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Value-Based Reimbursement

MIPS & Oncology Care Model APM

Community-based cancer care is the most cost-effective setting for Medicare and its beneficiaries and The US Oncology Network continues to engage with the Centers for Medicare & Medicaid Services (CMS) in developing new value-based payment methods for cancer care.

Radiation Oncology Model

On July 10, the Centers for Medicare & Medicaid Services (CMS) and the Center for Medicare and Medicaid Innovation (CMMI) announced a proposed Radiation Oncology (RO) model that would test whether prospective, site neutral, episode-based payments to physician group practices (PGPs), hospital outpatient departments (HOPD), and freestanding radiation therapy centers for radiotherapy (RT) episodes of care would reduce Medicare expenditures while preserving or enhancing the quality of care for Medicare beneficiaries. The proposed RO Model would test the cost-saving potential of prospective episode payments for certain RT services furnished during a 90-day episode and whether shorter courses of RT would encourage more efficient care delivery and incentivize higher value care. The RO Model would qualify as an Advanced APM and a Merit-based Incentive Payment System (MIPS) APM for the Quality Payment Program. The five-year model is currently projected to begin either January 1, 2020 or April 1, 2020, and end December 31, 2024.

The Network submitted comments in response to the proposed RO model, stating, “For years, The Network has advocated for an alternative payment model (APM) to promote quality outcomes and provide payment stability in RO…However, our analysis of the RO model, as currently proposed, has identified significant flaws in the Base Rate calculation, and we believe it would add material financial and administrative burden on participating practices.” The letter provides several recommendations to CMS for ways to improve the model.

To read The Network’s comment letter and to learn more about the proposed RO model, click the links below:

Oncology Care Model

The US Oncology Network is committed to working with CMS to enhance the delivery of cancer care and protect patient access to high‐quality care in the most efficient manner. This dedication is demonstrated by the 16 oncology practices within The Network, encompassing roughly 900 providers, that are participating in CMS’s Oncology Care Model. These practices have accepted the challenge of participating in the pilot with the shared goal of improved patient outcomes and cost savings for the Medicare program. Network practices have embraced innovation in both treatment options and care delivery, and are actively working to transition to value based care.

Part B Drug Spending and MIPS

Many community oncologists also participate in the Merit-Based Incentive Payments System (MIPS) – a program created under the Medicare Access and CHIP Reauthorization Act of 2015 (MACRA) that rewards physicians with bonuses for providing quality care and penalizes those who perform poorly. While MIPS’ goals are laudable, the system has presented physicians with numerous burdens that have hindered their ability to provide quality care.

One such burden has been the inclusion of Medicare Part B drug spending in the calculation of MIPS payment adjustments. In its 2018 Quality Payment Program final rule, CMS announced that it would begin to impose these payment adjustments to Part B drug payments in addition to physicians’ services under the Medicare fee schedule, a significant departure from past policy.

Including Part B spending in MIPS adjustments would have created substantial volatility for community oncologists, some of whom could have seen their reimbursements fluctuate by as much as 29% by 2020 according to an analysis from Avalere Health. And, because the physicians working in hospitals and hospital outpatient settings would be exempt from MIPS, this policy change would create an uneven playing field between settings of care. Furthermore, the including Part B spending in MIPS would only exacerbate the financial problems of small and rural providers who already shoulder the significant financial burden procuring and administering expensive Part B drugs.

Thanks to the advocacy efforts of The US Oncology Network and other cancer community stakeholders, Congress excluded Part B drug spending from MIPS adjustments as a part of a February 2018 spending agreement.

Additional Resources