By Stephen S. Grubbs, MD, and Sybil Green, JD, RPh, MHA
- MACRA redefines how Medicare will reimburse oncologists for care they provide starting in January 2019.
- Oncologists will receive payment adjustments to established fee schedule reimbursement in 2019 based on participation and performance through MIPS or Alternative Payment Models.
- ASCO is actively assisting oncologists with this payment transformation through QOPI®, CancerLinQ™, and its Patient-Centered Oncology Payment model.
The Medicare Access and CHIP Reauthorization Act of 2015 (MACRA) redefines how Medicare will reimburse oncologists for care they provide starting in January 2019. This legislation repeals the flawed Sustainable Growth Rate reimbursement formula for the Medicare Physician Fee Schedule after years of last minute patches and corrections (“the doc fix”). The goal of the law is to promote a value-based practice environment ensuring high-quality and affordable health care.
Under the new Medicare Quality Payment Program, oncologists and their practices will either receive payments through the Merit-Based Incentive Payment System (MIPS) or participation in advanced Alternative Payment Models (APM). Data from physician services in 2017 must be submitted to the Centers for Medicare and Medicaid Services (CMS) in 2018. CMS will evaluate these data and use them to make payment adjustments starting in 2019. Because evaluation begins in 7 months, it is imperative that oncologists understand and prepare for this reimbursement change now.
For oncologists not participating in a CMS-approved advanced APM, 2019 fee-for-service reimbursement will be based, with possible adjustments, on a MIPS score calculated from 2017 practice activities. The MIPS score, ranging from 0 to 100, will be determined from quality activity (50% of score), electronic health record (EHR) use (25%), cost of care (10%), and clinical practice–improvement activities (15%). CMS already monitors oncologists for quality (through the Physician Quality Reporting System), EHR (through Meaningful Use), and cost (via the Value-Based Payment Modifier) with adjustments to current reimbursement. These traditional separate calculations will be merged along with the new clinical practice–improvement activity into a single MIPS score. Practices may choose to have MIPS scoring per oncologist or per practice.
Once MIPS scores have been calculated, potential adjustments to an oncologist’s Medicare Part B Payments will be applied. Calculated scores will be compared to a national threshold. Lower-scoring oncologists will receive a reduced fee schedule of up to 4% in 2019, with the adjustment rising annually to 9% by 2022. Likewise, high-scoring oncologists will have a possible increase of 4% in 2019, rising to 9% in 2022. Exceptional performers may qualify for an additional increase of three times the annual percentage, for a maximum 27% in 2022.
Oncologists practicing in a CMS-approved advanced APM are exempt from the MIPS payment system if they meet certain Medicare revenue or patient thresholds. Only those APMs meeting the CMS definition of advanced APMs will be exempt from MIPS. CMS-designated advanced APMs are those APMs that require payment based on quality metrics, use of certified EHR technology, and the agreement to bear more than nominal financial risk. A medical home model expanded under Center for Medicare and Medicaid Innovation authority may also qualify. Details are still pending.
Only qualifying practitioners in advanced APMs will be exempt from MIPS participation. To qualify, APM participation must represent a significant amount of the provider’s Medicare revenue (25% in 2019 and 2020) or patient population (20% in 2019 and 2020), which will increase incrementally each year through 2022. In addition to MIPS exemption, the provider will receive an annual 5% lump sum payment. Unfortunately, to date, CMS has qualified only six types of advanced APMs, including the Oncology Care Model if the practice is in the two-sided risk arrangement, which will be available in 2018.
How to Prepare
ASCO is actively assisting oncologists with this payment transformation. ASCO, along with other professional societies, is advocating and providing feedback to CMS in the development of the implementation rules and we will provide continuous education to our members about what is ahead and how to prepare. ASCO has developed an APM for oncology, the Patient-Centered Oncology Payment model, and continues to promote and measure oncology care quality in the Quality Oncology Practice Initiative (QOPI®) and CancerLinQ™. The payment model will be refined and presented to CMS for approval as a qualifying advanced APM. All are important tools in the new value based payment world.
MACRA legislation will have profound effects on all physician payments, including oncology payments, and appears to promote the CMS goal of restructuring delivery and payments through APMs. All practices must prepare now for reporting in 2017 and data analysis in 2018. The first step is to be sure your practice is reporting for the Physician Quality Reporting System and Meaningful Use. You should also review your Quality and Resource Use Report, which determines your Value-Based Payment Modifier score. The 2017 measurements will determine MIPS payment adjustments in 2019. Likewise, performance in an approved advanced APM in 2017 will determine MIPS exemption and 5% bonus reimbursement in 2019. Participation in QOPI and CancerLinQ will help prepare practices for this transition, and ASCO will continue to report and educate on the latest MACRA implementation developments.
Plan to attend the ASCO Town Hall at the ASCO Annual Meeting on June 4 and subsequent Best of ASCO® meetings to learn more about MACRA.
|Defining Common Terms|
Alternative Payment Model
Center for Medicare and Medicaid Innovation
|CMS||Centers for Medicare and Medicaid Services|
|CPIA||Clinical Practice-Improvement Activity|
|EHR||Electronic Health Record|
|MACRA||Medicare Access and CHIP Reauthorization Act|
Merit-Based Incentive Program
Oncology Care Model
Patient-Centered Oncology Payment
Physician Quality Reporting System
Quality Oncology Practice Initiative
Quality and Resource Use Report
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 Department.