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MACRA final rule offers more flexibility, but concerns remain about implications
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The final rule for the Medicare Access and CHIP Reauthorization Act addressed key concerns of hematologists and oncologists by including a choice in reimbursement path and a graduated transition period.
However, some clinicians expressed concerns about the fact the payment system relies on patient surveys, and the potential that the changes may discourage physicians from taking high-risk patients.
“Overall, the final rule signals more flexibility and less administration in implementing the program,” Blase Polite, MD, associate professor of medicine at University of Chicago Medicine, chair of ASCO’s Government Relations Committee and a HemOnc Today Editorial Board member, told HemOnc Today. “There are several positive outcomes for oncology in the final rule.”
The Medicare Access and CHIP Reauthorization Act’s (MACRA) value-based Quality Payment Program — designed to provide stable payment updates — will replace the widely criticized fee-for-service Sustainable Growth Rate payment formula. The change will financially reward practices for quality care and the use of electronic health records (EHRs) while penalizing doctors who receive subpar scores.
CMS will accept public comments on its final rule until Dec. 19.
Clinicians may not completely understand the complexity of the new rule, which relies on patient surveys to determine physician scores for quality care, James L. Gajewski, MD, MACP, professor at Oregon Health & Science University and member of the institution’s bone marrow transplant program, told HemOnc Today.
“People I talk to are concerned that, basically, it’s going to lead to cherry picking, and that the patients who most need access to care — those with very advanced disease, those with poor psychosocial support, those who have not always had the best compliance or those with multiple complex medical problems — those are the very patients doctors are not going to want because they’re going to adversely impact their scores or their finances,” Gajewski said.
Ted Okon, MBA, executive director of Community Oncology Alliance, agreed there could be an “inherent penalty” for oncologists.
“I don’t think physicians will be thinking about cherry picking,” Okon told HemOnc Today. “But, there is that inherent penalty that CMS has not really grappled with yet. The problem is that cancer care is really specialized and detailed. If you look at MACRA overall, it is meant for every specialty, including primary care. It’s a generalized program, but cancer care is very specific.”
MACRA implementation
To avoid penalties under MACRA, clinicians can choose between two reimbursement paths — the Merit-based Incentive Payment System (MIPS) or an advanced alternative payment model (APM).
By using the MIPS track, physicians can earn plus or minus 4% of reimbursement in 2019, with an adjustment potential of 9% in 2022.
Physician pay will be based on ratings in four weighted categories: quality, resource use, clinical practice improvement and advancing care information, a model in which the government determines whether doctors should be rewarded for use of EHRs.
For the 2017 transition year, CMS reduced the weight for resource use to 0, with MIPS scoring based only on the other three performance categories: quality (60%), advancing care information (30%) and improvement (15%). Beginning with performance year 2018, the resource use category weight in the MIPS final score will gradually increase to 30% by 2021.
“Most important for the oncology community is the removal of resource use for the first year of MIPS,” Polite said. “The ratings composite will reflect three categories rather than four. With 60% being awarded for the quality category, having the designation of general oncology added back [after it was excluded in the proposed rule] is good for oncology.”
The first performance period begins on Jan. 1, 2017, and runs through the end of the year. Clinicians can start collecting performance data between Jan. 1 and Oct. 2, and they must submit the data by March 31, 2018. The first performance-based adjustments will take effect Jan. 1, 2019.
Under the APM model, physicians can earn annual bonuses of 5% from 2019 through 2024, and they would be exempt from MIPS reporting requirements and payment adjustments.
To qualify for APMs, practices must meet three requirements: use of certified EHR technology, use of quality measures comparable to measures under MIPS, and assumption of more than a nominal financial risk.
Based on an earlier draft of the changes, ASH had requested CMS switch from its proposed reporting threshold increase to a graduated approach that would increase the threshold over time.
According to the final rule, CMS will require a 50% reporting threshold for claims, clinical registry, EHR and qualified clinical data registry mechanisms, consistent with the Physician Quality Reporting System requirements. For the 2018 performance year, CMS finalized a 60% reporting threshold in those categories.
Standards for measures, scoring and reporting across performance categories for MIPS–eligible clinicians are still being finalized, according to the CMS–issued executive summary of the MACRA final rule.
ASH also had requested that CMS rescind its proposal to continue to exclude the cost of Medicare Part D drugs from resource use measures. The society instead recommended that the cost of Medicare Part D drugs be included, despite the technical challenges to doing so.
CMS received comments both for and against this proposal. In its final rule, it stated that — to the extent possible — it will continue to investigate methods to incorporate this component of health care spending into its cost measures.
Impact on clinicians
With the implementation of MACRA’s final rule fast approaching, clinicians will need to familiarize themselves with the many changes that lie ahead.
“The bigger dilemma for doctors is implementing the coding system; that’s the real problem here,” Gajewski said. “The assumption is we all will see the bell-shaped curve of patients, but we don’t. Within hematology and oncology practices, both academic and private, doctors are focusing on certain types of cancers — like breast cancer, lung cancer or acute leukemia. The patients with acute leukemia have prolonged hospital stays. The doctors focusing their practices on these patients will have a lot more resource utilization expense.
“Steroids are [used in treatment] for lymphomas. If a patient is diabetic, (taking steroids) is going to worsen their diabetes,” Gajewski added. “How is MACRA going to adjudicate all that?”
