Change to Part B pay draws specialty ire

Bob GattyCongressional leaders are being urged by several leading medical societies, including the AUA and the American Society of Clinical Oncology, to prevent the Centers for Medicare & Medicaid Services (CMS) from applying Merit-based Incentive Payment System (MIPS) adjustments to Part B drug payments.

In letters recently sent to the chairs and ranking members of the Senate Finance, House Ways and Means, and House Energy and Commerce committees, the specialty groups warn that such action by CMS could jeopardize patients’ access to critical drug treatments.

Ability to provide Part B drugs ‘at risk’

The groups said applying MIPS adjustments would “put at risk the ability of specialists to provide the physician-administered drugs on which their patients depend,” noting that drugs covered under Medicare Part B include therapies that are typically administered by a physician, either in an independent practice or outpatient setting. The drugs are not generally available at pharmacies and are not part of Medicare Part D prescription drug plans.

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Under the Medicare Access and CHIP Reauthorization Act of 2015 (MACRA), Congress established a range of bonuses and penalties to which Medicare providers could be subjected through MIPS payment adjustments. In its 2018 Quality Payment Program final rule, CMS announced that it will immediately begin to impose these payment adjustments to Part B drug payments in addition to physicians' services under the Medicare fee schedule, a decision that represents a significant departure from current policy.

“We believe this policy is not consistent with congressional goals in the bipartisan passage of MACRA,” the letter states. “In the final rule, CMS states that the statute leaves them no flexibility in how to implement policy. 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. It will significantly amplify the range of bonuses and penalties intended by MACRA, only for certain specialties.”

In the letter, the groups said, "While we had substantial and bipartisan congressional support for a message to CMS to reevaluate their interpretation of the MACRA statute, CMS did not heed that request. We now need Congress to act immediately to curtail this policy and ensure patients have access to all the services and treatments they need."

Next: "Issues could create a perfect storm for specialties"

The letter also urges congressional leaders to address the weighing of the cost score category of MIPS.

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"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. 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. We believe that these methodologies and measures must be developed and validated before CMS moves forward with implementing this category," the letter states.

“Taken together, these two issues could create a perfect storm for specialties whose patients depend on physician-administered drugs,” the groups concluded.

According to Quardricos Driskell, MPS, MTS, government relations manager at AUA, the groups plan to meet with members of the Senate Finance and House Ways and Means committees to press the case.

“On Jan. 1, 2017, MACRA transitioned to MIPS, a new way to pay physicians for care, which will make Medicare Part B physician payment adjustments based on a composite performance score,” John Feore, JD, and Richard Kane, MIPP, of Avalere Health, noted in a press release.

MIPS is one of two pathways for clinician participation under MACRA. The other option, the Advanced Alternative Payment Model (AAPM), offers qualifying participants an annual 5% lump-sum bonus in payment years 2019 to 2024. For eligibility, a practice must either receive at least 25% of its Medicare Part B payments through the AAPM, or at least 20% of its Medicare patients must be seen through the AAPM.

In addition to the lump-sum bonus, qualifying participants will not be required to fulfill MIPS reporting requirements, and their Medicare physician fee schedule will increase by 0.75% starting in 2026. If AAPM entities do not meet the criteria, they may choose to participate in MIPS.

“Many specialists may not have an alternative to the MIPS track due to limited opportunities for specialists to join an Advanced Alternative Payment Model,” said Kane, senior director at Avalere.

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Under the new rule to take effect in 2018, calculations of MIPS adjustments will include the cost of Medicare Part B drugs, and this change could have a significant impact on payments for some physicians. Physicians who administer more Part B drugs may experience substantial payment variability and financial risk compared with other physicians.

Next: Specialists bill more often for Part B drugs

Specialists bill more often for Part B drugs

Research conducted by Avalere consultants showed that specialists such as oncologists, rheumatologists, and ophthalmologists more frequently bill for Part B drugs compared with physicians from primary care specialties.

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“As a result, Part B drugs represent a larger percentage of total billed Medicare allowed charges for these specialists,” and they “could see substantially higher payment penalties or rewards than their counterparts who administer fewer Part B drugs,” they noted.

Moreover, the level of financial risk for certain specialties will continue to rise as implementation of the MIPS program progresses over the next few years. For example, payment adjustments for rheumatologists and oncologists could increase or decrease by as much as 29% in performance year 2020. For urology, Avalere estimated that payments could increase or decrease by as much as 11% during that period.

Before MIPS went into effect, CMS programs including the Physician Quality Reporting System, Physician Value-Based Payment Modifier, and the Medicare Electronic Health Record Incentive only pertained to physician fee schedule services and did not include the cost of Part B drugs.

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