Gary Kirsh, MD
Several organizations are developing alternative payment models (APMs) they hope CMS will adopt as ways to encourage oncologists to deliver care at a lower cost while improving its quality. If approved, these proposals could become customized alternatives to the agency’s Oncology Care Model (OCM), which is being piloted by 190 practices, and the Merit-based Incentive Payment System (MIPS), the default Medicare reimbursement system for most clinicians.
However, as physicians, practice administrators, and advocates navigate the alphabet soup of federal payment reform, they continue to harbor serious doubts about the prospects for alternative models proposed by medical organizations. They note that CMS expects participants in advanced APMs, unlike those in MIPS models, to quickly take on heavy financial risk for meeting cost-saving and quality goals, and they say it is unclear how serious the agency is about approving physician-proposed payment arrangements. They also note the added uncertainty of a new administration and Republican efforts to repeal the Affordable Care Act, which had a major role in advancing the government’s promotion of value-driven care. The departure of experienced staff from CMS’s Center for Medicare & Medicaid Innovation (CMMI) could complicate the implementation of MIPS and APMs, and CMMI has been targeted for elimination by some politicians. At the same time, new CMS leadership might end up being more welcoming toward physicians’ reimbursement proposals.
“CMS has laid out a process, but we don't know how fast it’ll be to go through that process. We don't know what the regulatory burdens will be, whether the process will be efficient or inefficient, whether CMS will listen or won’t,” said Gary Kirsh, MD, immediate past president of the Large Urology Group Practice Association (LUGPA). “And at the end of the day, even if the process isn’t onerous, what will be their threshold for approving any of this? We have some ideas about what will be good, but we don't know if they’ll be interested in these things.”
LUGPA is developing one APM for localized prostate cancer and a second for sepsis after prostate biopsy. The sepsis model will include what Kirsh calls a “warranty” guaranteeing a lower cost for the bundle of services provided to each patient. Organizations that are submitting APMs include the American Society of Clinical Oncology (ASCO), the Community Oncology Alliance (COA), the American Society for Radiation Oncology (ASTRO), and the Society of Gynecologic Oncology (SGO).
The two-track system of MIPS and advanced APMs was created by the Medicare Access and CHIP Reauthorization Act (MACRA) of 2015 and codified in a final rule issued in October. Medicare providers may opt out and face a 4% payment cut in 2019; participate fully or partially in MIPS, which consolidated existing payment adjustment programs and added new elements; or join an advanced APM that balances a 5% bonus against sizeable potential penalties for underperformance. MIPS includes a number of nonadvanced APMs, some of which may be used in advanced form. Advanced APMs involve higher financial risk for providers than regular APMs, but the financial rewards may be higher, too.
MACRA calls for CMS to accept outside proposals for physician-focused payment models. The proposals will then be evaluated by a technical advisory committee, which can recommend models to the agency for testing as APMs or advanced APMs. Currently, the only oncology APM is the OCM, which supplements traditional fee-for-service reimbursement for chemotherapy care with monthly and performance-based payments. Medical organizations are eager to try out alternative models designed to spur efficiencies in other types of oncology treatments (eg, by testing clinical pathways).
“This has great appeal to us. Our ability to have large groups of urologists and allied professionals with business and clinical infrastructure get doctors to ‘swim in lanes’ is our sweet spot,” Kirsh said. “When we're able to do that, we’re going to deliver better care for the patient, and we’re going to get ourselves off fee-for-service. Fee-for-service is not our friend. It's a handcuff on our entrepreneurism and our creativity.”
Kirsh said the urology APMs would serve not just as payment models, but also as studies, allowing oncologists to test different prevention protocols or treatment methods. Those that prove most effective at the least cost could become standard methods. The proposed models could also be accepted by commercial payers even if CMS passes on them, he said.