Under the new Medicare Quality Payment Program, payments made to oncologists and their practices will be adjusted through either the Merit-Based Incentive Payment System (MIPS) or participation in advanced Alternative Payment Models (APMs). 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 less than 6 months(from the time of this writing), it is imperative that oncologists understand and prepare for this reimbursement change now.

Breaking Down MIPS

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 assessment and performance in:

• Quality (PQRS) - 50%
• Advancing Care Information (Meaningful Use) - 25%
• Clinical Practice Improvement Activities (Patient Satisfaction, Care Coordination, etc.) - 15%
• Resource Use (Value-based modifier) - 10%

CMS already monitors oncologists for quality (through the Physician Quality Reporting System), Electronic Health Record (EHR) use (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 assessed individually or by 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.

Breaking Down Advanced APMs

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 pending. 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 (not available until 2018).

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.

How to Prepare

ASCO is actively assisting oncologists with this practice transformation. ASCO, along with other professional societies, is advocating and providing feedback to CMS in the development of the implementation rules, and the society will provide continuous education to our members about what is ahead and how to prepare.

ASCO has developed three important tools that will be crucial in the new, value-based payment world. The Patient-Centered Oncology Payment (PCOP) model, ASCO's APM for oncology, will be refined and presented to CMS for approval as a qualifying advanced APM. Additionally the society continues to promote and measure oncology care quality through the Quality Oncology Practice Initiative (QOPI^®) andCancerLinQ^™.

Given the profound impact MACRA will have on all physician payments, including oncology payments, practices must prepare now for reporting in 2017 by:

• Step 1 - Participate in 2016 Quality Reporting to Avoid Negative Payment Adjustment
  • Successfully report to the Physician Quality Reporting System (PQRS)
  • Successfully attest to the Medicare EHR Incentive Program
  • Receive an upward or neutral Value Modifier payment adjustment
     
• Step 2 - Review Your Quality and Resource Use Reports (QRUR)
  • Annual QRUR available each autumn after reporting period (e.g. autumn 2017 for calendar year 2016)
  • One person from your Taxpayer Identification Number (TIN) must register to obtain your QRUR (one QRUR is provided per TIN)
  • Review how you performed on quality and cost
     
• Step 3 - Focus on Performance
  • Review quality measure benchmarks, understand what is required for above average performance
  • Implement strategies to help meet your chosen quality measures for PQRS and the quality and cost measures used under the Value Modifier program
  • Use EHRs
  • Monitor cost measures (e.g. hospitalizations)
     
• Step 4 - Ensure Data Accuracy
  • Check the accuracy of your comparison group critical (performance is compared among similar providers)
  • Check the NPI for each physician in practice
  • Review your own information in Physician Compare
     
• Step 5 - ICD-10 Coding
  • Code to the highest level of specificity
  • Code all co-morbidities and other pertinent conditions

ASCO members who missed the MACRA Town Hall during the Annual Meeting, or who want to see it again, can watch it online or attend a subsequent Town Hall at an upcoming Best of ASCO^®.

Stay tuned to ASCO in Action for the latest on MACRA and other related policy issues.

FYI: Commonly Used Acronyms

ACI	Advancing Care Information
APM	Alternative Payment Model
CMMI	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 of 2015
MIPS	Merit-Based Incentive Payment System
MU	Meaningful Use
OCM	Oncology Care Model
PCOP	Patient-Centered Oncology Payment
PQRS	Physician Quality Reporting System
QPP	Quality Payment Program
QOPI	Quality Oncology Practice Initiative
QRUR	Quality and Resource Use Report
VBM	Value-Based Payment Modifier