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On April 16, 2015, President Obama signed into law the Medicare Access and CHIP Reauthorization Act of 2015 (MACRA). As the policies passed in this new legislation are rolled out over the coming years, comprehensive changes in how Medicare pays physicians for services will be introduced. Reimbursement for rheumatologists and their practices will change significantly. The law:
Under MACRA, nearly all physicians will have to choose between one of two paths: Merit-Based Incentive Payment System (MIPS), which consolidates existing Medicare fee-for-service physician incentive programs such as PQRS and meaningful use or participation in an Alternate Payment Model (APM)
“MACRA is a reality that directly effects rheumatology practices and their ongoing viability for providing care to patients. Understanding this new payment system and the options available to physicians is critical. The ACR is working proactively to support the rheumatology community in this transition through provision of relevant up to date information for providers, through development and support of a patient registry that will provide MIPS credit for participating practices, and by funding development of a rheumatology specific alternate payment model.”
– David Daikh, MD, PhD
The Quality Payment Program (QPP) has two tracks to choose from which allow you to participate based on your practice size, specialty, location, or patient population: MIPS and APMs.
Note: Details on MIPS will be the subject of policymaking for several years, but it is important to understand that some of the assessments made at the effective date of 2019 will be based upon 2017 data.
ACR leadership from a number of highly engaged committees have joined forces to develop an action plan for the organization’s involvement in the implementation of the new law. This ACR MACRA Working Group is developing an education, communication, and advocacy strategy and is committed to helping our members navigate through the complexity of MACRA as it rolls out. We are currently working on an Alternative Payment Model (APM).
The ACR’s Alternative Payment Model (APM) addresses the treatment of rheumatoid arthritis (RA), a life-long condition whose appropriate care varies depending on the stage of the disease. The APM reflects the varied involvement of the rheumatologist during these distinct stages, splitting payment into an initial stage for diagnosis (including, for example, communication with primary care physicians), followed by ongoing care stratified by disease severity and recognizing other illnesses that complicate treatment. This model aligns payment with physician work and reimburses for services that have traditionally been undervalued. Quality measures are built into the APM to ensure that treatment adheres to best practices. We believe the services provided by cognitive specialists such as rheumatologists are undervalued in the current system, and the additional training and expertise of rheumatologists are not recognized. Additionally, non-face-to-face care and chronic disease care coordination reimbursement as currently configured is inadequate for the time and effort required to comply with current codes. In the ACR’s RA-APM, these valuable services which may prevent costly or unnecessary procedures are appropriately reimbursed, while the model is designed to lower overall costs.
Status of ACR APM Development
The ACR Board approved the next phase and continued funding in November 2017. Small-scale data collection is in progress. The RA-APM is in development and its design is intentionally flexible and scalable. Many details, including dollar amounts, are not final.
Overview of the ACR’s APM
Draft Rheumatoid Arthritis APM
Updated March 2018