The Medicare Access and CHIP Reauthorization Act of 2015 (MACRA) was passed in April 2015, introducing comprehensive changes to how Medicare pays physicians for services. As the policies passed in MACRA are rolled out over the coming years, they will profoundly impact reimbursement and care delivery for oncology practices throughout the United States.
ASCO will be your partner in preparing for these changes and will provide a wide range of resources and tools that are designed to help practicing oncologists adapt to and satisfy MACRA requirements as cancer care moves toward a value-based practice environment. ASCO will also aggressively advocate that provisions in the law are implemented in a manner that reflects the current realities of cancer care, enabling you to provide the full range of services and high-quality care that your patients with cancer need to fight their disease. For more information on MACRA and related resources, visit ASCO.org/MACRA.
MACRA makes three important changes to how Medicare pays health-care providers who care for Medicare beneficiaries. The new law:
1. Repeals the SGR formula as a mechanism for determining Medicare payments for physicians’ services. The SGR (sustainable growth rate) formula was responsible for determining the annual increases or decreases to the Medicare physician fee schedule and typically resulted in large proposed decreases to physician payments and annual congressional patches. MACRA puts an end to that process and instead puts into place a predictable annual increase of 0.5% through 2019 before a complete transition to the new system described here.
2. Establishes two payment options, beginning in 2019. One of the options retains the current fee-for-service structure with a new system for positive or negative adjustments to the fee schedule payments. The other—participation in an alternative payment model—is different from the current fee-for-service system. Both choices move toward a valued-based system, with an emphasis on quality—not volume—of health-care services provided.
3. Incentivizes practice transformation. Regardless of what path you take in MACRA, your reimbursement system will likely require changes to your practice. Both paths require practices to (1) report quality metrics, (2) demonstrate meaningful use of electronic health records and responsible use of resources, and/or (3) take on financial risk.
MACRA: Two Payment Options
The new law establishes two payment options: participation in the Merit-Based Incentive Payment System (MIPS) or Alternative Payment Models (APMs). Both systems go into effect starting in 2019, and physicians will be automatically enrolled in MIPS unless they choose to participate in an APM.
Merit-Based Incentive Payment System
MIPS is a new payment system that combines parts of the Physician Quality Reporting System, the Value Modifier, and the Meaningful Use program—and adds a new category of clinical practice improvement activities—into a single program that will assess physicians on these categories.
Although details on MIPS will be the subject of policymaking for several years, it is important to understand that some of the assessments made at the effective date of 2019 will be based on 2017 data. Furthermore, although MIPS payment adjustments will be transitioned over a period of years, these adjustments may be significant. ASCO will be analyzing this aspect of the new Medicare payment system very closely as more information becomes available.
Alternative Payment Models
Beginning in 2019, MACRA will incentivize participation in APMs by enabling qualifying health-care providers to receive a lump sum for participation in a certified APM at a certain level. Beginning in 2026, the lump sum payment will go away, but baseline fee-schedule payments will still be higher for qualifying APM participants than for other providers in the MIPS system.
Although currently there are not many APMs for oncology, the law encourages development and recognition of models available to medical specialists such as oncologists. How an APM will be recognized for purposes of the program is still evolving but may include existing models such as accountable care organizations, patient-centered medical homes, and bundled payment models. MACRA also introduces a new pathway to qualify APMs developed by stakeholders, called physician focused payment models (PFPMs). The Centers for Medicare & Medicaid Services (CMS) will determine which PFPMs qualify as an APM under MACRA.
Quality Reporting Under MACRA
Regardless of the path your practice takes, MIPS or APMs, quality reporting and improvement will be a bedrock requirement under the new law. Financial incentives in both systems will be tied to quality performance. Reporting as early as 2017 will affect your scores and adjustments in 2019, and practices should be focused now on preparing and enhancing their quality reporting systems.
ASCO: Your Partner in Preparing for the Future
Leadership from ASCO’s Clinical Practice Committee, Government Relations Committee, Quality of Care Committee, and State Affiliate Council are developing a blueprint for the Society’s involvement in the new law’s implementation. This new ASCO MACRA Task Force is developing an education and advocacy strategy that will require a multiyear effort and the collective expertise and leadership of all committees across ASCO.
MACRA will transform all oncology practices in two major ways: (1) how practices conduct Medicare reporting requirements, and (2) how providers are paid for the services they provide to Medicare beneficiaries. The ultimate goal of these changes is to move toward a value-based health-care system that ensures high-quality, affordable health care. ASCO has long embraced this goal and has dedicated significant resources that will provide you with the foundation needed to move into the MACRA era, specifically through its Quality Oncology Practice Initiative and its Patient-Centered Oncology Payment Reform model.
ASCO’s Quality Oncology Practice Initiative
ASCO’s Quality Oncology Practice Initiative (QOPI®) is a voluntary self-assessment and reporting program launched by ASCO in 2006 to help hematology/oncology and medical oncology practices assess the quality of the care they provide to patients. Through the QOPI program, practices submit data from patients’ records up to twice per year into a secure database. Nearly 700 oncology practices, representing more than 5,000 medical oncologists, have participated in the QOPI program.
CMS has approved QOPI as a Qualified Clinical Data Registry (QCDR), a pathway for oncologists to meet the agency’s current quality reporting requirements. The QCDR is available to practices piloting eQOPI this fall and will be made available to practices that choose eQOPI submission next year. Oncology practices participating in QOPI can fulfill CMS’ Physician Quality Reporting System reporting requirements by submitting data for the oncology measures group.
By providing a systematic process and methodology, a robust library of nearly 200 quality measures based on published guidelines and expert consensus, and access to quality-focused projects and programs, QOPI helps oncology practices evaluate the quality of the care they provide, engage in ongoing quality improvement, and demonstrate a commitment to quality care to patients and internal and external stakeholders.
Participation in QOPI is one essential preparatory step your practice can take for MACRA implementation. ASCO is working hard to ensure that through QOPI participation you will be able to meet requirements for reporting on meaningful use and clinical practice activities under MIPS.
ASCO Payment Reform Model
Over the past several years, ASCO volunteers developed a payment reform proposal designed to significantly improve the quality and affordability of care for cancer patients, consistent with the principles laid out in MACRA.
The Patient-Centered Oncology Payment: Payment Reform to Support Higher Quality, More Affordable Cancer Care (PCOP) would enable oncology practices to take greater accountability for key aspects of cancer care spending without harming patients and without putting practices at risk for costs they cannot control. At the same time, oncology practices would commit to delivering evidence-based care, ensuring patients receive the most appropriate tests and treatments while avoiding unnecessary expenses.
ASCO believes that PCOP would meet MACRA’s definition of an Alternative Payment Model and will advance PCOP as a potential certified APM.
To learn more about MACRA and access resources and tools for your practice, visit ASCO.org/MACRA today. ■
Originally printed in the ASCO Quality Care Symposium Daily News. © American Society of Clinical Oncology. “Understanding and Preparing for MACRA.” quality.asco.org/dn. February 22, 2016. All rights reserved.