Seeking an APM that Is Workable and Fair

Blase Polite, MD

OncLive: CMS Acting Administrator Andy Slavitt has said MACRA reforms may be too much, too soon for physicians.

Are you relieved about potential implementation delays?

What are you hoping will result?

Did CMS accept much input from physicians?

ASCO is working on the assumption MACRA changes will be minimal?

What’s your take on MIPS versus the APM?

And you think the OCM—as an APM—is too restrictive?

A year ago you sounded more optimistic about MACRA.

The month of July saw CMS Acting Administrator Andy Slavitt tell lawmakers in Congress that the agency is considering delaying and restructuring elements of the Medicare Access and CHIP Reauthorization Act (MACRA), which would introduce payment reforms and new business models for physicians. The move was welcomed by members of the oncology community. Below is an interview with Blase Polite, MD, chairman of ASCO’s Government Relations Committee, who discussed the ramifications of Slavitt’s remarks and lingering concerns about MACRA.Polite: It reflects lot of the thinking at ASCO. The methodologies aren’t ready for prime time. Many things revolving around resource use measurements and quality metric certification need to be ironed out.Yes. We’re still very supportive of MACRA, in concept. I think the proposed rule had a lot of clarifying elements in it, but what it also showed was that there are a lot of placeholders. And what makes everybody a little nervous is how some of this stuff is going to play out, given that, basically, our 2017 performance is going to determine our 2019 payment updates. The twoyear lag makes this really difficult for everybody.That CMS will lay out a more streamlined process and give people more time to see what kind of quality metrics they’re going to be under. Basically, more information and better ways to risk-adjust for the resourceuse category. It’s way more complicated than it looked on paper.The two areas we, at ASCO, spent time discussing with them were on development of specialty-specific quality metrics and on flexibility in development of alternative payment models (APMs). On the quality measures side, they clearly listened in designing MIPS (Merit-Based Incentive Payment System), such that the choice of quality metrics was much more broad than available under PQRS (Physician Quality Reporting System). We were disappointed that they have created a somewhat cumbersome process to get quality metrics certified. Even if you already have quality metrics certified under the Qualified Clinical Data Registry (QCDR) program, they are still requiring us to resubmit metrics for certification. On the APM side, we feel that CMS did not really listen. They created a very high bar for something to be considered an advanced APM, which we do not believe was the intent of Congress.I would not say minimal. The framework is not too dissimilar to the current Value-based Payment Modifier program. The problem is that very few practices have really wrapped their heads around that process. What we are preaching to practices is that you should know about your QRUR (Quality and Resource Use Reports) and where you are in terms of resources and quality under the value-based modifier. That’s the big message. If you’re not reporting even PQRS data, right now, you’ve got to start doing that. Your best predictor of how you’re going to come out in 2019 is how you came out in 2015/2016.Almost no one’s going to be in an advanced APM early on because the only certified advanced APM for oncology is the two-sided risk Oncology Care Model (OCM) that is not going to be available for two years. We think that they made the advanced APM way too stringent, especially in terms of loss ratios. It was clearly congressional intent to have many specialty-specific APMs available for practices to try.We’re concerned that they’re going to lock us into the OCM. I think Congress’s intent was to give us some other models, to allow some experimentation with different APMs. I think CMS realized they were making it difficult. My feeling is they see the 5% bonus that practices get for being in the advanced APM as such a huge incentive that they wanted to set the bar really, really high. I think Congress was very aware that specialty APM models need to be developed, and I think their intent was to really encourage people to start testing—to have CMS test some of these different models.I still like the idea that quality is now going to get more specialty specific, so we’re not going to get tied into—for many of us—an irrelevant set of PQRS measures. That wouldn’t have spawned improvement. Now, they’re going to let you get judged on what it is you do. Once they figure out what the quality measures are and how you get judged, I think this will be vastly more improved on the quality side.

The resource side—what you include in the costs of care—probably has the same set of concerns that we had back then, which is for oncology what you include in the resources and, specifically, how you hold us accountable for drug prices which we have no control over. That remains a concern. Back on the positives, I do like the continuous scale scoring, as opposed to putting you in one of the four buckets that the value-based modifier does—based on cost and quality measures. This one at least gives you the potential, if you’re above the median, to earn some bonus.

Any thoughts on the rollout of the OCM?

Right now, under the value-based modifier, so many people are in the middle category where you don’t lose, you don’t gain. Now, a lot more people have the potential to gain from doing a little better than the median.CMS has been very responsive to questions and has tried their best to help practices begin the OCM process. There were several unfortunate circumstances where practices either had to drop out of the OCM or had to make very hard decisions that many of us felt were unnecessary. This primarily involved practices sending their physicians out to critical access hospitals once a month, twice a month. Those folks were all excluded from the OCM because they weren’t allowed to bill at both a critical access hospital and at their practice. That left a bad taste. They’re doing that out of public service. CMS made it so you either cut off all access to those hospitals or you have one person who’s there full time. I understand, technically, why they did that: it has to do with how critical access hospitals are paid on a cost-reimbursement basis. To me it was more of the letter rather than the spirit. That was unfortunate.

The other area causing some concern right now is how we are going to transmit patient data to CMS for quality metric-tracking purposes. They are also requesting additional information on patients’ stage and molecular characteristics, but, as of yet, have not given us the details and vendor information we will need to do it. Those who have worked on the IT side, or with IT teams, know how much work needs to go into the secure transfer of sensitive patient data. This is not something where you just turn the switch on one day and it happens.

But having said that, they’ve got roughly 200 practices enrolled in the OCM. Many of us are excited about really getting to see our own granular data on costs and resource use. I think we’ll learn a lot. I hope they’ll remain open to suggestions for improvements along the way. That will be key. This has to be viewed as a partnership between pioneering oncology practices and CMS. For many of us in the cancer community, we have not always felt like CMS was interested in hearing our thoughts and recommendations on reforming cancer care. We hope they will see through this that many practices have really given this a great deal of thought and together we can come out with an APM that is workable and fair.