Erin Crum, MPH
Nearly a decade ago, CMS started healthcare providers on the road to value-based care. Along the way, we have seen a variety of quality programs that impact community oncologists, including the Physician Quality Reporting System (PQRS), the Value-Based Modifier (VBM) program, and the Meaningful Use (MU) initiative. Although these programs have moved us along the trajectory from the traditional pay-for-reporting payment model to a pay-for-performance payment model, nothing has shown as much promise to impact the way we reward comprehensive patient care as CMS’ latest proposal, the Quality Payment Program, created by the Medicare Access and CHIP Reauthorization Act of 2015. Whether it proves to be the Utopia of value-based care is debatable, but we have embarked on a new era of healthcare reform and providers should take action now to ensure future success.
The new Quality Payment Program comprises two arms: the Merit-based Incentive Payment System (MIPS) and Advanced Alternative Payment Models. Through MIPS, Medicare aims to consolidate the PQRS, VBM and MU programs under one umbrella and introduce a new element, Clinical Practice Improvement Activities (CPIAs). Providers will receive points in each of the four categories, and these points will be rolled into one composite score that determines whether the provider receives an incentive or a penalty on future Medicare reimbursement after the reporting year has ended. Although the majority of all Medicare providers will be subject to the requirements of the MIPS program, there is an opportunity to be “MIPS-exempt” by participating in Advanced APMs if they meet specific program criteria.
MIPS is a budget-neutral program with stricter reporting requirements than we’ve seen with past programs. Long gone are the days when practices could ignore these programs and feel little financial impact. Although CMS recently announced a phased-in approach for MIPS in 2017, it is important to start working on strategies now to help providers thrive in this new environment.
OCM Practices and Other APMs Have Options
Many community oncology practices—including 80% of physicians in The US Oncology Network—are participating in the CMS Oncology Care Model (OCM), which launched in July. Although the OCM is a recognized Alternative Payment Model (APM), it will not qualify as an Advanced APM track until 2018. If practices choose this option to become an Advanced APM with two-sided risk, they would be MIPS-exempt, as well as be eligible for an additional 5% bonus payment from CMS. However, along with this comes the burden to achieve cost savings and show improved patient outcomes or suffer the consequences of having to pay money back to CMS. Many OCM providers are expected to stay in the one-sided risk model. Although this means these practices will be subject to MIPS, many of the core MIPS activities will be either waived or achieved through their OCM participation. Furthermore, these quasi-APMs could be well positioned to benefit from both MIPS incentives and the upside opportunity to receive a shared portion of cost savings through the OCM program.
Unlike MIPS incentives, Advanced APMs are not budgetneutral and offer an opportunity to effectively drive cost savings to our healthcare system, while, at the same time, rewarding practices for making process improvements to impact patient-centered care. Although CMS intended to spur involvement in Advanced APMs beginning in 2017, when providers would participate in a risk-bearing system, there are very few programs that are truly Advanced APMs. It is estimated that less than 10% of all Medicare providers will be eligible to participate in an Advanced APM in 2017. This creates an unusual situation, since many APMs, like the OCM and Medicare Shared Savings Programs (Track 1), do not have two-sided risk.