MACRA: What Oncologists Do This Year Will Affect Payments in 2019

The United States Medicare Access and CHIP Reauthorization Act of 2015 (MACRA) quality- and payment-related provisions took effect January 1, 2017, and how oncologists comply this year will determine their payments in 2019, according to a speaker at the 34th Annual Miami Breast Cancer Conference, held March 9­–12 in Miami Beach, Florida.

“This was the ‘doc fix’,” said Anees B. Chagpar, MD, MSc, MA, MPH, MBA, FRCSC, FACS, associate professor of surgery at the Yale School of Medicine, director of The Breast Center-Smilow Cancer Hospital at Yale, and assistant director of Global Oncology at the Yale Comprehensive Cancer Center, in New Haven, Connecticut.

MACRA is part of a spate of recent healthcare reform legislation passed to improve the quality of care while reducing costs and improving population health. There is no current push to repeal the law, she noted: “This act was passed with bipartisan support and actually has nothing to do with the ACA [Affordable Care Act]. This still exists; it’s on the books.”

The MACRA’s Quality Payment Program (QPP) includes the Merit-based Incentive Payment System (MIPS), which supersedes the Centers for Medicare & Medicaid Services (CMS) Physician Quality Reporting System (PQRS), but retains the Medicare fee-for-service payment structure, Chagpar said.

“It will affect all of us in terms of how we get paid,” Chagpar said. “What we do this year determines how we get paid in 2019 and beyond. People in first year of practice don’t have 2 years prior, so they’re exempted.”

There are other exemptions, as well, Chagpar noted: Those with a very low proportion of medicare payments-less than 100 patients or $100,000 a year-are exempted from MIPS, she said. Accountable Care Organizations and Oncology Care Model facilities are also exempt from MIPS.

For others, “it is really important that you do something this year,” she emphasized. “If you do nothing, if you send nothing in, then you’re eligible for a 4% hit in 2019.”

MIPS consist of four components: quality (replacing PQRS), improvement activity, advanced care information, and cost.

“They are not looking at cost right now,” Chagpar said. “In 2019 and going forward, they will be looking at cost and cost will represent 30% of that composite [MIPS] score.”

MIPS is a budget-neutral system, meaning that “the losers pay the winners,” she said. “If you take a hit, then that pays for the people who do well.”

Weighted MIPS scores for quality, improvement activity, advanced care information, and (starting in 2019) cost are added together for the final performance score.  

“It is rather complicated,” Chagpar said. “You must report on at least 50% to 60% of patients in 2017 if you want to get your full payment.”

The quality of care reporting measure is composed of an administrative claims measure for readmissions, and six other measures, at least one of which must be an outcome or high-priority measure. Additional points are awarded for electronic reporting and “more than one high-priority measure,” such as not administering human epidermal growth factor receptor 2 (HER2) therapy to HER2-negative patients, she said.

Other high-priority breast cancer-related quality measures include image confirmation of excision, limiting radiation dose to normal tissue, and administration of chemotherapy with trastuzumab to patients with HER2-positive disease. Non-high-priority breast cancer-related quality measures include pathology reporting of tumor (pT), node (pN) and grade data, and proportion of mammograms administered to women aged 50 to 74 years.

“Truthfully, the quality measures aren’t terribly difficult to get; it’s not going to be as onerous as it might at first seem on the web site,” she said.

Advancing care scoring is based on electronic prescribing, security measures to protect patient health information, patients’ access to their electronic records, and other performance measures, such as immunization registry reporting, and providing patients with summaries of care. Bonus points are awarded for certain forms of data reporting, such as syndromic surveillance reporting and public health registry reporting.

Improvement activities include expanding access to one’s practice, care coordination, beneficiary engagement, patient safety and practice assessments, behavioral and mental health integration, and the use of risk calculators and decision aids, for example.

When cost scoring begins in 2019, mastectomy will be among the list of procedures for which per-episode costs are tracked and scored, Chagpar noted.

Cost will represent 30% of the total MIPS score.

There are different ways to achieve a total MIPS score of 100%. “Add all these up and it exceeds 100%, but CMS caps you at 100%,” she said.  

“MACRA, MIPS, QPP; this is more than alphabet soup,” Chagpar concluded. “Our practices now influence payments in 2019. It pays to educate yourself now.”