How Your Oncology Practice Can Thrive with MACRA: Get Ready for the Quality Payment Program

Meg Barbor, MPH

October 2017, Vol 7, No 10 - Reimbursement


Washington, DC—By now all oncologists know that the implementation of the Medicare Access and CHIP Reauthorization Act of 2015 (MACRA) is shifting physician reimbursement from a volume- to a value-based model. To succeed with MACRA, practices must become familiar with how this will affect them and get ready to incorporate the new measures to ensure they get the best level of reimbursement under this program.

At the 2017 Association of Community Cancer Centers annual meeting, Robin Zon, MD, FACP, Medical Oncologist, Michiana Hematology Oncology, South Bend, IN, Chair, American Society of Clinical Oncology (ASCO) Government Relations Committee, and member of ASCO’s MACRA Task Force, provided tips on how oncology providers and practices can thrive, not just survive, under this new legislation.

“The most common question I get is, ‘Will this affect me?’ If you’re a Medicare Part B provider, the answer is yes,” said Dr Zon.

Providers can choose 1 of 2 ways to participate in MACRA’s Quality Payment Program—through the Merit-Based Incentive Payment System (MIPS), or through an advanced alternative payment model (APM).

MIPS measures quality, use of certified electronic health record (EHR) technology, improvement activity, and cost. It consolidates penalties, increases incentives by ranking peers nationally, and reports publicly.

APMs use new payment mechanisms and delivery systems, negotiated incentives, and automatic bonuses for participation. As of 2017, most providers will participate in MACRA through MIPS, although the Centers for Medicare & Medicaid Services (CMS) is pushing all providers toward becoming part of an APM, Dr Zon said.

“One of the main differences between legacy reporting systems and MIPS is that some of the activities have been renamed,” she said.

The new names represent the 4 new performance categories on which CMS will base its payment adjustment to each MIPS-eligible provider, beginning in 2019. The 4 performance categories and/or their new names are:

  • Quality is replacing Physician Quality Reporting System
  • Advancing Care Information is replacing the category of Meaningful Use
  • Clinical Practice Improvement Activities is a brand new category that was introduced with MIPS
  • Resource Use.

Cost will become part of the MIPS equation in 2018, but in 2017 it is only being calculated, not counted.

Low and High Performers

With MACRA, providers are ranked against their peers on a 0-to-100 scale, and low and high performers fall on either side of a national median composite score. Low performers may receive a penalty, and high performers may receive a reward. MACRA’s rewards and penalties are contingent on the rules of a zero-sum game. Those receiving rewards must receive them from those being penalized. “And if there are very few penalties, that means there is very little put into the bucket for high performers,” said Dr Zon.

Payments for 2017 will begin on January 1, 2019, but the penalty and reward percentages will change with time. For the next several years, the rewards will be:

  • ±4% in 2019
  • ±5% in 2020
  • ±7% in 2021
  • ±9% from 2022 onward.

Providers can choose to report as groups or as individuals across all performance categories, and each performance category can use a distinct reporting mechanism. Quality is reported via a qualified registry, whereas Clinical Practice Improvement Activities and Advancing Care Information are reported by attestation of participation.

Reporting Measures

The final rule introduced a General Oncology Measures Set consisting of 19 reportable process and outcome measures for quality. Reporting requirements for 2017 mandate reporting on 6 quality measures, at least one of which must be an outcome/high-priority measure.

In 2017, providers must report on at least 50% of patients eligible for each measure and have a 20-case minimum. They can choose to report on more than 6 measures, in which case they will be judged on the 6 highest scores. The patient population includes all insurance types, not just Medicare beneficiaries, but providers must report a minimum of 1 measure for each Medicare beneficiary.

These measures apply to all providers, not just oncologists. For example, oncologists, cardiologists, and primary care providers could report emergency department visits. “You will be compared to everyone reporting on that measure, no matter the specialty,” said Dr Zon. “One way to protect yourself is to report on more than 6 measures.”

Advancing Care Information

Advancing Care Information will be scored from 3 EHR categories:

  1. A required base score from traditional EHR activities (ie, security, e-prescribing, patient access, health information exchange)
  2. Performance measures
  3. A bonus score for public health and clinical data registry reporting. To receive any score in this category, the base score must be met.

Providers can choose from more than 90 activities in 9 subcategories in the new performance measure of Quality Improvement Activities.

“A lot of us have been doing this all along, so it’s nice to actually get some recognition for things we’ve been doing routinely to improve the quality and value of care for our patients,” said Dr Zon. “I don’t anticipate this category will be difficult to comply with.”

Most participants must attest to completion of 4 quality improvement activities for a minimum of 90 days, but groups with 15 or fewer participants, or providers in rural areas or in areas with health professional shortages, must only report 2 activities. Participants in certified patient-centered medical homes, comparable specialty practices, or an APM designated as a Medical Home Model will automatically earn full credit.

Participants in MIPS-based APMs, such as the Oncology Care Model, will automatically receive points based on the requirements of participating in the APM. Current APMs under the APM scoring standard will receive full credit, and all future APMs under the APM scoring standard will receive at least half credit. Participants in any other APM will automatically earn half credit and may report additional activities to increase their score.

Quality Payment Program

In response to feedback asking that cost (formerly Value-Based Modifier) be exempt from the MIPS equation this year, CMS will start counting cost in 2018, through the Quality Payment Program (QPP). In 2018, cost will account for 10% of the MIPS equation, and in 2019 for 30%.

Total per-capita cost measure will be risk-adjusted by specialty. As it stands, Medicare Part B drugs are included, and Medicare Part D drugs are not. According to Dr Zon, this is of great concern to oncologists because of the shift away from chemotherapy toward precision medicine, next-generation testing, and immunotherapy.

“If we’re going to provide our patients with value, we’re going to have to give the right drug, at the right time, to the right patient, and those are typically very expensive drugs,” she said, adding that oncologists will be compared with their peers nationally, and could potentially be penalized for “doing the right thing for patients.” This methodology is subject to change based on forthcoming rules.

“The QPP is asking us as providers to provide high-quality care, but it has not been taken into account that there’s a cost for that,” she added.

Clinical Pathways Linked to Reimbursement

Dr Zon urges oncologists to discuss MACRA and the QPP with other local providers to strengthen collaboration and communication. She suggests practices educate all their providers and staff on the new measures, and use clinical pathways to reduce unwarranted variation in care. ASCO published a policy statement with recommendations and criteria for high-quality pathways to guide future development (www.ascopost.com/issues/march-25-2017/the-path-forward-for-clinical-pathways-in-oncology).

“I anticipate pathway utilization will be a linchpin for reimbursement methodologies in the future,” said Dr Zon. She notes that clinical pathways “should be comprehensive (not just drug-related), transparent, modifiable, and easily analyzed, to determine if they’re preserving quality for the patient, but also doing what they’re supposed to do—containing and controlling costs—not necessarily reducing them.”

Finally, Dr Zon urges practices to begin conversations with commercial payers about value-based reimbursement and APMs, preparing staff for value-based care, and reviewing ASCO’s resources regularly for new tools and resources (www.asco.org/macra; www.qpp.cms.gov).