The final rule for the Quality Payment Program (QPP) authorized by the Medicare Access and CHIP Reauthorization Act of 2015 (MACRA) was recently released. This rule has two tracks for Medicare providers to choose from: the Merit-Based Incentive Payment System (MIPS) and the Advanced Alternative Payment Model (APM). Fortunately, there are a lot of positives for community oncology practices in the final details. Additionally, there are now several options for providers to participate in 2017 at a pace that meets their readiness:

Participate fully in MIPS. Submit data for all required measures in all categories for the full year and be eligible for the maximum positive payment adjustment.

Participate partly in MIPS. Report a minimum of 90 days of data including one Quality measure, one Improvement Activity, or more than the required measures in the Advancing Care Information (ACI) performance category to avoid negative payment adjustment and be eligible for a modest positive payment adjustment.

Submit some data. Report on one measure in the Quality category, one Improvement Activity, or the required number of measures of ACI to avoid a negative MIPS payment adjustment.

Participate in an Advanced APM and avoid MIPS participation.

​Oncology practices participating in the Center for Medicare and Medicaid Innovation’s (CMMI) Oncology Care Model (OCM) also have some readiness choices. These practices now have the option to participate as Advanced APMs in 2017. An Advanced APM is a two-sided risk model that totally exempts practices from MIPS participation. Those considering this option need to look carefully at the pros and cons of moving more quickly to a two-sided risk model versus participation in MIPS. The upside of the two-sided risk option is that practices are eligible for an additional 5% bonus payment from CMS, but they must achieve cost savings and improve patient outcomes, or they will face a penalty.

Practices that do not participate at all in 2017 will receive a 4% negative payment adjustment in 2019.

Now that the final MIPS rule has been issued, there are various activities practices can undertake to ensure they are well positioned to succeed when the program launches in January. The following are several critical areas all oncology practices should consider.

Engage your electronic health record (EHR) vendor about readiness for MIPS.

Understanding the practice’s electronic health record (EHR) MIPS capabilities and knowing when program reporting functionality will be available are critical first steps, as they enable the practice to determine which participation option is best for them. Requirements for the different levels of participation for 2017 must be closely examined and compared with practice readiness, both from technology and process standpoints. Once the level of readiness has been determined, providers can then decide if they are capable of submitting a full year of data, which would allow the opportunity for the maximum incentive payment in 2019.

Examine practice performance in the Physician Quality Reporting System (PQRS)

If neither the practice nor its technology is fully prepared to begin reporting on January 1, an action plan can be created to identify areas in need of improvement and plan corrections during the first part of the year. Practices have until October 2, 2017 to start collecting performance data and still avoid a penalty. However, the more they report, the more opportunity there is for a higher incentive payment in 2019.

Many oncology practices are participating in PQRS, a quality improvement incentive program providing rewards or penalties for reporting data to CMS. Those that are doing well in the program are in a good position to transition to MIPS because many of the quality reporting measures for MIPS are a continuation of PQRS, now called the Quality Performance Category.

Review and select measures for the Improvement Activities category

Practices not participating in PQRS may want to use the first nine months of 2017 to learn more about MIPS requirements and their readiness to meet these provisions. Start by looking at charting procedures. This will provide insight into which measures are the best fit for the practice based on patient volumes and other key factors related to MIPS quality measures. Part of this process involves engaging the practice’s EHR vendor to determine which measures are included in the EHR. Practices also need to make certain their EHR is fully certified for Meaningful Use, which is now called ACI.

The Improvement Activities category represents 15% of the MIPS 2017 composite score. Practices have to attest they have completed up to four improvement activities for a minimum of 90 days; therefore, the selected activity must be started no later than October 2, 2017. Activities are worth 10 or 20 points each, for a maximum score of 40. Practices with fewer than 15 physicians have only to complete two activities.

