Dec 22, 2016
By Shira Klapper, Senior Writer
VBM. QCDRs. QRURs. APMs. The vocabulary of the Medicare Access and CHIP Reauthorization Act of 2015 (MACRA) can be mystifying. But beyond the acronyms and the wonky policy language lies nothing less than a historic piece of health care legislation.
The new law, called the Medicare Quality Payment Program, from the Centers for Medicare & Medicaid Services (CMS), not only promises to deliver a more consistent and reliable system of payment compared to the previous Sustainable Growth Rate (SGR), but also heralds a fundamental shift in CMS’s conception of reimbursement incentives—from a model that emphasizes volume to one that emphasizes quality of care. Under MACRA, oncologists will still continue to be paid along a fee for service (FFS) schedule, but a crucial difference is that now, doctors will receive substantial bonuses for delivering care that scores high on quality and low on cost. Conversely, doctors will incur penalties for care that is low on quality and high on cost. (But rest assured: initially, most doctors will score in the “neutral” average zone, incurring neither benefit nor loss).
MACRA, which eliminates the SGR, brings to fruition a core policy of ASCO’s advocacy work: shifting health care incentives from volume of care to value in care.
As with all changes, even positive ones, MACRA will require physicians to climb a somewhat steep learning curve as they make adjustments to many aspects of their practice, from educating providers and staff on the new data requirements to allocating resources to quality initiatives, and ensuring that their practices are using electronic health records (EHRs) in the most effective way. MACRA will require an investment of time and energy, but it is ASCO’s belief that once the new Quality Payment Program (QPP) starts rolling, oncologists will find it a strong fit for their practices, for a simple reason: the new program rewards the kind of work oncologists have always carried out, but have never been reimbursed for, such as implementing quality improvement programs, connecting patients to supportive services, and delivering difficult news. These services, which have always been part and parcel of high-quality care, are now incentivized by being tied to financial bonuses.
“In my 32 years of practicing oncology, MACRA is the biggest change in medicine I’ve seen,” said Philip J. Stella, MD, of St. Joseph Mercy Hospital and immediate past chair of ASCO’s Government Relations Committee. “Documenting quality metrics will require an immense change in how we approach things, but it also represents a great opportunity for us to try to get the reimbursement system right—we all know that there’s so much more to treating a patient with cancer than pushing a drug. MACRA acknowledges this fact and enables us to be paid for managing our patients in a way that’s better for us, and most importantly, better for the patient.”
In the following article, ASCO Connection unpacks MACRA for you, taking you step by step through the most important aspects of the new policy. Here you will find answers to your most pressing questions, including:
- How will MACRA benefit my practice, and my patients?
- What kinds of information will I need to report under MACRA?
- Which steps can I take to prepare?
- How will MACRA affect my reimbursement?
- How can ASCO, and particularly the Quality Oncology Practice Initiative (QOPI®), help me through the transition?
Incentivizing high-quality care
The SGR formula, which governed Medicare reimbursement from 1997 to 2015, was untenable—every year, doctors faced Medicare reimbursement deficits of 20% or more, and every year doctors had to wait anew as Congress deliberated whether to pass “patches” to cover the gaps. ASCO was deeply involved in the efforts to repeal SGR, including meeting with Congress and orchestrating social media campaigns. In April 2015, the hard work of ASCO and many other medical organizations paid off as Congress repealed SGR and replaced it with MACRA. CMS released the final ruling for MACRA on October 14, 2016.
MACRA addresses a fundamental challenge of our time: the need to rein in ever-increasing medical costs. This challenge is especially acute in oncology care, in which an aging population is rapidly increasing the demand for oncology services, even as expensive medications, such as immunotherapy, become the primary form of cancer treatment.
MACRA responds to this challenge by financially rewarding care that is higher quality and lower cost than the national average and financially penalizing care that is lower quality and higher cost than average.
2016-2017 ASCO President Daniel F. Hayes, MD, FACP, FASCO, explained how MACRA upends the old model of incentives in favor of quality care.
“I’ve been in academics all my life, and while I get rewarded for hard work and production, which I agree people should, it’s always disturbed me that physicians get paid to do things to patients, more than they get to do things for patients,” Dr. Hayes said. “For example, if I saw a patient who has node-negative, estrogen receptor–positive breast cancer, the chances that chemotherapy will improve her survival are about 4% to 5%. Now, I can spend 45 minutes with that patient, explain the numbers to her, go through the risk, benefits, and toxicities, and help her make her decision. But the reimbursement for that kind of discussion is considerably lower than if I just say, ‘Ms. Jones, you came to the right place, we can improve your survival, and you should get IV chemotherapy.’ What MACRA does is incentivize the first way of giving care.”
