- Specialists could face up to a 16 percent value-based incentive payment or penalty under MACRA’s Merit-Based Incentive Payment System (MIPS) in 2018 if a proposed rule to include Medicare reimbursement for Part B drugs in the program is finalized, a recent Avalere analysis showed.
CMS proposed in June 2017 to factor in Medicare Part B drug reimbursement when calculating MIPS payment adjustments. The federal agency plans to use billed Medicare Part B allowable charges associated with purchasing and administering drugs covered by the program for payment adjustments and MIPS eligibility determinations.
The proposal would significantly impact the revenue of eligible clinicians who administer more Part B drugs, such as rheumatologists, oncologists, and ophthalmologists, Avalere researchers stated.
“Certain specialists administer more Part B drugs than others and, therefore, may be exposed to significant financial risk and payment swings year-over-year under the CMS proposal,” stated John Feore, Director at Avalere. “If the proposal is finalized, these specialists could see substantially higher payment penalties or rewards than their counterparts who administer fewer Part B drugs.”
In 2018, the specialists who would see the greatest potential MIPS payment adjustment of negative or positive 16 percent would be rheumatologists, hematologists/oncologists, and medical oncologists, researchers found using data from the 2015 Medicare Physician Supplier Procedure Summary File.
In contrast, general practice and internal medicine providers in MIPS would only face a positive or negative 5 percent payment adjustment for their performance in the program in 2018.
Other specialists who could see a larger MIPS payment swing than their primary care-based peers included:
• Ophthalmologists with a positive or negative 7 percent swing
• Allergists/immunologists with a positive or negative 7 percent swing
• Urologists with a positive or negative 6 percent swing
• Neurologists with a positive or negative 6 percent swing
Specialists who qualify for MIPS would also see even more of their revenue at risk as the Medicare value-based reimbursement program matures, researchers added.
CMS plans to increase MIPS payment adjustments each year. For most eligible clinicians, the federal agency expects to cap maximum value-based penalties under MIPS at 7 percent for the 2021 payment year and 9 percent for the 2022 payment year and after.
However, incorporating Medicare reimbursement for Part B drug purchases and administration would increase the penalties and incentive payments eligible clinicians could earn under MIPS.
Researchers found that specialists who administer more Part B drugs than their peers could face up to a 29 percent MIPS payment adjustment swing when MACRA is fully implemented by the 2020 performance year.
Rheumatologists, hematologists/oncologists, and medical oncologists would be subject to the greatest potential MIPS payment adjustments at positive or negative 29 percent, followed by ophthalmologists with a 13 percent swing, allergists and immunologists with a 12 percent swing, and urologists and neurologists with an 11 percent swing, respectively.
Eligible clinicians in the internal medicine space could also face a slightly bigger MIPS payment adjustment than the maximum 9 percent adjustment. Researchers reported that internal medicine clinicians could see a positive or negative 10 percent MIPS payment adjustment.
Researchers stated that the proposed MIPS policy would represent a “significant shift in CMS’ approach to payment adjustments.”
Legacy Medicare value-based reimbursement programs, such as the Physician Quality Reporting System and meaningful use, only used Medicare Physician Fee Schedule services to calculate incentive payments and penalties. The programs did not incorporate Medicare Part B drug payments.
The shift could spell trouble for specialists in MIPS who have limited opportunities to join MACRA’s other value-based reimbursement track, Avalere’s Senior Direct Richard Kane explained.
Under the Advanced Alternative Payment Model (APM) track, qualifying participants would receive a 5 percent incentive payment between 2019 and 2024 based on their performance in lieu of MIPS payment adjustments. After that period, CMS proposes to give qualifying Advanced APM participants higher fee schedule updates based on their performance, rather than incentive payments or MIPS payment adjustments.
However, recent research from Leavitt Partners revealed that specialists have few, if any, APM options. Specialists from emergency medicine and audiology had no Medicare alternative payment model opportunities and respiratory therapists only had three models they can join.
Surgeons and cardiologists fared better with six Medicare alternative payment models available to them. But not all the models qualified as Advanced APMs.
The lack of Advanced APMs for specialists could counter MACRA’s goal of encouraging providers to transition to risk- and value-based reimbursement arrangements under the MACRA track. Specialists may focus more on MIPS performance because of the track’s greater financial impact on revenue compared to Advanced APMs.