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 New Analysis Points to Wider Payment Swings Under MACRA

A fresh report by Avalere Health finds that certain physician specialists may experience a much broader range of payments under a new merit-based payment system that is currently underway as part of Medicare Access and CHIP Reauthorization Act of 2015 (MACRA) implementation.

In a proposed rule released on June 20, the Centers for Medicare & Medicaid Services (CMS) seeks to change the calculation of the Merit-based Incentive Payment System (MIPS) payment adjustment to include Medicare payments for Part B drugs. A final version of that rule is expected later this month. Long term and post-acute care providers may not be directly affected by the possible changes, but clinicians who perform care in facilities for Medicare beneficiaries will be.

In the report, the nonpartisan consultants at Avalere said MIPS payments could increase or decrease by as much as 16 percent for these specialists’ 2018 performance. “The adjustments could take effect if CMS finalizes its proposal to change how payments to clinicians are calculated under MIPS,” Avalere said. “For most types of physicians, these payment adjustments would only range between plus or minus 5 percent, as provided for under MACRA.”

But under the CMS June 20 proposal, the magnitude of risk for certain types of specialists would continue to increase as the MIPS program reaches full implementation. In performance year 2020, for instance, the payment adjustments could reach as high as plus or minus 29 percent for rheumatologists and oncologists, the report said.

John Feore, director at Avalere, tells Provider the reason for this is that certain specialists administer more Part B drugs than others, exposing them to significant financial risk and payment swings. “Our analysis found was that for certain specialties where Part B drugs make up a large percentage of a clinician’s revenue, and that is obviously areas like rheumatology and oncology, there are these swings,” he says.

MACRA is the law passed with strong support by both Democrats and Republicans to reform the Medicare payment system. MACRA repealed the sustainable growth rate formula, the longtime system for calculating payments for physicians, and created a new framework for rewarding physicians who provide higher-value medical care.

The law sets a statutory maximum and minimum for MIPS’ adjustments, like for 2017 it is 4 percent plus or minus, and next year it is 5 percent, then it is 7 percent for 2019 and finally 9 percent going forward from 2020. On Jan. 1, 2017, MACRA transitioned to MIPS.

As way of explanation, under MACRA there is the Quality Payment Program, a new payment framework that presents stakeholders two separate paths for payment: MIPS and APMs, or Alternative Payment Models.

APMs are not expected to attract too many physicians, according to the American Medical Association, “as many APMs are not yet available in all states.” APMs will likely be characterized by featuring shared savings and flexible payment bundles and include entities like accountable care organizations.

But specialists may not have a choice on which track to take and be stuck with the MIPS model and the range of payment possibilities that Avalere discovered. “Many specialists may not have an alternative to the MIPS track due to limited opportunities for specialists to join an Advanced Alternative Payment Model,” says Richard Kane, senior director at Avalere.

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