Dr. Stella provided another case study illustrating how tying reimbursement to quality metrics ultimately translates into higher quality care for patients.
“In the old system, we give patients highly toxic drugs on day 1, provide them some education, and say, ‘Call us if you have any problems.’ Then, a caregiver calls on day 10 and says to the nurse, ‘My mother has been in bed for 5 days, she’s real weak, has diarrhea, is not drinking much, and can barely lift her head.’ At this point, the nurse’s only option is to send the patient to the emergency room because she’s clearly dehydrated. That patient is going to get admitted for around 3 to 5 days for hydration, blood counts, fever checks, and to control diarrhea, at the cost of tens of thousands of dollars,” Dr. Stella said. “Now, what if you incentivize the doctors to come up with systems where that nurse would call the patient on day 5, when you know diarrhea will likely happen and when the nurse can intervene early by pushing the fluids, recommending medication, and watching for fever? In that scenario, if, on day 6, the dehydration gets worse, you say to the patient, ‘Come into the office, and we’ll give you fluids here!’ This way, we’ve lowered costs, but above all, we’ve improved life for the patient.”
The nuts and bolts of MACRA
MACRA encompasses two programs: the Merit-Based Incentive Payment System (MIPS) and the Advanced Alternative Payment Model (APM). Collectively, these programs comprise what CMS calls the Quality Payment Program (QPP). Both the MIPS and the APM pathways incentivize high-quality, low-cost care, but differ from each other in several ways.
Nearly all oncologists will meet the inclusion criteria for the MACRA law, which states that all providers who bill under Medicare Part B must participate. Exceptions are provided for physicians who are newly enrolled in Medicare, bill less than $30,000 per year in allowable charges, or see 100 or fewer Medicare patients.
Merit-Based Incentive Payment System (MIPS)
Most practitioners will fall into the MIPS and not an APM. This will be especially true in 2017, the first year of MACRA, which CMS has designated a transition year.
The basic idea of MIPS is that doctors receive a composite quality score based on data from four performance categories, described in more detail below: Quality, Quality Resource Use, Clinical Practice Improvement Activities, and Advancing Care Information. Each of these categories will contribute a certain percentage to the overall composite score. Whether doctors’ scores compare favorably or unfavorably to the national average determines whether doctors receive either a bonus on top of their usual FFS reimbursements, a penalty, or a “neutral” reimbursement.
During the first year of MACRA, the percentage that each of the four categories contributes to the composite score is as follows:
- Quality: 60%
- Advancing Care Information: 25%
- Clinical Practice Improvement Activities: 15%
- Quality Resource Use: 0% (this category will not be included in the composite score for 2017)
Doctors will begin collecting data in 2017 and will submit data in 2018; the percentages above apply to the data submitted during 2018. Scores will be publicly reported on the CMS Physician–Compare website.
The MIPS categories are not new, but simply variations on categories of data that many oncologists have been submitting for years. Quality corresponds to the Physician Quality Reporting System (PQRS), Advancing Care Information corresponds to the Meaningful Use Electronic Health Records Incentive Program (MU), and Quality Resource Use corresponds to the Value-Based Modifier (VBM). Under the old system, those three categories functioned as individual quality programs so that physicians might have been neutral in one category, negative in another, and positive in yet another. MIPS combines these three current reporting programs into one new system, with the addition of the Clinical Practice Improvement Activity (CPIA).
To ease the transition into quality reporting, CMS has substantially reduced the burden of MIPS reporting for the first year; this change was a result of comments submitted to CMS by ASCO and other medical organizations. You can read more about the first-year data requirements in the “Timeline” section further down.
QOPI: Quality Reporting Made Easy
ASCO’s Quality Oncology Practice Initiative (QOPI) is one of the single most valuable resources oncologists can utilize to ease the transition to MACRA. QOPI is a quality assessment tool that allows oncologists to choose quality measures from a robust library of oncology-specific metrics, and continually assess data for those metrics. QOPI is available for free to ASCO members and has been deemed by CMS as a Qualified Clinical Data Registry (QCDR); a QCDR is defined by CMS as “a CMS-approved entity that collects medical and/or clinical data for the purpose of patient and disease tracking to foster improvement in the quality of care provided to patients.” As a QCDR, QOPI will be able to build specific quality measurement for oncologists and fine-tune subsets of measurements for oncology specialties, thus helping practices satisfy reporting requirements.
