CMS Proposal for New Medicare Payment System Could Lead to Large Payment Variability for Specialists | Avalere Health

Upcoming Medicare payment changes could affect your care.

Through a series of complex new regulations physician specialists face severe reduction in reimbursments. The group includes ophthalmologists, rheumatologists and oncologists.

New analysis from Avalere finds that payments to certain physician specialists could increase or decrease by as much as 16% for their 2018 performance under the Merit-based Incentive Payment System (MIPS).

The adjustments could take effect if the Centers for Medicare & Medicaid Services (CMS) finalizes a proposal to change how payments to clinicians are calculated under MIPS. For most types of physicians, these payment adjustments would only range between +/- 5%, as provided for under the Medicare Access and CHIP Reauthorization Act of 2015 (MACRA).

The changes will be transparent for most patients.  The specialties most impacted are those which use designer antiinflammatory and/or those which decrease blood vessel growth to malignant tumors and age related macular degeneration (VEGF).  These drugs are covered under Part B of Medicare.

The drugs are a new class of therapeutics, and are expensive, also requiring continuing usage by patients. They are often used as a mainline or last resort treatment.

Avalere’s research finds certain types of specialists, including rheumatologists, oncologists, and ophthalmologists bill for more Part B drugs than their counterparts in primary-care focused specialties. As a result, Part B drugs represent a larger percentage of total billed Medicare allowed charges for these specialists. Under the CMS proposal, Avalere found that some specialists could see payment adjustments as high as +/-16% for MIPS performance year 2018 (see Figure 1).  


Under the CMS proposal, the magnitude of risk for certain types of specialists would continue to increase as the MIPS program reaches full implementation. In performance year 2020, the payment adjustments could reach as high as +/- 29% for rheumatologists and oncologists (see Figure 2).

If finalized, this policy would mark a significant shift in CMS’ approach to payment adjustments. Payment adjustments for the legacy programs that MIPS sought to replace, like the Physician Quality Reporting System and Meaningful Use, have applied only to Medicare physician fee schedule services and not to Part B drugs.

“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 Richard Kane, senior director at Avalere.