Seeking an APM that Is Workable and Fair

Tony Hagen @oncobiz
Published: Tuesday, Aug 02, 2016
Blase Polite, MD

Blase Polite, MD

The month of July saw CMS Acting Administrator Andy Slavitt tell lawmakers in Congress that the agency is considering delaying and restructuring elements of the Medicare Access and CHIP Reauthorization Act (MACRA), which would introduce payment reforms and new business models for physicians. The move was welcomed by members of the oncology community. Below is an interview with Blase Polite, MD, chairman of ASCO’s Government Relations Committee, who discussed the ramifications of Slavitt’s remarks and lingering concerns about MACRA.

OncLive: CMS Acting Administrator Andy Slavitt has said MACRA reforms may be too much, too soon for physicians.

Polite: It reflects lot of the thinking at ASCO. The methodologies aren’t ready for prime time. Many things revolving around resource use measurements and quality metric certification need to be ironed out.

Are you relieved about potential implementation delays?

Yes. We’re still very supportive of MACRA, in concept. I think the proposed rule had a lot of clarifying elements in it, but what it also showed was that there are a lot of placeholders. And what makes everybody a little nervous is how some of this stuff is going to play out, given that, basically, our 2017 performance is going to determine our 2019 payment updates. The twoyear lag makes this really difficult for everybody.

What are you hoping will result?

That CMS will lay out a more streamlined process and give people more time to see what kind of quality metrics they’re going to be under. Basically, more information and better ways to risk-adjust for the resourceuse category. It’s way more complicated than it looked on paper.

Did CMS accept much input from physicians?

The two areas we, at ASCO, spent time discussing with them were on development of specialty-specific quality metrics and on flexibility in development of alternative payment models (APMs). On the quality measures side, they clearly listened in designing MIPS (Merit-Based Incentive Payment System), such that the choice of quality metrics was much more broad than available under PQRS (Physician Quality Reporting System). We were disappointed that they have created a somewhat cumbersome process to get quality metrics certified. Even if you already have quality metrics certified under the Qualified Clinical Data Registry (QCDR) program, they are still requiring us to resubmit metrics for certification. On the APM side, we feel that CMS did not really listen. They created a very high bar for something to be considered an advanced APM, which we do not believe was the intent of Congress.

ASCO is working on the assumption MACRA changes will be minimal?

I would not say minimal. The framework is not too dissimilar to the current Value-based Payment Modifier program. The problem is that very few practices have really wrapped their heads around that process. What we are preaching to practices is that you should know about your QRUR (Quality and Resource Use Reports) and where you are in terms of resources and quality under the value-based modifier. That’s the big message. If you’re not reporting even PQRS data, right now, you’ve got to start doing that. Your best predictor of how you’re going to come out in 2019 is how you came out in 2015/2016.

What’s your take on MIPS versus the APM?

Almost no one’s going to be in an advanced APM early on because the only certified advanced APM for oncology is the two-sided risk Oncology Care Model (OCM) that is not going to be available for two years. We think that they made the advanced APM way too stringent, especially in terms of loss ratios. It was clearly congressional intent to have many specialty-specific APMs available for practices to try.

And you think the OCM—as an APM—is too restrictive?

We’re concerned that they’re going to lock us into the OCM. I think Congress’s intent was to give us some other models, to allow some experimentation with different APMs. I think CMS realized they were making it difficult. My feeling is they see the 5% bonus that practices get for being in the advanced APM as such a huge incentive that they wanted to set the bar really, really high. I think Congress was very aware that specialty APM models need to be developed, and I think their intent was to really encourage people to start testing—to have CMS test some of these different models.

A year ago you sounded more optimistic about MACRA.

I still like the idea that quality is now going to get more specialty specific, so we’re not going to get tied into—for many of us—an irrelevant set of PQRS measures. That wouldn’t have spawned improvement. Now, they’re going to let you get judged on what it is you do. Once they figure out what the quality measures are and how you get judged, I think this will be vastly more improved on the quality side.

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