Preparing to Implement MACRA: Implications for Oncology Practices

Gail Thompson

June 2017, Vol 7, No 6 - 2017 Cancer Center Business Summit Highlights


Las Vegas, NV—Death and taxes are inevitable, and so are the Medicare Access and CHIP Reauthorization Act of 2015 (MACRA) changes for all medical practices across the country, (not just for oncology). Practices may choose how far to dip their toes into MACRA or into the Merit-Based Incentive Payment System (MIPS) waters, but they will be penalized, rewarded, or not affected in 2019 based on their decisions in 2017. Strategic planning for practices often spans 3 to 5 years; there is a very real financial component that affects oncology practices’ billing and revenues 2 years out and beyond.

Linda D. Bosserman, MD, FACP, Clinical Assistant Professor, City of Hope Medical Foundation, Duarte, CA, moderated a panel discussion at the 2017 Cancer Center Business Summit that looked at the most recent changes in the MACRA regulations, and reviewed how oncology practices could best prepare for the looming changes that will directly affect their financial future.

Preparing for Impending Changes

Robin Zon, MD, FACP, FASCO, a practicing oncologist at Michiana Hematology Oncology, PC, Mishawaka, IN; ASCO Government Relations Chair-Elect; and ASCO MACRA Task Force member, kicked off the discussion on MACRA. She outlined some of the new changes to MACRA’s final rule, including:

  • Physicians being able to select 1 of 3 levels of entry into the MIPS program for 2017 participation
  • The Centers for Medicare & Medicaid Services (CMS) will not count resource use (ie, cost) in the providers’ composite performance score for 2017
  • The establishment of general oncology measures
  • Additional flexibility for small or rural practices
  • Enhancements of the Oncology Care Model (OCM) for participants.

The latter means that OCM practices will not have to report on quality measures twice, because they are already reporting through the OCM program, and OCM practices will get 100% credit. In addition, certain oncology medical homes may receive at least 50% credit toward the Clinical Practice Improvement Activities performance category in the MIPS program.

These changes allow practices time to adjust to the process of MIPS reporting. However, Dr Zon cautioned practices to “please look at your 2015 and 2016 Quality Resource and Utilization Report, available on the CMS website, and make certain that the numbers make sense. You do have a chance now to appeal and make changes before this becomes the fixed standard against which you are held,” adding that in her practice, they are appealing some of the cost components.

MIPS Scoring

Under the MIPS program, performance and reporting in 2017 and beyond will directly result in positive, neutral, or negative payment adjustments on an individual practice level. No additional money is being introduced into the system, so all payment adjustments at the practice level will be offset by payment adjustments at other practices. The payment adjustment will be ±4% in 2019, ±5% in 2020, ±7% in 2021, and ±9% for 2022 and beyond.

The MIPS program includes a list of 19 general oncology measures—reportable process and outcome measures. Under the MIPS reporting requirements, 6 measures must be reported, 1 of which must be an outcome measure.

In 2017, practices must report on at least 50% of patients eligible for each measure, and have a 20-case minimum. Practices may report on more than 6 measures, and will be judged only on the 6 highest scores.

The new concept that practices should consider is that their quality scores are not just reviewed against an arbitrary benchmark point, but against all practices that reported on that measure. MIPS points will be assigned in relationship to the practice score and the benchmark.

The Advancing Care Information portion of the MIPS scoring system accounts for 25% of a practice’s 2017 MIPS reporting score. Base scores are calculated from reporting on traditional electronic health record (EHR) activities (eg, security, e-prescribing, patient access, and health information exchanges).

Once practices have successfully reported on all base scores, they may report on additional performance measures for additional points, and a possible bonus score for public health and clinical data registry reporting.

Clinical Practice Improvement Activities is a new performance category in the MIPS program and accounts for 15% of the 2017 MIPS composite performance score. Practices are allowed to report by attestation for the improvement activities, and can choose from more than 90 activities in 9 subcategories.

The majority of practices will be expected to attest to up to 4 improvement activities, for a minimum of 90 days. If your practice is expending the effort to be certified as a patient-centered medical home, comparable specialty practice, or an advanced Alternative Payment Model (APM) designated as a medical home, your practice will automatically earn full credit for the Clinical Practice Improvement Activities category.

MIPS Reporting

CMS’s Quality Payment Program is in effect now, and any practice that does not submit reporting data in 2017 will automatically receive a 4% negative payment adjustment for services in 2019. What do practices need to decide now regarding MIPS participation? Practices have to decide to what extent they want to report in 2017, with the following implications:

  • No reporting: practices will receive a negative 4% payment adjustment in 2019
  • Minimal submission: submit 1 quality measure, 1 Clinical Practice Improvement Activities measure, 4 or 5 of the base Advancing Care Information measures, or data from 1 patient chart; your practice will avoid the negative payment adjustment if it submits these items
  • Partial submission: submit the MIPS 2017 score measures for 90 consecutive days; your practice may earn a neutral or a small positive payment adjustment
  • Full submission: practices that submit a full year of 2017 data may earn a moderate positive payment adjustment.

All practices, regardless of their decision to submit reporting data in 2017, are required to submit full reporting in 2018. There are alternatives to the MIPS program if a practice qualifies for the advanced APM, which includes specific financial standards (ie, at least 5% of revenues at risk) and other requirements. Any practice participating in the OCM in 2017 that entered the 2-sided risk track would qualify for the advanced APM.

Dr Zon shared the following tips for practices that want to participate in MIPS reporting, especially in 2017:

  • The ASCO Quality Oncology Practice Initiative (QOPI) platform can be used to report 1 measure in 2017 to avoid penalties in 2019; in 2017, the QOPI platform will become electronically functional to allow practices to report at the required 60% of patient charts for 2018
  • Practices can leverage 1 measure to achieve points across multiple MIPS categories, including:
    • Documented chemotherapy plan
      • Quality measure for 3 to 10 points
      • Advancing Care Information performance score: patient-specific education (up to 10%)
      • Advancing Care Information bonus score: Clinical Practice Improvement Activities using certified EHR technology (10% bonus)
      • Clinical Practice Improvement Activities medium-weight activity (eg, use a personalized plan of care that integrates patient goals, values, and priorities for patients at high risk for an adverse health outcome or harm)
    • Documentation of current medications or medication reconciliation
      • Quality measure for 3 to 10 points
      • Advancing Care Information performance score: medication reconciliation (up to 10%)
      • Advancing Care Information bonus score: Clinical Practice Improvement Activities using certified EHR technology (10% bonus)
      • Clinical Practice Improvement Activities medium-weight activity (chronic care and preventive care management of empaneled patients, including routing medication reconciliation).

Dr Zon said that additional information and resources regarding MACRA and MIPS are available at www.asco.org/macra or www.qpp.cms.gov.