“Our QOPI measures give the best foundation for everyone in oncology to measure quality,” said Dr. Stephen S. Grubbs, vice president of Clinical Affairs at ASCO. “In coming years, we will begin to bundle certain QOPI measures together so a practice can choose a bundle that fits their specific needs, for both MIPS and APMs. By using QOPI, practices can be sure that they’re measuring quality at the level they need.”
The QOPI program was conceptualized, developed, and is guided today by world-renowned practicing oncologists, nurses, health service researchers, and quality experts. The quality metrics offered in QOPI were created and adapted from clinical guidelines and established measures, such as the National Initiative on Cancer Care Quality (NICCQ), ASCO/NCCN Quality Measures, and ASTRO/ASCO/AMA PCPI Oncology Measures.
Practices that want to take their commitment to quality improvement to a new level can enroll in the QOPI Certification Program, which launched in 2010. To achieve QOPI Certification, a practice must have participated in QOPI and met or exceeded a benchmark score on measures that compare the quality of its care against national standards. Practices also undergo an onsite audit to evaluate quality of oncology care.
ASCO’s Quality Training Program
Learn more about how to implement a quality improvement program by participating in ASCO’s Quality Training Program. The program includes 5 days of in-person learning with expert faculty and coaches, during which participants attend seminars and sessions that enhance practical team skill-building using real-world clinical scenarios. Learning then continues over 6 months of on-demand, remote coaching sessions. (See p. 56 for a personal perspective from a Quality Training Program participant.)
Many practices have already been involved in submitting quality information to CMS through the PQRS program. However, there are some important differences between PQRS and MACRA’s Quality category. Under MACRA’s Quality category, which accounts for 60% of the composite score for 2017, practices will have to select six quality measures (as opposed to nine in PQRS) to report annually, including one cross-cutting measure and one outcome measure.
ASCO has been working with CMS to develop quality measures that are specifically relevant to oncology clinical practice. Examples of measures that have already been developed include the proportion of patients admitted to
the intensive care unit in the last 30 days of life and the number of patients with breast cancer and negative or undocumented HER2 status who are spared treatment with trastuzumab. Cross-cutting measures are defined as measures that are broadly applicable across multiple clinical settings and eligible professionals or group practices within a variety of specialties. An example of a cross-cutting measure is the percentage of patients in a practice who have a care plan or surrogate decision maker documented in the medical record.
Practices will have several options for how to submit quality data, with some differences depending on practice structure, whether individual or group. Options include using Qualified Clinical Data Registry Reporting (QCDR), EHRs, Administrative Claims, and the CMS Web Interface. A QCDR is an entity that supports practices in identifying, collecting, managing, and submitting data. Read the sidebar to learn more about ASCO’s Quality Oncology Practice Initiative (QOPI®), a CMS-deemed QCDR that can greatly ease your transition into MACRA reporting.
Quality Resource Use
It is important to note that Quality Resource Use will not be included in the composite score for the first year of MACRA reporting.
Quality Resource Use, which will eventually account for 10% of the MIPS composite score, corresponds to the old Value-Based Modifier (VBM). CMS calculates the Quality Resource Use score in a similar way to the VBM. First, CMS calculates the average costs and outcomes across the nation based on information from quality reporting and claims nationwide. This score is then used to rate individual practices by how well they compare to the average—did the practice score high on quality, but also higher than average on cost? Or did the practice score average on costs and low on quality care compared to other practices around the country?
Practices do not have to report any specific information for this category since CMS calculates the Quality Resource Use score based on information pulled from the Quality category and claims.
One of the most important steps to take in preparing for MACRA is understanding how your practice has been performing on quality and costs compared to the rest of the country. This information is readily available from CMS through the Quality Resource Use Reports (QRURs), part of CMS’s Physician Feedback Program. QRURs are available in the fall after the reporting period (information for 2016 will be available in fall 2017). You can find information on accessing the QRUR on CMS.gov.
Advancing Care Information
The Advancing Care Information (ACI) category corresponds to Meaningful Use (MU), and will account for 25% of the MIPS composite score. The ACI scores practices on how effectively they use EHRs, with an emphasis on interoperability (the ability to share data across different systems), information exchange, and security measures.
The total score for this category is calculated from a base score, performance score, and bonus score. For the base score, which constitutes 20% of the score, practices will simply provide the number of patients or yes/no answers for measures such as electronic prescribing, access to patient portals, and patients included in Public Health and Clinical Data Registry Reporting. For the performance score, which constitutes 80% of the total score, physicians choose to report on one of three categories that best fit their practices: patient electronic access, coordination of care through patient engagement, or health information exchange. Practices can receive a bonus point for participating in the Public Health Registry for immunization.
