MIPS Will Hold Practices to Higher Standards

Oncology Business News®, October 2016,

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.

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.

OCM Practices and Other APMs Have Options

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.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.

MIPS Providers Will See Increasing Reporting Requirements

Providers in these programs will be subject to the terms of their APMs, and since they will have only an upside risk, they will also be subject to certain MIPS program requirements. Providers will actually see some benefits of being in this situation: they will essentially forgo some of the MIPS obligations by being part of an APM, and they could actually benefit from an improved MIPS performance score and shared cost savings from their APM. This situation bears watching, as it will be interesting to see if providers decide opt-in to the advanced APMs once they become available in January.Providers not participating in an APM, like the OCM, or those who qualify as Advanced APM providers will be purely MIPS-eligible providers. Their situation will be quite different from what they experienced under PQRS and VBM, where there was not a lot of risk involved and practices could report on a subset of patients to meet program requirements and avoid penalties with minimal effort. For example, under the new MIPS program, quality measure reporting equates to half of the total MIPS composite score for 2017, and depending on how the provider chooses to submit data, it could require reporting on 90% of all eligible Medicare patients for a minimum of six measures. This is an exponential amount of reporting burden, along with significantly more performance risk.

With MIPS, everyone will see some adjustment to their reimbursements because of the way the program is designed. Four performance categories are utilized to determine a composite score, which will then be compared with a national threshold. For performance in 2017, the provider will see a plus or minus payment adjustment as great as 4% in 2019, depending on whether their score is above or below the threshold. The program is budget-neutral, so if CMS collects a substantial amount of money from poor performers, in theory, there should be an opportunity for high performers to earn more than 4%.

How Can Practices Prepare for a Successful First Year of MIPS?

With the recent announcement from CMS softening the original rollout plan and allowing providers to pick their pace for MIPS, it is highly unlikely that incentives will extend above 4% in the first year— virtually all participants should be able to avoid penalties with minimal reporting. However, there is a $500-million bonus pool set aside for top-tier performers, so the question remains: if this new Quality Payment Program is here to stay, why not choose to be an early adopter and reap the potential benefits of achieving high performance through the MIPS program? There is no reason to wait. We have embarked on a brave new MIPS world and there is really no turning back.While we wait for the final rule to be released this fall, providers can take some steps to prepare for the MIPS program and position themselves for success. First, they should examine which quality measures are clinically relevant for them and decide which measures they intend to participate in beginning January 1. The measures a provider selects should be relevant and a good barometer of patient care quality or reflective of activities that impact patient outcomes.

Next, practices should engage their electronic health record (EHR) vendor to determine if the quality measures are supported through their EHR to ensure appropriate data collection. In addition to this, practices should ask their EHR vendor how it will support the practice with continuous data monitoring or reporting to track performance throughout the year, so that there are no surprises when it comes time to submit data to CMS. Does the vendor provide advanced technology solutions to help support adherence to specific quality measures—such as clinical decision support tools—or the ability to review patient lists when target measures have not been met?

Practices can no longer be successful in these programs on their own, relying on manual data entry. Innovative technology is necessary to provide actionable insight and enable informed decision-making to drive better program performance, improved patient care, and lowered costs.

Practices can further prepare by closely examining the CPIAs to see which ones they can implement now. This new component is intended to spark change so practices can adopt new and better ways of practicing medicine and engaging patients to improve care and outcomes. Ultimately, CPIAs have the potential to impact performance in other areas of the program when implemented effectively, such as providing 24/7 access to care or same-day slots to avoid more costly emergency department visits for patients in need of immediate care.

Although there are many concerns about the Quality Payment Program, CMS is taking healthcare in the right direction and there is reason to be cautiously optimistic. We need to work together as a healthcare system and remain focused on our shared vision to improve the delivery of patient care and achieve better patient outcomes.

Erin Crum, MPH, is director of Quality Reporting Programs for McKesson Specialty Health.