Stephen S. Grubbs, MD, FASCO, and Sybil Green, JD, RPh, MHA
- MACRA is being implemented as the Quality Payment Program, which is administered by CMS.
- Performance data from year 1 was submitted to CMS earlier this year. Participating oncologists and practices should receive their performance scores during the last quarter of 2018, and adjustments will apply to 2019 fee schedule payments.
- ASCO continues to assist oncologists with this payment transformation. Continued advocacy efforts and feedback to CMS and Congress have helped to bring about flexibilities that allow practices to ease into the program.
Since the enactment of the Medicare Access and CHIP Reauthorization Act of 2015 (MACRA), ASCO has been engaged in helping members to prepare and succeed under this new reimbursement mechanism. Prior to MACRA, physicians were reimbursed under the flawed Sustainable Growth Rate Formula for the Medicare Physician Fee Schedule. MACRA redefines Medicare reimbursement for providers, including oncologists and aims to promote payment based on value and quality rather than quantity to ensure high-quality, affordable health care.
MACRA is being implemented as the Quality Payment Program (QPP), which is administered by the Centers for Medicare and Medicaid Services (CMS). Oncologists and practices are required to choose from two different reimbursement mechanisms. For oncologists not participating in a CMS-approved Advanced Alternative Payment Model (Advanced APM), 2019 fee-for-service reimbursement will be based, with possible adjustments, on a Merit-based Incentive Payment System (MIPS) score calculated from 2017 practice activities.
The MIPS score, ranging from 0 to 100, is determined from quality activity (60% of score), advancing care information, which refers to electronic health record (EHR) use (25%), and practice improvement activities (15%). These categories are an outgrowth of legacy quality and performance measurements monitored by CMS for quality (PQRS), EHR (MU), and cost (VBM). Improvement Activity is a new category. These four categories are merged into a single MIPS score to determine fee schedule payment adjustments. The CMS Innovation Center Oncology Care Model, if a practice chooses two-sided financial risk, is a CMS-approved Advanced APM.
In 2017, the first performance year for the program, MIPS participants were given flexibility to either pick their pace and avoid penalties by reporting on just one measure in the quality, advancing care information, or improvement activity categories or to aim for positive adjustments by reporting in all available MIPS categories. The performance threshold was also predetermined, requiring oncologists and practices to only achieve a score of 3 (i.e., a single quality report on one chart) to avoid negative payment adjustments.
Performance data from year 1 were submitted to CMS earlier this year. Advanced APM participants will receive reimbursement based on the terms of the APM, plus a 5% bonus in 2019, while MIPS participants will be evaluated and scored based on their performance and receive fee schedule adjustments ranging from a reduction of up to 4% to additional payments up to 4%. Importantly, these adjustments will apply to all Part B items and services, except Part B drugs. Participating oncologists and practices should receive their performance scores during the last quarter of 2018, and adjustments will apply to 2019 fee schedule payments.
Performance year 2, which began in January 2018, ramps up reporting requirements, and participants must report in all categories, including the cost category. Once again, CMS has opted to allow some flexibility for program participants. Small practices with fewer than 15 practitioners will have fewer reporting requirements than other eligible clinicians, with priority given to those in rural areas, designated health professional shortage areas, or designated medically underserved areas. Additionally,
the performance threshold to avoid a negative 2020 fee adjustment is set at 15 points, and weighting for the categories will change slightly to capture the cost category. The quality category will be weighted at 50%, cost will be weighted at 10%, advancing care information at 25%, and improvement activity at 15%.
Performance year 3, which will be in 2019, is also the year participants will see QPP-related payment adjustments based on their 2017 MIPS score. There will likely be future programmatic changes because CMS has the authority to set the MIPS score threshold and not use the national average as prescribed in the MACRA legislation and to gradually increase the weighting of the cost category.
ASCO’s Quality Oncology Practice Initiative (QOPI®) provides a useful platform for practices to meet reporting requirements. As a Qualified Clinical Data Registry (QCDR), the QOPI Reporting Registry allows both medical and radiation oncology practices to choose and report on the most appropriate measures in the quality, advancing care information, and improvement activity categories. Users can see their performance compared to other QOPI users and estimate their QPP scores. Likewise, CancerLinQ can also take advantage of ASCO’s QCDR platform for reporting QPP program requirements.
The MACRA legislation and the QPP program align with ASCO’s goals of providing value-based care to patients with cancer. ASCO continues to assist oncologists with this payment transformation. Continued advocacy efforts and feedback to CMS and Congress have helped to bring about flexibilities that allow practices to ease into the program. As implementation moves forward, ASCO will provide continuous education to our members to help them succeed. ASCO has developed an APM for oncology, the Patient-Centered Oncology Payment Model (PCOP), and continues to promote and measure oncology care quality through QOPI and CancerLinQ. The PCOP model will be refined and presented to CMS for approval as a qualifying Advanced APM.
About the Authors: Dr. Grubbs was a practicing oncologist and managing partner of Medical Oncology Hematology Consultants, PA, in Newark, Delaware. He is Vice President of ASCO’s Clinical Affairs Department. Ms. Green is an attorney and pharmacist who has worked in the health policy arena and served as an appointed health official in Florida and Louisiana. She is Director of Coverage and Reimbursement in ASCO’s Policy and Advocacy