Clinical Practice Improvement Activity (CPIA)
This category, which constitutes 15% of the composite score for MIPS, requires practices to engage in a minimum of one practice improvement activity per year. Examples of improvement activities include achieving health equity, emergency preparedness and response, and integrated behavioral and mental health. CMS offers a list of more than 90 possible activities, which are assigned weights of “high” or “medium” and count for 20 or 10 points each, respectively. To earn full credit in this category—and thus be eligible for a bonus—practices must carry out activities that together add up to 60 points. Practices designated as patient-centered medical homes, Medical Home, or comparable specialty practices automatically get full credit for this category.
Alternative Payment Models (APMs)
Few practices will participate in an APM in 2017. APM practices fall into one of five categories: Oncology Care Model practices, CMS Innovation Center Models, Medicare Shared Savings Program (MSSP), demonstration under the Health Care Quality Demonstration Program, and demonstration required by federal law. Most APMs will be subject to MIPS data requirements, except for a type of APM that CMS designates an Advanced Alternative Payment Model. Advanced APMs are defined as practices that have advanced EHR technology, use quality measures at least as rigorous as MIPS measures, and pose more than nominal two-sided financial risk. To be exempt from MIPS, practices will need to have a threshold volume of 25% of patients participating in the Advanced APM.
PCOP: ASCO’s Alternative Payment Model
As part of MACRA, CMS has invited providers to develop APMs that best suit their individual disciplines and practice models. ASCO has responded to this call by developing an APM of its own called the Patient-Centered Oncology Payment (PCOP), which is specifically designed to meet the needs of oncology practices. ASCO is pursuing designation for PCOP as an Advanced APM, and is currently piloting the model in a single practice, with more practices slated to join over the next year. PCOP addresses a central problem in the current CMS reimbursement system—currently, oncologists get reimbursed only for direct facetime with patients and for administering chemotherapy. “Non-coded” services such as coordinating treatment plans, delivering bad news, and helping patients navigate care are not reimbursed, even though they comprise the bread-and-butter services of day-to-day patient management. In addition to bringing these services into the reimbursement fold, the PCOP model aligns with MACRA’s emphasis on high-quality, cost-effective quality care—data show that when doctors know they can take adequate time to work with patients, quality of care improves and costs are reduced.
Timeline for MACRA Quality Payment Program
Practices will be required to begin reporting quality information to CMS beginning in early 2018. However, since they will be reporting on data from the 2017 calendar year, practices should be sure to start collecting data in January 2017. CMS will analyze information reported during 2018 to adjust the 2019 Medicare Physician Fee Schedule. In response to comments from ASCO and other medical organizations, CMS has eased the requirements for 2018, the first reporting year of MACRA, allowing practices time to adjust to the new system. Below is a list of four options for reporting in 2018, along with the specific reimbursements tied to each option:
- Report complete data for three MIPS categories (Quality, Advancing Care Information, and Clinical Practice Improvement Activity) for the entire year: Receive a bonus
- Report some data from any of the three categories for the entire year: Neutral reimbursement—receive neither bonus nor penalty
- Report complete data for some of the year: Neutral reimbursement—receive neither bonus nor penalty
- Join an Advanced APM in which at least 25% of patients are treated through the APM (this option will apply to very few physicians)
ASCO Webinars and Educational Sessions About MACRA
ASCO provides a wealth of educational resources on MACRA, whether you prefer a dynamic live webinar or a captured session to review at your leisure.
Links to videos and slides from the following past webinars are available at ASCO.org:
Save the date: Attend the ASCO Oncology Practice Conference: The Business of Cancer Care in Orlando, FL, on March 2, 2017, for in-person educational sessions focused on MACRA.
ASCO members are also encouraged to visit the CMS website to find extensive resources on MACRA from the agency, including webinars and booklets on each of the four MIPS categories.
The first reimbursements under the MACRA system will arrive in 2019, based on data collected during 2017 and reported during 2018. The maximum bonuses as well as minimum penalties (as percentages of the practice’s total FFS reimbursements) will increase incrementally over the first few years of MACRA. The schedule below lists the maximum percentage that can be added or subtracted from your FFS payments, per year, starting in 2019:
- 2019: ± 4%
- 2020: ± 5%
- 2021: ± 7%
- 2022 and beyond: ± 9%
ASCO resources help you successfully implement MACRA
ASCO provides a wealth of resources to help doctors understand, implement, and succeed in the new MACRA reimbursement system. On the educational front, ASCO offers numerous workshops and webinars—providers can tune into these live, or listen later by accessing video presentations. The site also provides information on the Value-Based Modifier (VBM), Quality Oncology Practice Initiative (QOPI), and the Patient-Centered Oncology Payment (PCOP) model, and provides links to CMS resources such as a MACRA glossary and FAQs (see sidebar for a list of past and upcoming webinars, workshops, and symposia focusing on MACRA).