Examine the ACI measures and prepare to do more than the minimum

There are 93 different activities practices can consider, so there should be no difficulty finding several that are a good match for any particular practice. Practices should consider reporting on measures they are already meeting and just need to formalize the process or make minor changes to meet MIPS requirements. The intent behind this category is to drive innovation that benefits both the patient and the practice. The best way to approach this task is to consider activities that make the practice more efficient and effective in providing quality care to patients.

The final MIPS rule reduced the number of measures initially proposed for reporting in the ACI category, formerly called Meaningful Use. Practices will now be required to report on only five measures, representing 25% of their MIPS 2017 composite score. However, practices can raise their score by reporting on more than ve. The final rule included nine additional measures practices can submit. The maximum score is 100 points, but a score of up to 155 can be achieved by reporting on all 14 measures.

Decide whether to report as individuals or as a group

Practices should strive to do more than the minimum in this category. By talking to their EHR vendor now, they can make sure they are fully prepared to report on all of these measures. If their EHR is 2014 certified, these measures should be available. Practices should also make sure the vendor is prepared for the 2015 Edition Health IT Certification, which will be required in 2018.

Another important decision to make between now and the start of MIPS is whether to participate through group reporting or as individuals. If the practice has been participating in PQRS, they may want to report the same way after analyzing how well that approach has worked. Those not participating in PQRS should closely examine the pros and cons of reporting as a group versus individually. Some of this decision making will be driven by the performance of different physicians in the practice. If a physician is an outlier because of a different patient mix or other factors, group performance may be negatively impacted, and reporting individually may be preferred.

The MIPS final rule gives practices various options for participation, enabling them to transition into the program at their own pace. However, practices should be careful not to become complacent. While they may not have to participate fully in 2017, it is just a matter of time until they do. Value-based care is not going away, and this new way of reimbursement is only going to become more stringent and complex as time goes on.

Practices should immediately strive to gain an understanding of the various measures in each MIPS component, drilling down into the details. They should also be working closely with their EHR technology vendor to make certain they will be able to sufficiently report on MIPS requirements. If practices look at 2017 as an opportunity to learn and prepare for the future, they will be well on their way to building a strong foundation for value-based care while meeting the many challenges MIPS presents.

Linda Pottinger is director of Payer Initiatives, Innovative Practice Services, at McKesson Specialty Health.

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The final rule for the Quality Payment Program authorized by the Medicare Access and CHIP Reauthorization Act of 2015 was recently released.

MIPS Transition: CMS Cushions the Leap to Value

The evolving healthcare landscape creates many challenges for community-based oncology practices. As the market shifts from fee-for-service to value-based care, practices are tasked with improving quality while reducing costs. They must also report on a multitude of clinical and financial performance metrics, a complex undertaking if not properly managed.

How can independent practices successfully make the move to new care and reimbursement models while remaining focused on their primary mission of providing quality care? In supporting community-based practices, McKesson Specialty Health has identified eight core activities on which practices should concentrate to ensure a smooth, successful transition to value-based care:

Build a collaborative, patient-centric culture with a team approach to care.

	Collaboration and team care are critical to all value-based care programs, and practices should strive to build a culture that supports this environment. In the past, clinical and administrative functions were often siloed. Today’s value-based care models drive a whole new way of doing business by recognizing that every practice member has a role in providing care and value to patients. From the front office team to physicians and the supportive care team, staff must collaborate to provide patients the best possible care and experience while ensuring all requirements of the value model are met.

Educate practice staff and physicians so they understand value-based care.

	Physicians and staff must thoroughly understand value-based care and the role they play in its success. Practices also need to understand how the industry is evolving and the processes required to address new care delivery models. Value-based care is not solely about reducing costs; it includes higher quality coordinated care, smarter spending, and ultimately better outcomes for patients. Education is essential to creating a culture that seamlessly merges value and quality.

Develop strong patient navigation and follow-up processes.

	Physicians must be responsible for ensuring patients receive the care they need when coordinated care extends beyond their practice’s specialty. Referring patients to another provider is not enough—there needs to be a process in place to confirm that care is delivered and that there is appropriate follow-up on the outcome of that care.

