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Evidence-Based Oncology April 2017
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An Oncologist's Perspective: Preparation for New Payment Models in Cancer Care

Sachin M. Apte, MD, MS, MBA
A dive into the Quality Payment Program and other healthcare reform models introduced in cancer care that healthcare providers are adjusting to as we move toward value-based care.

In 2013, the Institute of Medicine (IOM; now called The National Academy of Medicine) described a cancer care delivery system in crisis.1 The stress on our healthcare system is amplified by an aging population, healthcare workforce shortage, and rising costs. By 2020, the cost of cancer care is estimated to be $173 billion, a staggering 39% increase over 2010 levels. In a 2001 report, Crossing the Quality Chasm, the IOM described 6 aims for healthcare: safe, effective, patient-centered, timely, efficient, and equitable.2 Components of the 13 IOM recommendations directly address issues such as providing high-quality, evidence-based care; sharing health information; improving processes of care; using resources efficiently; coordinating care; and redesigning payment methods to incentivize quality enhancement and remove barriers that impede quality improvement.2 In the 16 years since the publication of Crossing the Quality Chasm, several key issues have remained unresolved and barriers to improving quality and value in oncology have persisted. The Quality Payment Program (QPP) by CMS aims to drive further transformation forward in oncology.

The care for a patient afflicted with cancer is complex, resource-intense, and constantly evolving. These challenges are compounded by the changes underway in physician payment reform. It is critical that oncologists and leaders of hospitals and healthcare systems comprehend these changes to successfully adapt and remain agile while providing high-quality, compassionate, and timely care to patients with cancer. In parallel with the QPP, cancer care providers need to develop comprehensive, individualized, and forward-thinking strategies to successfully adapt to new payment models in oncology. Such strategies may necessitate workflow changes that must be tracked.

Quality Payment Program

Strong bipartisan support for the Medicare Access and CHIP [Children’s Health Insurance Program] Reauthorization Act (MACRA) in 2015 led to the final rule being published in October 2016. MACRA, rebranded as QPP, includes 2 tracks:
•  The Merit-based Incentive Payment System (MIPS)
•  Advanced alternative payment models (APMs)
•  MIPS, which includes Medicare Part B payments and excludes Part A (hospital payment), combines portions of existing programs into a single composite score. The legacy programs include the Physician Quality Reporting System, “Meaningful Use,” and the Value-based Payment Modifier. For 2017, the score for the 4 MIPS categories will be weighted as follows:
•  Improvement activities (IAs), 15%
•  Advancing care information (ACI), 25%
•  Quality, 60%
•  Cost, 0%

It is important to note that the weighting will change over time: by 2019, both quality and cost will be weighted at 30%. CMS’ QPP interactive website contains tools and information for providers and hospitals.3 For 2017, providers may choose not to participate, but will receive a 4% payment reduction. Submission of at least 1 quality or IA metric, or the required ACI metrics, will avoid any penalties. The provider may choose to submit data for 90 consecutive days or an entire year. Submitting all MIPS data for at least 90 days may result in up to a 4% increase plus a performance bonus. For the first MIPS payment year in 2019 (performance year 2017), payment adjustments will be at ±4% based on the MIPS composite score, and by 2022, the adjustment will be at ±9%.

Advanced APMs provide incentives to promote high-quality and cost-efficient care for a specific condition, defined episode, or a population. Advanced APMs require use of certified electronic health record (EHR) technology; they tie payment to quality and entail downside financial risk. A subset of advanced APM participants, defined as Qualifying Professionals (QPs), will see a 5% increase in Part B payments from 2019 to 2024, be exempt from MIPS, and will have higher base rates beginning in 2026. In 2019, QPs must meet minimum requirements of defined percentages of Medicare payments and patients (25% and 20%, respectively) coming through the advanced APM. For 2023 and beyond, the payment and patient thresholds increase to 75% and 50%, respectively. Advanced APM participants who do not satisfy the QP requirements may still receive favorable MIPS scores.

Physician-Focused Payment Model Technical Advisory Committee

MACRA incentivizes physicians to participate in APMs, including the development of physician-focused payment models (PFPMs). The Physician-Focused Payment Model Technical Advisory Committee (PTAC), created by MACRA, provides recommendations to the HHS secretary on proposals for PFPMs. Ten criteria are used to assess a proposed PFPM, including an emphasis of value over volume, care coordination, defined quality and cost components, and whether the PFPM will expand the existing scope for APMs. The PTAC mechanism may be an opportunity for advanced APM development for subspecialty societies, large community-based multi-specialty groups, and tertiary cancer centers.

Strategic Considerations for QPP Implementation

Although MIPS may appear to represent a rebundling of existing programs, the mounting financial penalties for sub-optimal MIPS composite scores may push providers into an APM over the next several years. The assumption of risk could usher in dramatic changes as providers assess the scale of their operations and place a premium on care coordination and resource management. These changes will force oncologists to develop or acquire the necessary subject matter expertise. At Moffitt Cancer Center in Tampa, Florida, a multi-disciplinary team meets regularly to share information and begin building institutional knowledge, with outside consultation obtained in a targeted manner. This knowledge must be disseminated throughout the practice or organization to facilitate the change management required for QPP implementation. Successful adaption to new payment models will rely heavily on strategy, and subsequent workflow changes can then be designed to deploy strategy. The 6 issues listed below can help inform the organization’s multi-disciplinary team as it starts designing a strategy.

1. Determine if a cancer care provider qualifies. A provider is part of the QPP if it participates in an advanced APM or bills Medicare
Part B more than $30,000 a year and provides care for more than 100 unique Medicare Part B patients a year.3 MIPS-eligible providers include:
•  Physicians
•  Physician assistants
•  Nurse practitioners
•  Clinical nurse specialists
•  Certified registered nurse anesthetists.
At Moffitt, these nonphysician mid-level providers are an integral and large part of our care team. Their impact must be accounted for, a difference from prior physician-focused federal programs, such as Meaningful Use.

2. Determine a 2017 reporting period. Providers have an option to choose their pace for 2017. While reporting began on January 1, 2017, a provider who wants to participate in a limited fashion can begin reporting by October 2, 2017. Providers may opt not to report, submit a minimum amount of data (ie, 1 quality measure), report on 90 days of data, or submit data for an entire year. Data submission is due by March 31, 2018. Although the reporting year is 2017, the payment adjustment is made on January 1, 2019.

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