OCTOBER 1, 2019

Welcome to the MACRA MIPS/APM Update eNewsletter
Editor: Philip L. Ronning
This issue is sponsored by the National ACO Summit, the National Bundled Payment Summit,
the National Medical Home Summit, and the National MACRA MIPS/APM Summit

Providers Still Waiting for 2017 Advanced APM Bonuses
About 90,000 clinicians who participated in advanced alternative payment models in 2017 are concerned that they haven't received bonuses from the CMS. Advanced alternative payment models, also known as advanced APMs, were created under MACRA in 2015 and offer an opportunity for clinicians to receive a 5% bonus to their Medicare payments if they participate. It requires clinicians to take on significant downside risk. The CMS said it would provide the positive payment adjustment in 2019 to eligible clinicians who participated in 2017. But providers are worried the bonuses still haven't been distributed. In a letter Tuesday to CMS Administrator Seema Verma, nine provider groups, which include the American Medical Association and the National Association of ACOs, claim the bonus payments are delayed and it's unclear why. (Modern Healthcare, September 17, 2019)

Making Quality Performance Manageable: Three Strategies for Health Plans
HARRISBURG, Pa., Sept. 18, 2019 /PRNewswire/ -- Physician practices report spending an average of 787 hours per physician annually on reporting and entering quality data, amounting to $15.4 billion annually. A survey of health plans revealed they used more than 500 provider quality measures with very little overlap between insurers or with the 1,700 measures used by national and regional programs such as NCQA HEDIS®, Medicare Stars, PQRS, MACRA / MIPS, FEP, DSRIP and bundled payments. "Undoubtedly, healthcare quality matters and measuring quality performance does too," said Shelley Riser, Geneia's vice president of consulting services and clinical innovations. "There's also no doubt that we can -- and must - do much better in reducing the burden of quality performance on health plans and their physician partners." (PRNewswire, September 18, 2019)

2017 MIPS Final Scores: Are Small Practices Being Left Behind?
2017 was the first reporting year for MACRA/MIPS (Quality Payment Program). Only recently has it been possible to begin the deeper analysis of the data generated out of that year. We are now able to go to the CMS website, Physician Compare, to see some of the publicly reported data. However, the single most import data, the final MIPS score, is buried in data bases. That data can be accessed but not too many folks are going to examine gigantic spreadsheets to get at that data. The spreadsheet for individual MIPS eligible clinicians has over 400,000 rows. You might want to add a little RAM to your computer to play with that data. The MACRA/MIPS program is complex, much more so than the Meaningful Use program. Since it is also a zero-sum reimbursement scheme, funds are shifted from providers with low scores to those that score high. My concern has always been that small practices would not have the administrative resources to manage the program in comparison to larger or hospital affiliated practices. The playing field would not be level. Resources and program modifications have been created to support small practices (i.e. the Small, Underserved, and Rural Support initiative) but has it been enough? The data says "no". CMS, in their 2017 Quality Payment Program Reporting Experience report, states that "1,057,824 clinicians were eligible for MIPS in 2017. Of these, 1,006,319, or 95 percent, participated in the program and avoided a negative payment adjustment by receiving at least 3 points as their MIPS final score." Sounds pretty good, but let's break down that claim. In the charts below we see that the participation rate of all MIPS eligible clinicians was 95% in 2017. For clinicians in a small practices the participation rate was 81%. (HITECH Answers, September 16, 2019)

2017 Quality Payment Program Reporting Experience

CMS Advanced Payment Model Physician Participation Doubling 2017-2018
The number of doctors participating in advanced payment models (APMs) nearly doubled in 2018 to 183,306 compared to 99,076 doctors participating in 2017, according to new data. Centers for Medicare & Medicaid Services (CMS) Administrator Seema Verma attributed the increase to more opportunities to participate in such models last year, especially via affordable care organizations (ACOs). Additionally, CMS is proposing new rules governing APMs in its Quality Payment Program for 2020. As CMS Administrator Seema Verma stated in the agency's news release, the number of qualifying APM participants in Advanced APMs nearly doubled in 2018 from the previous year. These qualifying participants receive a five percent APM incentive payment in their Medicare rates and are excluded from having to participate in the MIPS reporting requirements and payment adjustment. Additionally, the number of clinicians participating in MIPS through an APM--meaning the APM did not qualify for Advanced APM status--also increased from 341,220 participants in 2017 to 356,828 in 2018. CMS suggests these participation improvements may be related to the increasing number of participation opportunities in 2018, particularly through ACOs in the Shared Savings Program. "I am excited about this progress, as it is a critical indicator we are succeeding in our goal of maximizing participation in MIPS APMs and Advanced APMs," Verma said. "This increase in APM participation supports the evolution of the program and incentives towards a system of value that puts patients first." (Policy & Medicine, August 26, 2019)