There also are implications for patients with benign hematologic conditions.
“Anemia ranges anywhere from iron deficiency anemia, where you do a bowel workup, or anemia of chronic disease from arthritis, where you do nothing, to aplastic anemia, where you need a bone marrow transplant,” Gajewski said. “Doctors like me are not going to see a bell-shaped curve of anemia patients. Doctors like me will be doing a bone marrow transplant. Other doctors, probably family doctors, will hopefully be seeing anemia of chronic disease or iron deficiency anemia.”
Quality scores that clinicians receive from patients are highly subjective and in need of additional variables, especially when it comes to communication between clinicians and patients with cancer, Gajewski said.
“The issue with oncologists is that we have no validation of these surveys,” he said. “Patients often don’t want to hear it when physicians don’t sugarcoat what their survival chances are, and some patients get very angry and depressed, and they may not fill out the surveys positively. Patients may appreciate those doctors over time, but we all get graded on one survey at one moment in time rather than over a continuum of care.”
Further, hematologists and oncologists may see patients with chronic pain, for whom narcotics prescriptions are necessary.
“Some of those patients have become addicts, and doctors have to help them see that taking too much is a bad thing, and you have to set limits,” Gajewski said. “The doctors who set limits with patients may not get high marks, even though they are doing their jobs correctly.”
Clinicians should remember the intention of MACRA’s final rule instead of focusing on whether they will receive financial bonuses or penalties as a result, Okon said.
“This should be about improving and enhancing the care that is provided to patients with cancer by measuring it and implementing changes to make it better,” he said. “It is a daunting process, but you are laying down the baseline measure for 2017 that is going to affect 2019.
“It should be more about understanding the care you are giving and making that better than to provide a change in reimbursement,” he added. “Too much in medicine revolves around the physician, and it really needs to revolve around the patient.”
An estimated 592,000 to 642,000 eligible clinicians will be required to participate in MIPS in its transition year. Assuming 90% participation, CMS estimates MIPS’ positive payment adjustments will be $199 million, equal to the projected $199 million negative adjustments.
“That was the only way this legislation had to pass, with budget neutrality,” Gajewski said. “You could not reward doctors without penalizing others.
“If you have a loss that drives you into bankruptcy, those providers may leave town,” he added. “Or, if you are an employed physician and your patients become expensive because of acuity adjustments, that employer may say you’re fired. What are the protections for doing good patient care?”
CMS estimates that 70,000 to 120,000 clinicians will become qualified practitioners in 2017 through participation in advanced APMs, with those numbers increasing to a projected 125,000 to 250,000 in 2018. Those clinicians are projected to receive between $333 million and $571 million in APM incentive payments in 2019.
Practices with 100 or fewer Medicare patients, or those with $30,000 or less in Medicare Part B–allowed charges, will be excluded from MACRA’s new requirements. The original draft rule set the threshold at $10,000.
An analysis conducted by AMA showed that 30% of physicians will be exempt under MACRA’s final ruling.
“One concern was the dollar amount for the low-volume threshold exemption,” Polite said. “Raising the threshold from $10,000 to $30,000 will allow more practitioners to opt out of MIPS.”
Small practices with three or fewer clinicians may face the greatest challenge complying with the new reporting rules, Okon said.
“Although there is a tremendous amount of consolidation going on, there are still small providers out there, and the concern for small practices is the complexity of reporting,” Okon said. “It makes it easier for someone who is in the oncology care model to be more seamlessly involved in MIPS. I think if you are not in the oncology care model, then you have to be more cognizant of your reporting requirements under MIPS.”
Polite said 2017 will serve as a true transition period for oncologists.
“ASCO has always encouraged members to participate in the Physician Quality Reporting System, Medicare Meaningful Use and Value–based Payment Monitor programs. By doing so, members could have a head start in at least testing the system, which under the ‘pick-your-pace’ option allows them to avoid any negative adjustment,” Polite said. “Those members that are ready to do more by reporting more, and for the entire year, can do so by taking advantage of ASCO’s Quality Oncology Practice Initiative module and actually get positive adjustments in the first year of MIPS payments.”
Physician education
To help educate doctors on the MACRA changes, Medicare has launched a new website with interactive features. AMA also unveiled practical tools to help physicians succeed under the new program.
The AMA Payment Model Evaluator will give physicians and their staffs a brief assessment and recommendations on which MACRA payment model is best for them.
The AMA Steps Forward program offers real-world solutions, steps for implementation, case studies, continuing medical education, and downloadable tools and resources to help improve practice efficiency and enhance patient care.
The AMA also launched a ReachMD podcast, titled “Inside Medicare’s New Payment System,” in which notable healthcare experts inform physicians on upcoming Medicare changes.
“There’s very little that can be changed right now,” Gajewski said. “When I talked with staffers on the Senate finance committee, they said they didn’t hear about all these potential problems, these in-the-weeds issues, from the major medical societies. I think it’s important doctors understand all the implications.” – by Chuck Gormley
For more information:
James L. Gajewski, MD, MACP, can be reached at jamesgajewski@gmail.com.
Ted Okon, MBA, can be reached at tokon@coacancer.org.
Blase Polite, MD, can be reached at bpolite@medicine.bsd.uchicago.edu.
Disclosure: Gajewski, Okon and Polite report no relevant financial disclosures.