Payments to specialists could yo-yo under MIPS


Avalere conducted an analysis to assess the effect of MIPS. Here are the surprising results.

Payments to specialists could waffle under the Merit-based Incentive Payment System (MIPS), according to new analysis from Avalere.

Rheumatologists, oncologists, and ophthalmologists could see their payments increase or decrease by as much as 16% for their 2018 performance under the CMS proposal.

Avalere conducted the analysis to assess the effect of MIPS, which is now under review at the Office of Management and Budget.

“MIPS introduces a value-based payment structure into Medicare fee-for-service that will reward providers that perform better on quality measures relative to their peers,” says Richard Kane, senior director at Avalere.

Specialists bill for more Part B drugs than their counterparts in primary-care focused specialties, according to Avalere. Therefore, Part B drugs represent a larger percentage of total billed Medicare allowed charges for these specialists. For most physicians, these payment adjustments would only range between +/- 5%, as provided for under the Medicare Access and CHIP Reauthorization Act of 2015 (MACRA).

Medicare payment data was used to estimate for each type of specialist their average Part B charges before and after drug acquisition costs.


“This allowed us to estimate for each type of specialist how much of a difference it would make, to include Par B drug payments in the MIPS adjustment calculation,” says Kane. “By including Part B drug payments in the MIPS calculation, CMS will place a greater portion of provider payments at risk under MIPS. While this is unlikely to change prescribing patterns for Part B drugs-since they do not impact quality measures-it exposes providers with higher Part B drug payments to a greater risk under MIPS.”

This may encourage providers in these specialties (e.g., oncology, rheumatology, ophthalmologists) to be more focused on MIPS quality performance, since it will have a larger financial impact, says Kane.

“Many specialists may not have an alternative to the MIPS track due to limited opportunities for specialists to join an Advanced Alternative Payment Model,” he says.

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