Stakeholders Rap CMS Mandatory Radiation Oncology Model
The American Hospital Association and other key stakeholders are raising concerns about a proposed mandatory alternative payment model for radiation oncology that is scheduled to take effect in less than four months. The Centers for Medicare & Medicaid Services announced in July that the five-year model would make prospective payments to cover radiotherapy services, in 90-day episodes, for patients diagnosed with 17 types of cancer. The model would link payment to quality metrics and would require participation from physician group practices, hospital outpatient departments and freestanding radiation therapy centers in randomly selected geographic areas. It would also qualify as an Advanced Alternative Payment Model (APM) and Merit-based Incentive Payment System (MIPS) APM under the Quality Payment Program (QPP), CMS said. model would test whether episodic payments in a prospective and site-neutral fashion would reduce the amount Medicare spends on radiation services while maintaining or even improving quality. In written comments, AHA called on CMS to a delay of the Jan. 1, 2020 starting date for the model, make the model voluntary, and "balance the risk versus reward equation much more appropriately." "Our members support moving toward the provision of more accountable, streamlined care and are redesigning delivery systems to increase value and better serve patients," AHA wrote. (HealthLeaders Media, September 17, 2019

Accuray Educates Radiation Oncology Practices on the Potential Impact of the Proposed Alternative Payment Model (RO-APM)
Accuray Incorporated recently published an informational guide designed to help radiation oncology practices understand the complexities of the much-anticipated proposed Medicare & Medicaid reimbursement changes. The new guide -- available at www.accuray.com/apm/ -- serves as an informational tool for healthcare providers who find themselves balancing their desire to invest in improved patient treatment technologies with the disruptiveness of a new billing model. Titled, "Thriving Under the Radiation Oncology Alternative Payment Model: A Definitive Guide to a New Reality," the guide aims to help radiation oncology professionals understand the changes outlined in the Radiation Oncology -- Alternative Payment Model (RO-APM). "We believe that the proposed alternative payment model will reshape economic realities and evolve clinical best practices for radiation oncologists," said Joshua H. Levine, President and Chief Executive Officer of Accuray. "Accuray technologies uniquely empower the clinical capabilities necessary to thrive under the proposed reimbursement changes. We are ready to help our customers understand how the RO-APM will likely impact the use of our products in their practices." The July 2019 announcement of the RO-APM outlined a progressive course toward value-based care, shifting reimbursement to prospective, episode-based payments and providing equal base-rate compensation at the tumor-site-specific level -- regardless of technique or modality, number of fractions delivered or setting of care. Among the immediately evident impacts, the episodic payment model aligns patient, provider and payer interests with a shift to delivering hypofractionated radiotherapy wherever clinically appropriate -- which should firmly establish hypofractionation as an essential treatment modality. (PRNewswire, September 19, 2019

Gencia White Paper: Take Control and Improve Quality Performance

MACRA MIPS/APM Update e-Newsletter is one of a family of free e-Newsletters providing a complimentary video presentation and regularly updated news and key resources on major health care issues such as ACOs, patient safety, pay for performance, bundled payment, readmissions, and Medicaid. To view and subscribe to other e-Newsletters go to healthcareeNewsletters.com.

HHS/CMS/CMMI Keynote Address

Adam Boehler
Senior Advisor to the Secretary, US Department of Health and Human Services; Deputy Administrator and Director, Center for Medicare and Medicaid Innovation (CMMI), Centers for Medicare and Medicaid Services, Washington, DC