Healthcare Revenue Cycle Management, ICD-10, Claims Reimbursement, Medicare, Medicaid

Reimbursement News

Orgs Argue MIPS Adjustments for Drug Payments Harm Patient Access

Eleven medical societies called on policymakers to prevent CMS from applying MIPS adjustments to Part B drug reimbursements and limiting patient access to drug treatments.

Merit-Based Incentive Payment System (MIPS) adjustments and patient access

Source: Thinkstock

By Jacqueline LaPointe

- Applying Merit-Based Incentive Payment System (MIPS) adjustments to Medicare Part B drug payments will restrict patient access to critical treatments, 11 medical societies recently told congressional leaders.

The medical societies, including the American College of Rheumatology, American Society of Clinical Oncology, and American Urological Association, urged Congress to abandon a new policy detailed in the final 2018 MACRA implementation rule that will apply MIPS payment adjustments to Part B drug payments in addition to fee schedule services reimbursements starting in 2018.

“If left as is, this policy will negatively impact patients’ access to critical life and sight-saving treatments by putting specialties that provide high-cost drugs at risk,” the medical societies wrote. “It will significantly amplify the range of bonuses and penalties intended by MACRA, only for certain specialties.”

Under the new MIPS payment adjustment policy, specialists will face a 16 percent payment swing, on average, in 2018, a recent Avalere analysis revealed. In contrast, general practice and internal medicine providers in MIPS only face a 5 percent payment adjustment swing.

The MIPS payment swing will also increase as the Quality Payment Program matures, the analysis added. Some specialists could see MIPS penalties as high as 29 percent by 2020 under the new policy.

The revenue of rheumatologists, oncologists, and hematologists is especially at risk because the specialists administer high volumes of Part D drugs. Ophthalmologists, allergists, immunologists, urologists, and neurologists will also see their Medicare revenue affected by the policy, Avalere reported.

With revenue at greater risk, specialists may have to choose between serving their patients or keeping their practices open, David Daikh, MD, PhD, American College of Rheumatology President, and Cynthia A. Bradford, MD, American Academy of Ophthalmology President, explained in a recent opinion piece in The Hill.

Patient access to affordable Part B drug treatments will be jeopardized if the policy stands as is.

“Either way, patients lose,” Daikh and Bradford wrote. “With providers unable to shoulder the financial burden of obtaining and administering these expensive drugs, many patients will be forced to seek treatment in much more expensive and inconvenient settings – if they can access these therapies at all.”

Part B drug treatments are typically administered in physician offices or hospital outpatient departments. But the MIPS payment adjustment policy could steer patients to expensive hospital settings.

The policy is also a major deviation from payment adjustment rules in other Medicare programs, the medical society leaders added. Historically, CMS did not include the costs of provider-administered drugs in value-based reimbursement and quality programs.

“We now need Congress to act immediately to curtail this policy and ensure patients have access to all the services and treatments they need,” the 11 medical societies urged.

Additionally, the group of medical societies called on congressional leaders to reconsider adding the cost category to MIPS until meaningful measures are developed.

“CMS has not outlined sound methodologies for risk adjustment for physicians with patient populations at risk for high resource use, and cost measures necessary under MIPS are still under development,” the organizations stated. “Work remains to ensure that the new measures are developed and integrated in a way that accurately reflects the complexities of cost measurement and does not inadvertently discourage clinicians from caring for high-risk and medically complex patients.”

The 2018 performance period is the first year that CMS will account for cost performance when determining final scores and MIPS adjustments.

“Taken together, these two issues could create a perfect storm for specialties whose patients depend on physician-administered drugs,” the letter concluded. “We stand ready to work with you on ensuring the implementation of MACRA is successful.”


Join 30,000 of your peers and get free access to all webcasts and exclusive content

Sign up for our free newsletter:

Our privacy policy

no, thanks

Continue to site...