In addition, several ASCO committees are involved in ongoing efforts to collaborate with CMS to ensure that MACRA meets the needs of the oncology community. These committees include the Government Relations Committee, Clinical Practice Committee, State Affiliate Council, and Quality Care Committee.
“There’s been a major effort by ASCO now and in the last 18 months to get as much educational information out to the oncology community as possible,” said Stephen S. Grubbs, MD, vice president of Clinical Affairs at ASCO. “We will continue to develop resources to help oncologists prepare their practices for conversion into this new health payment system from CMS.”
In 2017 ASCO will also be launching ASCO COME HOME consulting services to help practices understand the steps they need to take to be successful in the new payment system, whether MIPS or an APM. The services will send consultants directly to practices to evaluate current systems and provide the tools needed for practice transformation and the successful implementation of MACRA.
According to Dr. Grubbs, ASCO resources will not only enable oncologists to comply with MACRA requirements, but, most importantly, will help oncologists achieve their ultimate goal: improving care and outcomes for patients.
“All of our work comes back to the basic point: we need to be delivering quality cancer care to our patients, and to do that, we have to make sure this conversion into MACRA works well for the practices,” Dr. Grubbs said. “If practices are successful with the transformation, they will be able to provide the best care for patients. We talk on the business side of things about payment reform and [reimbursement], but the bottom line is making sure practices are healthy and in a position to provide the best possible care.” •
ASCO’s Top 10 List for MACRA Readiness
Program changes under the Medicare Access and CHIP Reauthorization Act (MACRA) are set to begin on January 1, 2017, and will completely transform Medicare reimbursement and care delivery for oncology practices throughout the United States. ASCO has compiled the top 10 things you need to do to prepare your practice for MACRA implementation and offers guidance for each step of the way.
1. Participate in the 2016 CMS Quality Reporting Programs and avoid 2018 penalties.
- PQRS and the EHR Incentive Program (Meaningful Use).
- Are you successfully reporting in the PQRS program today?
- Have you successfully attested to Meaningful Use Stage II?
- Are you using ASCO’s QOPI program for PQRS reporting?
2. Obtain your Quality and Resource Use Reports (QRUR), the basis for the value-based modifier.
- Has someone from your practice registered with CMS to obtain your QRUR?
- Have you reviewed your most recent performance on quality and cost?
3. Focus on performance improvement in your practice.
- Have you reviewed your quality measure benchmarks in the QRUR and do you understand what is required for above average performance?
- Have you implemented strategies and workflows in your practice to be successful?
- Can you demonstrate effective care coordination with primary care and other members of the patient’s care team?
- Are you participating in ASCO’s QOPI Certification Program and/or the Quality Training Program?
- Have you reviewed the inventory of Clinical Practice Improvement Activities in the MACRA regulation?
4. Ensure data accuracy.
- Is your QRUR correct?
- Are the NPIs for each provider in your practice accurate with the correct specialty, address, and group affiliation?
5. Optimize your use of ICD-10 coding (particularly important).
- Are you coding to the highest level of specificity for the patient’s diagnoses?
- Are you coding all co-morbidities and concurrent conditions for your patients?
6. Review your contracts for the impact of value-based reimbursement.
- Have you thought about the impact on your physician compensation model?
- Do your contracts and/or professional service agreements with hospitals need to be adjusted?
- Do you have commercial payer contracts tied to Medicare reimbursement rates?
7. Evaluate your electronic health record.
- Does your EHR support quality reporting and practice improvement?
- Does it include a robust (and user-friendly) patient portal?
- Does it have e-prescribing capability and health information exchange capability?
- Can it produce a treatment plan and a post-treatment summary document for the patient?
8. Evaluate your payer relationships and begin discussions with commercial payers about value-based reimbursement and alternative payment models.
- Who are your top two or three commercial payers?
- Have you discussed ASCO’s Patient-Centered Oncology Payment (PCOP) model with them?
9. Prepare your practice staff for value-based practice.
- Does your staff understand the changes that are coming?
- Is your practice culturally prepared for the shift to value-based payment models?
- Are you employing elements of an oncology medical home including pathway utilization and ER and hospitalization avoidance?
10. ASCO’s MACRA resources. Check out ASCO’s MACRA calendar of events and register for educational events, including webinars and in-person workshops, designed to help you and your practice prepare (asco.org/MACRA).