Editor’s note: Dr. Hudis hosts the ASCO in Action Podcast, which focuses on policy and practice issues affecting providers and patients. An excerpt of a recent episode is shared below; it has been edited for length and clarity. Listen to the full podcast online or through iTunes or Google Play.

I'm excited to have as my guest ASCO's own vice president of Clinical Affairs, Stephen S. Grubbs, MD, FASCO. Before coming to ASCO, Dr. Grubbs worked as a community oncologist and the managing partner at Medical Oncology Hematology Consultants, PA, in Newark, Delaware. Dr. Grubbs has been an active ASCO volunteer, and he was the principal investigator of the Delaware/Christiana Care National Cancer Institute Community Oncology Research Program before he came to ASCO. He also serves on the advisory council of the Delaware Cancer Consortium, of which he's been a member since 2003.

Our conversation is going to focus on the Quality Payment Program, known as QPP, and our goal is to illuminate what oncology providers and practices need to know and what they have to do to successfully participate in this program for 2018. The Quality Payment Program, or QPP, was established by the Medicare Access and CHIP Reauthorization Act of 2015, generally known as MACRA. And it is transforming the way that physicians are reimbursed for the services they provide under Medicare Part B. Program implementation began last year, and while 2018 can be seen as a second transition year, the requirements for demonstrating and reporting quality improvement, appropriate use of technology, and prudent use of resources are heavier this year than they were last year. So it's important that everybody understand the changes that they have to address to avoid financial penalties potentially in 2020.

CH: Give me your elevator pitch on how MACRA and, subsequently, QPP are transforming physician reimbursement.

SG: QPP is the government's attempt to rapidly transfer physicians from a volume-based payment program to a value-based program. There are some who believe this is the biggest change in reimbursement in medicine since the onset of Medicare back in the 1960s. There is a publication from the Centers for Medicare and Medicaid Services (CMS) that says they would like to see at least 50% of all their payments in Alternative Payment Models in the future, and this program is set up to transition physicians into Alternative Payment Models eventually.

CH: I understand that we're in the middle of a multiyear implementation process. Exactly where are we in this process? How many years long will it be? What are the steps that everybody should be anticipating?

SG: The first thing to know is the timeline in the program. Most physicians are in the Merit-based Incentive Payment System, called MIPS. 2018 will be measured by CMS in 2019. And then in 2020, a potential adjustment will be made to your Medicare fee schedule. So, if we actually back up one year, this whole program began last year. 2017 was the first performance year, which CMS will be evaluating this year for your scores you received in the MIPS program, and that will potentially affect your payments in 2019.

CH: You said most physicians are covered by MIPS this year. Can you clarify? We have a wide range of ASCO members. Which kinds of practice settings are most clearly engaged in this? And, by the way, which practices or settings are engaged, but maybe the members don't realize it?

SG: All physicians that report in Part B are required to be in this system and do reporting. Let's concentrate on MIPS because, really, 100% of oncologists are in that right now. If you're in an independent practice, you need to know how to do this because you are required to report as an independent practice. If you're in a multispecialty practice as an oncologist, you probably don't need to think so much about this right now because your multispecialty practice will be reporting data that is most likely coming from your primary care physicians, and you'll be brought along with the score that they get. Having said that, in the future, there's the possibility that the specialists will be broken out of the multispecialty group, so it's important for everybody to know about this system right now.

CH: What about the large chunk of ASCO members in traditional academic practice?

SG: They are mostly at large hospital-based or university-based programs that are multispecialty, so they're going to be covered by their multispecialty group. As I said, they don't need to think so much about it today, but they should learn about it because I expect some day they will be reporting independently.

CH: What, exactly, do the physicians who are fully engaged in this have to do that's different in 2018 as opposed to 2017?

