Our company has a user bulletin board where anyone can ask questions, give advice, or discuss the big issues of the day. MACRA/MIPS is the hot topic right now, as providers debate how to participate, or even whether to participate at all. For example, a physician recently posted the following comment:
“I am not participating in MIPS and plan to fully ignore MACRA, taking the maximum penalty. Wellness exams and CCM [Chronic Care Management] will more than make up for any potential penalties.”
For the uninitiated, MACRA is the Medicare Access and CHIP Reauthorization Act, a new law that replaces the old Sustainable Rate Growth (SRG) formula for Medicare payments to providers. Within MACRA is a new Quality Payment Program with two tracks. The track for small practice providers is called the Merit-based Incentive Payment Program (MIPS).
Although this is not the opinion of the majority of providers, it is a viewpoint shared by a large minority. All physicians should educate themselves on the long-term effects of not participating. The penalty-takers will suffer a 4 percent reduction in Medicare reimbursements in 2019, which grows to 9 percent by 2022.
Some of these non-participating providers plan to make up the difference with additional income from Annual Wellness Visits (AWV), telemedicine, in-house dispensaries, and other billable services. They see it as just a simple math equation. Take your expected Medicare billings and multiply by a four percent reduction for 2019. Then see how many other services you need to make up the difference.
Here’s an example. Let’s say you take the reduction on $50,000 in Medicare billings. You will lose $2,000 in payments. With AWV reimbursements averaging $140, you would need about 15 additional patient visits per year to make up the difference. Getting patients to come in for wellness visits, however, is not easy, and adding even one per month could take some effort.
A Deep-dive Into Specialty Pharma
A specialty drug is a class of prescription medications used to treat complex, chronic or rare medical conditions. Although this classification was originally intended to define the treatment of rare, also termed “orphan” diseases, affecting fewer than 200,000 people in the US, more recently, specialty drugs have emerged as the cornerstone of treatment for chronic and complex diseases such as cancer, autoimmune conditions, diabetes, hepatitis C, and HIV/AIDS.
CCM codes average $42 nationally for 20 minutes of non-face-to-face care services. In a 12 month period, approximately 50 CCM encounters would be required to make up for $2,000 in lost income. This translates into an extra 20 minutes of work per week.
We wonder if the same physician who left the comment on our user board would have a change of heart if they were completely educated on how effortless it can be to avoid any reduction in Medicare payments in 2017. The so-called “Test Path” for avoiding a penalty requires completing one Clinical Practice Improvement Activity (CPIA) for 90 days and then attesting on the CMS website. Providers can choose from 94 individual CPIAs in eight sub-categories, some as simple as expanded practice hours. Compare that to the labor involved in performing 20+ Annual Wellness Visits, or 50+ CCM sessions.
In addition, starting in 2018, the Centers for Medicare and Medicaid Services plans to publish provider-specific quality data online in order to help consumers choose the most effective doctor for their needs. Physicians who do not participate in MACRA/MIPS will not be listed in this database. Will patients care if their doctors aren’t on the list? Will new patients only consider seeing providers who are rated? Time will tell, but this could be yet another factor that will impact a practice’s bottom line.
For those who feel the same way as the physician who wrote on our user board – you need to sit down, sharpen your pencils, and do a little math. Consider the horizon of how long you will practice and accept Medicare coverage. You may find that the effort required to avoid the penalty is small compared with the energy needed to make up the lost income. With so little time in our personal and professional lives these days, that’s a conclusion no one can afford to ignore.
Photo: Peter Macdiarmid, Getty Images