	Consistent patient navigation and follow-up processes are critical, as is having staff members who are truly responsible for these functions. Patient navigation is most effective when each team member understands his/her role in the follow-up process.

	Mental, financial, and nutritional care are important elements of patient navigation, ensuring patients receive the full spectrum of care for body, mind, and spirit. Ultimately, the goal is to develop a circle of care around a patient, providing the best possible outcome, patient experience, and quality of life while reducing unnecessary emergency department visits and hospital admissions.

	By participating in value initiatives, such as ASCO’s Quality Oncology Practice Initiative and payer-driven Alternative Payment Models, practices have already begun building a strong foundation for value-based care, since these programs include measurement tools and data elements to define quality. Practices should review various program requirements against their current reporting capabilities, identifying data elements that are already being captured while determining where gaps exist.

Establish solid front office and billing procedures with advanced reporting capabilities.

	Successful practices must have strong front office and billing leadership that supports a value-based culture, along with technologies that enable advanced reporting of critical value-based care metrics. Staff members must thoroughly understand their practice management and electronic health record (EHR) systems, what value-based care is, and their responsibility in delivering that care. Front office staff members are typically the first point of contact with patients, and as such play a critical role in beginning the patient practice relationship. In addition to collecting all of the required demographic and insurance information, front office staff also may be responsible for collecting necessary medical records from the referring physician, ensuring that clinicians can deliver the appropriate level of care. Counseling on financial matters and documenting these conversations are important components of value-based care and are usually performed by front office staff.

	Consistent documentation is increasingly important in transitioning to value-based care, as reporting requirements are becoming more complex. Making certain all providers within a practice are documenting activities the same way in the EHR is essential for clinical assessment, quality care, and seamless patient transition from one team member to another. This is especially important for after-hours care, as on-call physicians need quick access to health records for all patients in the practice. If all physicians are documenting care and treatment history the same way within the EHR, it is easier for on-call providers to interpret records and ensure that appropriate follow-up care occurs.

Build strong relationships with referral partners.

	In a value-based world, providers are part of a larger community responsible for the full spectrum of patient care. Consequently, they need to work together to share information about what happens to their patients outside of their clinics. Maintaining close connections with such referral partners as palliative care specialists, hospice workers, home care aides, social workers, and others is an essential aspect of patient navigation and ensures appropriate care while minimizing hospital admissions and emergency department visits. Practices must also utilize interoperative technologies so patient information can easily be shared.

Engage strong clinical and administrative leaders.

	Strong leadership is important in both the clinical and administrative areas of the practice. Not all physicians adapt well to the changes required for value-based care. A strong physician leader can mentor peers to help ensure broader provider buy-in. On the administrative side, a highly-skilled leader can effectively coordinate both clinical and administrative staff, nurturing the collaborative team culture necessary for successful value-based care.

Value-based care is not going away, and it will continue to evolve in various forms in the future. To thrive in this new environment, practices need to embrace this new reality sooner rather than later. By participating in pilot programs and other value-based initiatives, practices can play a critical role in actively developing and defining these new models of care and reimbursement.

If the transition to value-based care is overwhelming and negatively affecting the practice’s ability to deliver quality care, it may be time to get help. The move away from fee-for-service requires massive top to bottom changes, and the task can often be made much easier with guidance from experts. Assistance is available from organizations like McKesson Specialty Health, which offers comprehensive services, expertise, and technologies to help oncology practices make the necessary changes to prosper in the new value-based environment.

Linda Pottinger is director of operations for Innovative Practice Services at McKesson Specialty Health.

The evolving healthcare landscape creates many challenges for community-based oncology practices. As the market shifts from fee-for-service to value-based care, practices are tasked with improving quality while reducing costs.

Linda Pottinger

Articles

MIPS Transition: CMS Cushions the Leap to Value

A Step-by-Step Guide to Value-Based Care