SG: We'll concentrate on MIPS. You will get a score every year for you or your practice, depending on how you report, anywhere from 0 points to 100 points. When you get your scale of points, it will be compared to all other physicians in the United States. If you're on the low end of the scale, you'll receive a penalty on your fee schedule 2 years later; if you're on the upper end, you'll actually have a positive adjustment. And, again, the way CMS works is every year, they publish the fee schedule for the next year, and then you individually will have some adjustment up or down or neutral based on your score.

CMS made 2017 a transition year to get people into the system, and they had a minimal requirement to stay out of trouble, not to lose the penalty. The penalty last year, if you didn't do well, was minus 4% off your 2019 fee schedule. This year it's going to be minus 5% or plus 5% off your 2020 schedule. Several years from now, that will increase to minus 9% or plus 9%. This is a graduated scale up, and the penalties will get higher, but the potential benefits could get higher, too. It is revenue-neutral. The money that's taken away from those that are at the bottom of the scale will be given to those at the top of the scale, so it's a zero-sum game in terms of Medicare payments.'

2018 is still a transition year, but it's more rigorous than 2017. Last year, all you had to do is report on one quality metric, on one patient, or do some practice improvement activity. This year you have to do much more work. And in the scale of 0 to 100, last year, if all you had was three points, you wouldn't get a penalty. This year it's 15 points. That means you must report, say, on five or six quality metrics and get a certain amount of points to get there. Next year, we anticipate it'll be a full-blown requirement.

CH: To back up and focus on this revenue-neutrality, people will probably wonder about that. It implies that every reward is matched by a penalty for somebody. Ultimately, it isn't about getting over an arbitrary line. It's about where you are relative to your peers, and it's a way of forcing everybody to march up. But it guarantees that some people are going to bear a financial hit, right?

SG: If you really project out over the years, I think what you'll see is that those at the bottom of the list that are taking penalties on will drop out and go elsewhere, so that group that pays a penalty will gradually march up the scale. Why is that going to happen? Because CMS really wants us in Alternative Payment Models. They don't want us in this MIPS system. This is going to be a system of increase and penalties and people dropping out, and then the scale moving up to probably push all of us into an Alternative Payment Model.

CH: It sounds like practices, unfortunately, have to continue to make special investments in the management of all of this, right?

SG: Right. One needs to have a transformation of your practice to be able to do well both in MIPS or in the Alternative Payment Model. You have to be doing practice improvement. You have to be carefully monitoring your quality metrics and make sure that they are improving over time, and you have to begin to look at containing costs.

CH: Of course, ASCO has some resources that we're able to bring to bear to assist practices, right?

SG: Absolutely. First of all, ASCO developed its own idea of a good oncology Alternative Payment Model, the Patient-Centered Oncology Payment Model, published in 2015. As we worked with that, it became very clear that you need to have a change in infrastructure to make either that or any other Alternative Payment Model work. In response, over the last 12 months, ASCO has started its first consulting program where we have consultants that will come to your practice, They’ll do what we call a readiness assessment evaluation, where they look for gaps in how you're practicing in areas that are required to make any of these systems work properly. Then we're able to come back if needed and do consultation to help you realign what you're doing in your practice.

We're also promoting practices looking at triage pathway systems, because triage pathway systems have shown that you'll keep your patients out of the emergency room and out of the hospital, which is one of the biggest things that you can do to contain costs.

CH: We make the point in all of this that, ultimately, it's about the patient. How, if at all, would an individual patient perceive that their doctor's practice was enmeshed in all of this right now?

SG: One of the things that's going to happen is once these quality data are obtained and your MIPS scores are calculated, CMS will start publishing those. That hasn't happened yet, but on Physician Compare, which is their site where you can look at any physician right now and find out about them, you'll eventually see these scores and quality metric evaluations show up there.

I think patients will recognize if they're in an Alternative Payment Model because those models require certain specific things, like patient navigation and other items. I think they'll see an upgrade, perhaps, in their care.

The important thing that physicians are learning now is they have to report on quality and other parts of their practice that should show up as better care for the patient.

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