Dr Samyukta Mullangi on the EOM: MIPS Disproportionately Penalizes Oncologists; ePROs Need Refining


"It's really important that oncologists are on level footing along with the rest of their medical peers," said Samyukta Mullangi, MD, MBA, incoming medical director at Thyme Care.

Samyukta Mullangi, MD, MBA, incoming medical director at Thyme Care, has recently published research suggesting that oncologists will likely be disproportionally penalized after the incorporation of cost measures into the Merit-based Incentive Payment System (MIPS) under the Enhancing Oncology Model (EOM). Here, Mullangi explains the implications of MIPS composite scores for oncologists, and some barriers with electronic patient-reported outcomes (ePROs).

Mullangi will present data on the association between Oncology Care Model participation and spending, utilization, and quality outcomes among patients with commercial insurance and Medicare at the 2023 American Sociaty of Clinical Oncology Annual Meeting.


How can specialty-specific solutions maintain health care quality and outcomes amidst value-based care policy efforts?

All physicians who are participating in Medicare are subject to quality performance review activities, either through MIPS, or Advanced Alternative Payment Models called APMs. In MIPS, clinicians earn a yearly composite score that are based on 4 domains: cost, quality, improvement activities, and achieving interoperability. While clinicians who are participating in Advanced APMs are exempt from MIPS reporting requirements, clinicians who are participating in non-Advanced APMs may still participate in MIPS. This is important because, for example, within oncology, physicians who are going to participate in the upcoming Enhancing Oncology Model—definitely for 2023 and many practices even into 2024—will not meet either the payment or the patient volume criteria to qualify them to be an Advanced APM, so they may still end up participating in MIPS.

MIPS is not a perfect program. It's a really nice amalgamation of all of the reporting requirements that came before it, but it still has some problems. One that I see is that the cost criteria within MIPS is just a global measure that's specialty agnostic—it's just basically looking at spending per beneficiary. In some previous work that we published this year in The Oncologist, we found that oncologists who treated patients of greater clinical complexity were also receiving lower composite MIPS scores, and much of that was actually driven by their performance on the cost metric. Our work actually used data from 2019, back when the cost metric only accounted for 15% of the MIPS composite score, and quality accounted for 45%. As of 2022, those things have equalized, so they're both 30% each, and we hypothesized that oncologists who treat these high complexity, high cost patients would be treated disproportionately unfairly in the program.

In some follow-up work, we actually studied this very question. We obtained publicly reported MIPS category scores for physicians from the year 2018, and then we apply the 2022 new reweighting criteria to their performance back then. We found that oncologists of every subspecialty—medical, surgical, radiation—were all being given disproportionately low composite scores relative to their non-oncology peers. And they actually, with the reweighting, sustained the biggest decrease in absolute numbers in this composite score, and that translates to big implications. So, 40% of oncologists will now not receive an exceptional payment bonus, and the maximum penalty has increased from $4000 to $18,000 per physician. So this has really, really big implications.

We did some sensitivity analyses to understand whether this was being driven by just clinical complexity, and we found that it did explain some of it, it also didn't fully explain it. So yes, clinical complexity is associated with a lower composite MIPS score. But we found that oncologists who were treating patients of every decile of clinical complexity had lower composite MIPS scores than non-oncologists. And within the oncology, subspecialties, medical oncology had the lowest mean cost score relative to surgeons and radiation oncologists.

I think there's a problem. I think policymakers need to look at this and try to work on their risk adjustment criteria to try and ensure that oncologists are not being penalized for doing their work. I mean, they're not to blame for the fact that our drugs are so expensive and that the cost of our care is so high. It's really important going forward, MIPS is the backbone of so many practices' value-based payment programs. It's really important that oncologists are on level footing along with the rest of their medical peers.

What are barriers to practices using ePROs and developing their own tools for reporting social determinants of health, and what solutions would you like to see?

I think the emphasis on increased reporting on social determinants of health and electronic patient-reported outcomes is great in theory, because there's a lot of data—randomized clinical control data—that shows that obtaining this information about our patients and then acting on it leads to a better care experience and leads to better clinical outcomes. But there's a couple things that I think are a little bit tough with the emphasis on doing so with a model like the Enhancing Oncology Model.

One is that these are process measures. There's really no accountability on practices to necessarily match resources to the data. So, if a patient reports a problem like food insecurity, yes practices will probably respond to that, but right now CMS is only looking at the process measure of having collected that data. And the other thing is that the EOM gives practices less up-front money through these monthly enhanced oncology services, payments, these per member per month payments, that practices previously used to furnish these types of transformation activities. So standing up a big reporting program like this, where you're systematically collecting this data from patients and then matching them to resources that could help them address whatever needs that they're bringing up, that's a big enterprise and I think practices need funding to do so. So it would be really nice if that was available.

But the other thing I'll say to your question is, I don't think that practices should be in the business of trying to develop these tech tools on their own. This is not an activity that requires some kind of custom bespoke tool. There are so many off-the-shelf tools that have been battery tested, that have been optimized for the user experience, that are based on best practices, that I think practices should honestly just procure one of those and spend most of their energy trying to understand how you develop these workflows to do this big activity. And then how do you, notwithstanding whatever funds are coming from CMS, how do you actually stand up programs that would meet the patient's needs?

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