On June 20, 2017, the Centers for Medicare & Medicaid Services (CMS) issued its proposed rule to implement the Quality Payment Program (QPP) for year two under the Medicare Access and CHIP Reauthorization Act of 2015, known as MACRA. The QPP awards bonus points for demonstrating high-quality care.
The year 2017 was considered a transition year. For the QPP program for year two, CMS stated it "wants to keep what's working and use stakeholder and clinician feedback to improve the policies finalized in the transition year."
As previously reported in Oncology Times, physicians hailed the passage of MACRA as a welcome replacement for the Sustainable Growth Rate (SGR) formula for determining CMS reimbursement of physician Medicare services. MACRA's QPP is a pay-for-performance system that places the emphasis on value-based care, not volume-based care. When CMS released its final MACRA policy in October 2016, Daniel F. Hayes, MD, then President of ASCO, praised the MACRA law.
"We are particularly encouraged that CMS has introduced a Quality Payment Program transitional period for 2017 and has included an oncology-based specialty measure set, which is more applicable to oncology practices than the general medical quality measures," stated Hayes, who is Clinical Director of the Breast Oncology Program and the Stuart B. Padnos Professor in Breast Cancer Research at the University of Michigan Comprehensive Cancer Center, Ann Arbor.
After the comment period on the proposed QPP rule, which ends Aug. 21, 2017, a final rule is expected sometime in the fall of 2017. The proposed rule aims to increase flexibility, simplify reporting requirements, and reduce burdens on clinicians, especially those in small and rural practices, according to CMS Administrator Seema Verma.
"We've heard the concerns that too many quality programs, technology requirements, and measures get between the doctor and the patient," she said in a statement when the proposed rule-which runs more than 1,000 pages-was released. "That's why we're taking a hard look at reducing burdens. By proposing this rule, we aim to improve Medicare by helping doctors and clinicians concentrate on caring for their patients rather than filling out paperwork. CMS will continue to listen and take actionable steps towards alleviating burdens and improving health outcomes for all Americans that we serve."
Verma said the quality component of MACRA is meant to promote greater value within the health care system. She said clinicians can choose how they wish to participate in the QPP based on their practice size, specialty, location, or patient population. The proposed rule contains some amendments to existing regulations and some new policies that encourage participation in either of MACRA's two quality payment pathways: Advanced Alternative Payment Models (APMs) or the Merit-based Incentive Payment System (MIPS).
Analysis of QPP
Early analysis of the proposed QPP rule reveals the following insights, according to Dennis Weaver, MD, MBA, Chief Medical Officer of the Advisory Board, a consulting and management company.
* While payment and health care delivery system reforms move ahead, the current administration wants to live up to its campaign promises of reducing the federal government's regulatory burden, in this case regulatory requirements of MACRA on providers. The new federal government administration largely left the structure the same, but "gave clinicians more ways to succeed in the program, while also offering significant flexibility to providers," according to Weaver.
* Some 134,000 more clinicians-mostly those who work in small practices and those who practice in rural areas and Health Professional Shortage Areas-would be totally exempt from having to participate in the QPP. In 2017, CMS allowed providers to be exempt if they had less than $30,000 in Medicare Part B revenue or saw fewer than 100 Medicare Part B patients per year. Now CMS wants to expand that exemption by proposing that physician practices making less than $90,000 or caring for fewer than 200 Medicare Part B patients annually would not have to participate in the QPP.
* CMS wants to ease MIPS burdens by offering bonus points to small practices as well as those that treat a high number of complex patients. Specifically, practices with 15 or fewer clinicians would have to submit data on at least one performance category to earn five additional points toward their final score. CMS could award providers 1-3 bonus points if their patient population is deemed especially complex.
* Providers based at a facility, such as hospital-based physicians, would be given a new reporting option for the MIPS program. The proposed rule would allow hospital-based physicians to submit their facility's inpatient value-based purchasing score to be used to calculate an individual score for the cost and quality categories of MIPS.
