Understanding and Preparing for MACRA

Understanding and Preparing for MACRA

The Medicare Access and CHIP Reauthorization Act of 2015 (MACRA) was passed in April 2015, effectively repealing the sustainable growth rate (SGR) and introducing comprehensive changes in how Medicare pays physicians for services. As the policies passed in MACRA are rolled out over the coming years, they will profoundly impact reimbursement and care delivery for oncology practices throughout the United States.

ASCO will be your partner in preparing for these changes and will provide a wide range of resources and tools that are designed to help practicing oncologists adapt to and satisfy MACRA requirements as cancer care moves toward a value-based practice environment. ASCO will also aggressively advocate that provisions in the law are implemented in a manner that reflects the current realities of cancer care, enabling you to provide the full range of services and high-quality care that your patients with cancer need to fight their disease.

This brief, prepared by ASCO in Action, is the first in a series that ASCO will provide outlining the provisions in MACRA. This first brief provides a high-level overview of MACRA to help readers understand and prepare for these changes, while subsequent pieces will go into greater detail on these provisions.

MACRA Snapshot

MACRA makes three important changes to how Medicare pays health care providers who care for Medicare beneficiaries. The new law:

1. Repeals the SGR formula as a mechanism for determining Medicare payments for physicians’ services. The SGR formula was responsible for determining the annual increases or decreases to the Medicare physician fee schedule and typically resulted in large proposed decreases to physician payments and annual congressional patches. MACRA puts an end to that process and instead puts into place a predictable annual increase of 0.5% through 2019 before a complete transition to the new system described below.

2. Establishes two payment options beginning in 2019. One of the options retains the current fee-for-service structure with a new system for positive or negative adjustments to the fee schedule payments. The other—participation in an alternative payment model—is different from the current fee-for-service system. Both choices move toward a valued-based system, with an emphasis on quality, not volume, of health care services provided.

3. Incentivizes practice transformation. Regardless of what path you take in MACRA, your reimbursement system will likely require changes to your practice. Both paths require–either through scoring or eligibility criteria—practices to (1) report quality metrics, (2) demonstrate meaningful use of electronic health records and use resources responsibly, and/or (3) take on financial risk. 

MACRA: Two Payment Options

The new law establishes two payment options: participation in the Merit-Based Incentive Payment System (MIPS) or Alternative Payment Models (APMs). Both systems go into effect starting in 2019, and physicians will be automatically enrolled in MIPS unless they choose to participate in an APM.

Merit-based incentive payment system

The Merit-Based Incentive Payment System (MIPS) is a new payment system that combines parts of the Physician Quality Reporting System (PQRS), the Value Modifier (VM or Value-based Payment Modifier), and the Meaningful Use program—and adds a new category of clinical practice improvement activities—into a single program that will assess physicians on these categories.

Although details on MIPS will be the subject of policymaking for several years, it is important to understand that some of the assessments made at the effective date of 2019 will be based upon 2017 data. Furthermore, although MIPS payment adjustments will be transitioned over a period of years, these adjustments may be significant. ASCO will be analyzing this aspect of the new Medicare payment system very closely as more information becomes available.

Fig. 1. MACRA Timeline Part 1 (2015-2018)

Click to Expand.

Fig. 1. MACRA Timeline Part 1 (2015-2018)
Alternative payment models

MACRA incentivizes participation in alternative payment models (APMs) by establishing a system in which, beginning in 2019, qualifying health care providers may receive a lump sum for participation in a certified APM at a certain level. That incentive payment will be equal to five percent of the prior year’s estimated aggregated expenditures under the fee schedule. Beginning in 2026, when the lump sum payment goes away, the baseline fee schedule payments will still be higher for qualifying APM participants than for other providers in the MIPS system. (See Figs. 1 and 2 for more information about timeline on incentives and fee schedule add-ons.)

Fig 2. MACRA Timeline Part 2 (2019-2026+)

Click to Expand.

Fig 2. MACRA Timeline Part 2 (2019-2026+)
Although, currently, there are not many APMs for oncology, the law encourages development and recognition of models available to medical specialists such as oncologists. How an APM will be recognized for purposes of the program is still evolving but may include existing models, such as accountable care organizations, patient-centered medical homes, and bundled payment models. MACRA also introduces a new pathway to qualify APMs developed by stakeholders, called physician focused payment models (PFPMs). Although the Centers for Medicare & Medicaid Services (CMS) will determine which Physician Focused Payment Models qualify as an APM under MACRA, the law mandates that qualifying PFPMs require the reporting of quality measures, the use of certified electronic health records, and that the physician has “more than nominal financial risk” (with the exception of a patient-centered medical home, for which the risk requirement is waived). A newly established Technical Advisory Committee will assess PFPM proposals from stakeholders and make recommendations to the Secretary of Health and Human Services about which models to adopt as a qualifying APM, and the Secretary will consider and release a list of available APMs.

