Orlando, FL—With the release of the final rule of the Medicare Access and CHIP Reauthorization Act (MACRA), participating providers will now be reimbursed by the Centers for Medicare & Medicaid Services (CMS) based on the quality of the care they provide rather than on the volume.
“CMS was one of the first major payers to approach the issue of reimbursing physicians for value as opposed to volume,” said Philip J. Stella, MD, Medical Director, Oncology Program, St. Joseph Mercy Health System, Ann Arbor, MI, at ASCO’s First Oncology Practice Conference. “This is an important transition,” he added.
High-value care will be defined by quality and efficiency measures, and providers caring for Medicare beneficiaries will earn more or less, depending on their performance against those measures.
“It’s a zero-sum game. They’re trying to reward quality and practice improvement in the new system,” Dr Stella said.
The New Medicare Reimbursement Models
The Quality Payment Program under MACRA introduces new value-based payment programs based on 2 reimbursement structures—the Merit-Based Incentive Payment System (MIPS) and the Advanced Alternative Payment Models (APMs).
MIPS measures quality, certified electronic health record (EHR) technology, advancing care information (another term for meaningful use), improvement activity, and cost, and utilizes peer comparisons and publicly reported incentives and penalties. APMs (eg, Oncology Care Model) are focused on new payment mechanisms, new delivery systems, negotiated incentives, and automatic bonuses.
MIPS composite scores in 2017 are predominantly based on quality (60%), followed by advancing care information (25%), and a new category of improvement activity (15%). Providers will be ranked against their peers, and if that rank falls below the median composite score, a penalty will be assigned, and those dollars will be given as bonuses to providers who scored above the median.
In the future, the 60% portion of the MIPS composite score that is assigned to quality will decrease, and cost will account for 10% of the equation, but cost will be excluded from 2017 scores. Low performers could receive as low as a –4% penalty, and high performers are eligible for a 4% bonus.
“This is real, this is happening, and our first performance year is now,” Dr Stella emphasized.
The MIPS timeline is divided into 3 years—performance year, analysis year, and the adjustment year, in which bonuses or penalties are distributed. Data submission mechanisms vary, because each performance category can utilize a separate and distinct reporting mechanism, and providers can report individually or as a group across all performance categories.
Calculating the Performance Scores
Reporting measures
The final MACRA rule debuted a general oncology measures set, consisting of 19 reportable process and outcome measures. Reporting requirements for 2017 mandate reporting on 6 measures, at least one of which must be an outcome or a high-priority measure. Providers must report on at least 50% of patients who are eligible for each measure, and they must have a minimum of 20 cases.
You can choose to report on more than 6 measures, in which case you will be judged on your 6 highest scores. The patient population includes all payers, not just Medicare patients, but providers must report a minimum of 1 measure for 1 Medicare beneficiary.
Quality measures
Quality measures will be compared with all providers that reported the same measure, and the majority of quality benchmarks will be published before the performance period. Advancing care information will be scored from traditional EHR activities, performance measures, and bonus scores for public health and clinical data registry reporting.
Improvement activities
The new improvement activity category is defined as “an activity that relevant eligible clinical organizations and other relevant stakeholders identify as improving clinical practice or care delivery and that the Secretary determines, when effectively executed, is likely to result in improved outcomes,” said Dr Stella.
Providers can choose from >90 activities in 9 subcategories, and must report by attestation to participation in the activities. It is suggested that practices maintain dated documentation about the improvement activity and any policies, procedures, or practice changes related to the activity.
Practices with >15 physicians must complete 4 improvement activities for a minimum of 90 days. Smaller groups and those in rural areas must complete 2 activities for a minimum of 90 days. Participants in certified patient-centered medical homes, comparable specialty practices, or an APM designated as a medical home model will automatically earn full credit.
Credits
Providers in the Oncology Care Model will automatically receive points based on the APM requirements, and participants in any other APM will automatically earn half credit, and may report additional activities to increase their score.
Cost measures
Cost (formerly defined as Value-Based Payment Modifier) measures Medicare spending per beneficiary. It is not being counted in 2017, but providers will receive a report in 2017 as feedback.
CMS encourages practices to participate in an APM, and participation in an advanced APM equates to exemption from MIPS, a 5% lump sum bonus, and APM-specific rewards.
Pick Your Pace in 2017
Make every activity count, Dr Stella suggests. For example, the activity “chemotherapy plan documented in EHR” can count for points in the categories of improvement activities, advancing care information, and quality measurement for high-risk patients.
“If you choose to test the program in 2017, report more than the minimum required number of measures to improve your chances of successful reporting,” said Dr Stella. He suggests using the period from July to December to practice full reporting for 2018.
“In 2017, you want to participate. Even if you just complete one activity, you’ve got to submit or you’ll be docked –4% in 2019 for failure to participate,” Dr Stella said.
The Quality Oncology Practice Initiative reporting registry, currently in development, will be providers’ “one-stop shop” for quality reporting and attestation for advancing care information and improvement activities.
Prepare the practice and staff for value-based care, advised Dr Stella. “To me, quality reporting on such a large number of patients is the biggest issue we face in oncology,” he said.