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Rheumatology Practice Management October 2015 Vol 3 No 5 - NORM Highlights
Chase Doyle

Bellevue, WA—Congress is keeping things interesting for rheumatology practice managers. If it wasn’t challenging enough to run a medical practice before, now there’s a whole new set of acronyms to contend with—MACRA, MIPS, and APMs.

Emily L. Graham, RHIA, CCS-P, Vice President of Regulatory Affairs at Hart Health Strategies in Washington, DC, addressed the details of these new payment systems at the 2015 annual meeting of the National Organization of Rheumatology Managers (NORM).

MACRA (Medicare Access and CHIP Reauthorization Act)


Passed into law on April 16, 2015, MACRA immediately repeals the sustainable growth rate (SGR) formula and provides a short-term “phase-in” to a new payment system for reimbursing Medicare physicians.

Current Centers for Medicare & Medicaid Services quality improvement programs, including Physician Quality Reporting System (PQRS), Value-Based Modifier (VM), and Electronic Health Record (EHR) incentive program (“Meaningful Use” [MU]), will continue until the start of 2019. Separate application of payment adjustments under PQRS, VM, and EHR-MU will sunset December 31, 2018.

Base payment updates will remain at 0.5% each year through 2019.

“We’re phasing into a new payment system,” said Ms Graham, “and at some level, it’s starting now. We’re at a 5-year holding pattern window. Once we reach 2020, we will no longer have regular payment updates.”

Payments can still go up and down, based on recording in a MIPS (see below) or an alternative model payment track, she noted, but the base conversion factor is going to remain a 0% update.

MIPS (Merit-Based Incentive Payment System)

As Ms Graham outlined, new “value-based” payment models begin January 1, 2019. Physicians can choose to participate in a MIPS or meet requirements to be a qualifying APM participant (see below).

The MIPS consolidates existing Medicare quality improvement programs (PQRS, VM, EHR-MU) and creates a composite performance score (0-100) to inform physician payment based on 4 “weighted” categories: Quality (30%) (PQRS), Resource Use (30%) (VM), Meaningful Use (25%) (EHR-MU), and clinical practice improvement activities (15%). The composite performance score will then be used to determine and apply a MIPS payment adjustment factor for 2019 onward.

“MIPS participants can receive positive, negative, or zero payment adjustment,” said Ms Graham. “Eligible providers receive a positive adjustment factor if the score is above the performance threshold and a negative adjustment factor if the score is below the threshold.”

Potential adjustments are as follows:

  • 2019 to 2020 (the first 2 years): –4%, up to +12%
  • 2021: –7% up to +21%
  • 2022 and beyond: –9%, up to 27%.

Negative adjustments are capped each year, she noted, whereas positive adjustment can be up to 3 times the amount (plus an additional bonus of up to 10% for exceptional performers).

APMs (Alternative Payment Models)


This system is for physicians receiving a significant share of their revenues through an APM that involves financial risk and quality measurement.

APMs are defined as a Center for Medicare and Medicaid Innovation (CMMI) demonstration, a Medicare Shared Savings Program (ie, a Medicare Accountable Care Organization), or certain other demonstration programs.

Participating in an APM offers:

  • A 5% participation bonus (lump sum) from 2019 to 2024
  • A higher baseline update in 2026 and beyond (0.75% vs 0.25%)
  • Technical assistance to help small practices participate and help poor performers improve.

With the exception of CMMI medical homes, APMs must bear “more than nominal” financial risk, said Ms Graham. Participants are required to use certified EHR technology and to report on “MIPS-like” quality measures.

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Last modified: November 3, 2015
  • American Health and Drug Benefits
  • Lynx CME
  • Value Based Care in Rheumatology
  • Oncology Practice Management
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