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In April 2015, Congress passed the Medicare Access and CHIP Reauthorization Act (MACRA). The law most famously repealed the Sustainable Growth Rate (SGR), ending the annual showdown over payment cuts to Medicare providers. MACRA also included ambitious reforms to the payment model with the introduction of two models to drive value-based payment to physicians: the Merit-Based Incentive Payment System (MIPS) and advanced Alternative Payment Models (advanced APMs).

What is MIPS?

While MIPS has not been fully developed, the broad constructs are intended to collapse the legacy quality models (e.g., Value Modifiers, Meaningful Use, Physician Quality Reporting System [PQRS]) into a single system. This payment system will use four assessment categories to determine a provider score, which will then be used to make a quality-based payment adjustment. The payment adjustments will be budget neutral, meaning all payments to “top performers” will come from the “bottom performers.” The amount of the adjustment will move on a sliding scale from 2019 to 2022 with a net adjustment of four percent to nine percent over that time period. This means that in 2022, if a provider falls below the performance threshold set by CMS, they could be penalized as much as nine percent of their total Medicare payments.

How do I prepare for MIPS?

The MIPS legislation notes that a provider will receive a score between 1 and 100, which will be determined by a formula that weights the individual scores of four distinct categories: Quality, Resource Use, Clinical Practice Improvement (CPI), and Meaningful Use (MU). Unfortunately there is not a great deal of clarity about how CMS will evaluate each of these sections. It is safe to assume that Quality and Resource Use measures will be based in part on the previous quality and costing metrics adopted by CMS for PQRS and Value-Based Payment Modifier (VBPM). The CPI measures may contain some of the medical home elements being required of the current Oncology Care Model member sites. The MU will likely require standard meaningful use measures.

In absence of further information on MIPS, cancer programs should ensure that they comply with MU, keep a close eye on CMS’ proposals for MACRA implementation, and begin to design and invest in practice transformation.

Can I avoid MIPS?

The MACRA legislation included a second avenue for providers wishing to avoid MIPS—advanced APMs. For providers participating in advanced APMs, MACRA legislation proposes a five percent annual bonus starting in 2019 and a .75% payment rate increase from 2026 onward. This bonus, payment rate increase, and exemption from MIPS will be attractive to a number of providers, but there is a catch. The advanced APM must be deemed “eligible” according to the MACRA standards—namely that the model must mirror many of the quality requirements in MIPS and require the provider to bear financial risk. There are a number of clarifications pending on these eligibility requirements; if they remain as currently interpreted, advanced APMs will need to be two-sided risk models where the provider can lose money if they do not control costs. This will preclude CMS’ own Oncology Care Model for those programs electing for one-sided risk.

Similar to preparing for MIPS, cancer programs that participate in advanced APMs should be building the competencies necessary for value-based care delivery. This means standardizing clinical pathways, providing symptom management and patient navigation, reducing unnecessary utilization, ED visits, inpatient admissions, and building the framework for measuring quality and tracking costs.

Oncology Solutions is working with a number of hospitals around the country on value-based strategic planning and program re-design, including participants in the Oncology Care Model and a number of commercial alternative payment models. If your organization is interested in learning more about how to navigate the value-based transition, please call one of our experts today at 404.836.2000 or email [email protected] .

Author Chartis Oncology Solutions

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