Quality Reporting Under MACRA

Regardless of the path your practice takes, MIPS or APMs, quality reporting and improvement will be a bedrock requirement under the new law. Financial incentives in both systems will be tied to quality performance. Reporting as early as 2017 will affect your scores and adjustments in 2019, and practices should be focused now on preparing and enhancing their quality reporting systems.

ASCO: Your Partner in Preparing for the Future

Leadership from ASCO’s Clinical Practice Committee, Government Relations Committee, Quality of Care Committee, and State Affiliate Council are developing a blueprint for the Society's involvement in the new law’s implementation. This new ASCO MACRA Task Force is developing an education and advocacy strategy that will require a multiyear effort and the collective expertise and leadership of all committees across ASCO.

MACRA will transform all oncology practices in two major ways: (1) how practices conduct Medicare reporting requirements, and (2) how providers are paid for the services you provide to Medicare beneficiaries. The ultimate goal of these changes is to move toward a value-based health care system that ensures high-quality, affordable health care. ASCO has long embraced this goal and has dedicated significant resources that will provide you with the foundation needed to move into the MACRA era, specifically, through its Quality Oncology Practice Initiative (QOPI®) and its Patient-Centered Oncology Payment Reform model.

ASCO’s Quality Oncology Practice Initiative

CMS has approved ASCO’s Quality Oncology Practice Initiative (QOPI®) as a Qualified Clinical Data Registry (QCDR), a pathway for oncologists to meet the agency’s current quality reporting requirements. The QCDR is available to practices piloting eQOPI this fall and will be made available to practices that choose eQOPI submission next year. As a “deemed” registry, oncology practices participating in QOPI can fulfill CMS’ Physician Quality Reporting System (PQRS) reporting requirements by submitting data for the oncology measures group.

QOPI is a voluntary self-assessment and reporting program launched by ASCO in 2006 to help hematology-oncology and medical oncology practices assess the quality of the care they provide to patients. Through the QOPI program, practices submit data from patients’ records up to twice per year into a secure database. Nearly 700 oncology practices, representing more than 5,000 medical oncologists, have participated in the QOPI program.

By providing a systematic process and methodology, a robust library of nearly 200 quality measures based on published guidelines and expert consensus, and access to projects and programs, QOPI helps oncology practices evaluate the quality of the care they provide to patients and engage in ongoing quality improvement.

QOPI offers provider, office location, and practice-specific measure performance to participants along with National benchmark comparative results. This information allows physicians and practice staff to identify areas for improvement activities, set and meet performance goals, and demonstrate quality care to patients and internal and external stakeholders.

Participation in QOPI is one essential preparatory step your practice can take to prepare for MACRA implementation. ASCO is working hard to ensure that through QOPI participation you will be able to meet requirements for reporting on meaningful use and clinical practice activities under MIPS.

ASCO payment reform model

Over the past several years, ASCO volunteers developed a payment reform proposal designed to significantly improve the quality and affordability of care for cancer patients, consistent with the principles laid out in MACRA. The Patient-Centered Oncology Payment: Payment Reform to Support Higher Quality, More Affordable Cancer Care (PCOP) would fundamentally restructure the way oncologists are paid for cancer care in the United States by providing sufficient payment to support the full range of services that patients with cancer need and removing the barriers created by the current payment system to delivering high-quality, affordable care.

PCOP would enable oncology practices to take greater accountability for key aspects of cancer care spending without harming patients and without putting practices at risk for costs they cannot control. At the same time, oncology practices would commit to delivering evidence-based care ensuring patients receive the most appropriate tests and treatments while avoiding unnecessary expenses. 

ASCO believes that PCOP would meet MACRA’s definition of an Alternative Payment Model and will advance PCOP as a potential certified APM.

ASCO Weighing In Throughout MACRA Implementation

CMS has already started the process of developing MACRA policies and has issued a request for information (RFI) regarding implementation of MIPS, promotion of APMs, and incentive payments for participation in eligible APMs. ASCO is responding to this RFI and will remain actively engaged to influence MACRA policies proposed in the current and future rulemakings.