savings” programs where if the physician or health system can reduce spending below the expected levels, then the provider receives a share of the payer’s savings. However, these shared-savings APMs all still use a fee-for-service structure, which makes them just a different form of pay for performance, according to Mr. Miller.

Physicians still don’t get paid for unfunded or underfunded services, and physicians who are already efficient receive little or no additional revenue and may be forced out of business, while physicians who have been practicing inefficiently or inappropriately are paid more than conservative physicians. There’s also the potential for rewarding the denial of needed care. Physicians in shared-savings APMs are also placed at risk for costs they cannot control and for random variations in spending. And most of all, the shared savings bonuses are temporary and when there are no more savings to be generated, physicians are underpaid, Mr. Miller said.

During 2013-2015, 46%-48% of Medicare shared-savings accountable care organizations (ACOs) increased their Medicare spending rather than reduced it, and only 24%-30% of the ACOs received shared-savings payments. In each year, Medicare spent more than it saved, with net losses ranging from $50 million to $216 million. This happened because physicians in the programs still got paid with fee-for-service payments, Mr. Miller said.