* CMS estimates that many more providers would qualify for the APM track for 2018 than did so in 2017. Specifically, with the new Medicare Track 1+ program as a qualifying APM and the reopening of applications for the Next Generation ACO program and the Comprehensive Primary Care Plus (CPC+) program, CMS estimates the number of clinicians in the APM track would double from an expected range of 70,000-120,000 in 2017 to 180,000-245,000 in the 2018 performance year. "The increase in APM track participants, combined with an increase in clinicians exempt from QPP, would make MIPS far more competitive," predicted Weaver.
* CMS has no plans to change the APM qualification criteria, which would remain the same through the 2019 and 2020 performance years.
* CMS proposes to maintain several flexibilities in the 2017 performance year that would help ease clinicians into MIPS requirements for another year. Significantly, the agency would delay required performance in the cost category for the second year in a row. Also, clinicians would be allowed to continue use of 2014 Edition Certified Electronic Health Record Technology rather than be required to upgrade to 2015 Edition technology.
* However, providers should continue to make cost-control efforts a priority, advised Weaver. By law, CMS is required to weigh the cost category at 30 percent by the 2019 performance year, so, Weaver cautioned, "the on-ramp will be much steeper if providers ignore these measures for another year."
* The proposed QPP rule would create new avenues for solo practitioners to participate and succeed under MIPS. Health and Human Services Secretary Tom Price, MD, has expressed his desire to ease the regulatory burden on independent physicians. Accordingly, the proposed rule would allow a solo practitioner to form a "Virtual Group" with other small groups to quality for MIPS participation for a performance period of a year. In a statement issued in March 2017, Price said, "[Our desire] is to drive down the health care costs for everybody. And the way that you do that is to increase choices for folks, increase competition, [and] return the regulation of health care where it ought to be, which is at the state level, not at the federal level." CMS said of Virtual Groups: "Our goal is to make it as easy as possible for Virtual Groups to form no matter where the group is located or what their medical specialties are."
* The proposed rule would raise the bar somewhat higher to earn full points in the quality category and avoid payment penalties overall in MIPS. Specifically, clinicians would be required to submit at least 12 months of data in the quality category rather than choose a 90-day performance period. To avoid a payment penalty in 2019, they would also have to earn three points across the three MIPS categories. CMS is proposing to raise that bar to 15 total points for the 2018 performance year.
ASCO Comments
As previously reported in Oncology Times, physician groups, including ASCO and the American Medical Association, were involved and engaged with Congress as it drafted the MACRA legislation.
In comments to CMS, ASCO urged the agency to take a more flexible approach toward inviting and adopting oncology-focused medical homes and alternative payment models developed in the private sector. ASCO provides the following general guidance for oncology practices in complying with MACRA rules, including quality reporting:
1. Do participate in the CMS quality reporting programs (unless exempted).
2. Obtain quality and resource use reports (QRUR), the basis for the value-based modifier. A designated practice staffer should register with CMS to obtain the QRUR.
3. Focus on performance improvement in the practice. For example, have quality-related strategies and workflows in the practice been implemented to be successful? Can the practice demonstrate effective care coordination with the patient's care team? Clinical performance improvement may include: same-day appointments for urgent needs; after-hours clinician advice; participation in a qualified clinical data registry; shared decision-making; and timely communication of test results.
4. Ensure data accuracy.
5. Optimize the use of ICD-10 coding. For example, is coding at the highest level of specificity for the patient's diagnoses? Are all comorbities and concurrent conditions being coded?
6. Review the practice's contracts for the impact of value-based reimbursement. For example, do contracts with hospitals need to be adjusted?
7. Evaluate the practice's electronic health record. Does it support quality reporting and practice improvement? Does it have a user-friendly patient portal? Can it produce a treatment plan and post-treatment summary document for the patient?
8. Evaluate the practice's payer relationships in light of value-based reimbursement and alternative payment models.
9. Prepare the staff for value-based practice.
10. Check out MACRA resources from ASCO, including the QPP toolkit and the MACRA decision tree tool.
According to CMS Administrator Verma, the agency is committed to working with physicians to make MACRA a success. To learn more about the CMS Quality Payment Program, go to http://qpp.cms.gov
Peggy Eastman is a contributing writer.