MIPS, OCM, and Weighing the Benefits of Two-Sided Risk


Journal of Clinical Pathways spoke with Richard Kane, MIPP, MA, senior director, and Josh Seidman, PhD, MHS, senior vice president, both with Avalere Health, about the intricacies of the Medicare Access and CHIP Reauthorization Act (MACRA) Merit-Based Incentive Payment System (MIPS) and the risk practices must accept when transitioning to the Oncology Care Model (OCM).

What are the benefits for practices to remain in MIPS rather than make the transition to OCM?

Mr Kane: A practice that chooses to participate in a new seamless payment model is one that is willing to take on some risk, even if the payment model itself is one-sided risk. There are costs and investments needed for that practice to strive for success under new financial arrangement. Not every practice is ready or willing to make these kinds of investments at this time, and so remaining in traditional Medicare fee-for-service, which is now the MIPS track, can make sense for these practices.  

Dr Seidman: In some ways, it is a question for practices of how much to take on and how quickly. In many cases, practices are looking for on-ramps to alternative payment models. In some ways, MIPS is taking what the practices have already been doing thus far and moving their payment systems in the direction of a value-based system. The OCM or some other alternative payment model might be the next step in that direction. So beginning with MIPS and transitioning to the OCM is certainly a way that practices can take that gradual transition towards value-based payment. 

In the near future, do you believe that more practices will begin making the switch from MIPS to OCM?

Mr Kane: Sure. Other than OCM, there are not currently any other alternative payment models where an oncology practice would be in the driver’s seat of that alternative payment model. I believe the success of OCM, or the Centers for Medicare and Medicaid Services (CMS’s) ability to refine OCM, in the coming years will play a huge role in whether more practices in Medicare join OCM or stay in MIPS.

Dr Seidman: As Dr Kane noted, there currently are not any other payment models to which practices can transition. It will be interesting to see how OCM evolves over the next few years with the influx of evaluations. There are still a number of questions remaining about how to ensure and measure quality. There will be a lot to keep an eye on with OCM in the coming years.

There is also the question as to what the new administration, or new since OCM was created, will do with regard to potential other alternative payment models and how oncologists might be part of some other kind of payment model.

In many cases, practices are realizing that under MIPS they are still unable to really drive management of care. At some point, a number of practices are realizing that the best way to maintain autonomy and control of decision making is by taking on additional risk. Practices realize that there is a tradeoff here. With additional risk comes greater autonomy, and we are increasingly seeing that practices are willing to make that tradeoff. 

How will the eventual inclusion of episode-based cost measures impact practices in MIPS?

Mr Kane: When cost measures become a larger part of the MIPS composite score, practices may find OCM to be a more appealing option. To cite a hypothetical example, for a practice with higher patient costs, the OCM could be more appealing because performance payments in OCM are designed to reward practice improvement. 

You both touched on the fact that practices are able to establish more control and autonomy when they take on additional risk. But practices are hesitant to take on more risk. In that sense, how can practices be persuaded to take on voluntary risk?

Mr Kane: Practices need to have a full understanding of how the payment model works, and the payment model needs to be designed so that it rewards what practices see as high quality, cost-efficient care. For instance, many oncologists think of treatment pathways rather than six-month episodes. When they are told that they have to measure performance based on 6-month episode costs, they are not necessarily assured that this performance-based measure is going to mesh well with how they treat their patients. I believe that there is a combination of establishing comfort and understanding on the part of the practices. There is also a challenge with CMS to make sure these payment models are designed in a way that rewards what practices see as high quality, cost-efficient care.

Dr Seidman: I believe that there is an issue here with what CMS is attempting to do. What Dr Kane just mentioned about providers thinking in terms of clinical pathways rather than episodes of care is an interesting issue because in many ways, that really is an orientation towards organizing care around the clinician’s point of view rather than around the patient’s point of view. For many patients, there is a sense that oncology care can often be disjointed, making patients often feel like they are not receiving a coordinated, holistic experience. This issue is something that OCM is designed to address. One of the questions we will have moving forward is will we have payment models that are oriented towards how clinicians have traditionally been organized or towards how patients with cancer live their lives.

Are there any other important points that either of you would like to make?

Mr Kane: I just want to reiterate that OCM is still a fairly new program and MIPS is also new. Participating practices are learning, and CMS is still learning as well. That is something to keep in mind when we determine whether one group is willing to take on risk, or one group is designing the appropriate incentives. There is definitely a big learning process on both sides.

Dr Seidman: We see this learning process in the data as well. There is more data in some of the other alternative payment models like accountable care organizations (ACOs); we see ACOs in their fourth performance year doing much better than ACOs in their first performance year. To Dr Kane’s point, that learning curve certainly exists, and attempting to change how you organize you practice, manage your care, and think about accountability for the health of the population require multiple fundamental changes. Success is going to take some time.

Furthermore, it will be important for practices to consider the optimal orientation of their team. In order to succeed under these alternative payments models, practices will have to rethink the roles of clinicians and other ancillary health professionals in serving the needs of the population. The practices that have been successful under alternative payment models have re-thought how they go about organizing care delivery.  

Dr Seidman, can you expand on your point about rethinking the roles of clinicians?

Dr Seidman: I will give you one very concrete example. When the Center for Medicare and Medicaid Innovation (CMMI) decided to test a whole series of innovations, they had these grants and they were calling the Health Care Innovation Awards (HCIAs). These particular grants were in different categories, with the only that had a significant impact on reducing cost of care being community health workers. This designation is for non-healthcare professionals that are essentially filling in gaps in the coordination of care.

Community health workers was a test from CMMI, but the general idea is rethinking how the care team is organized and making sure to go beyond simply deploying clinical expertise for the management of patient health. What practices have to do is create a system that supports the overall needs of the people that are being served.