Planning a patient’s oncology care has become more complex in the value-based era.

Hospitals need to know which insurance carriers and plans patients have, obtain the appropriate pre-authorizations and submit timely utilization reviews; but they must also know which reimbursement model will govern the course of care.

Is this a fee-for-service situation? Is it an Advanced Alternative Payment Model (APM) scenario? Are there Merit-based Incentive Payment System (MIPS) eligibility requirements to consider?

Physicians and healthcare executives alike must balance requirements for an increasingly dizzying array of fee structures.

Although momentum continues to shift toward value-based reimbursement models, under the Medicare Access and CHIP Reauthorization Act (MACRA), fee-for-service plans and APM plans will continue to exist side-by-side for the foreseeable future. Here’s a look at the landscape, which is evolving.

MIPS vs. APMs

MIPS and APMs form the two main branches of MACRA’s tree.

MIPS combined existing Medicare fee-for-service models, streamlined three reporting programs (the Physician Quality Reporting System, the Value-based Payment Modifier Program and Meaningful Use) and devised a carrot-and-stick system for incentivizing performance.

Providers can chose to participate in MIPS as individuals, or as members of groups.

Beginning in 2017, MIPS-eligible physicians who choose not to participate in its reporting structure faced negative Medicare payment adjustments that will be assessed in 2019.

Physicians who elect to participate in APMs can be exempted from MIPS reporting. That in and of itself is a strong incentive.

They can potentially also earn far more in performance-based incentive adjustments (although these are capped at 20%) and can back out at any time (although they would then once again become subject to MIPS).

On the downside, APM-aligned physicians assume more financial risk: they accept full accountability for controlling and reducing the costs of care they deliver.

So, MIPS offers less financial risk and less financial reward, but comes with complex reporting burdens. APM participation comes with a large amount of financial risk, but reporting burdens are reduced and reimbursement bonuses are more robust.

And, it’s important to note, both MIPS and APM are specific to Medicare; other, private payers may have their own value-based reimbursement systems that come with their own reporting and incentive structures.

Oncology-specific value-based reimbursement models.

MACRA’s APM track includes two programs that are specific to cancer care.

The Oncology Care Model (OCM) focuses on episodic cost reduction and and care coordination among provider groups.  It ensures accountability for chemotherapy administration and care navigation.

The Oncology Medical Home (OMH) program, on the other hand, is a bit more holistic in its approach. It centers care on an interdisciplinary, physician-led care team that provides coordinated services across the entire spectrum of cancer treatment.

Both programs aim to reduce variability in treatment, cost and care coordination by giving specific, program-aligned objectives to all the providers who participate in them.

Essentially, they streamline clinical decision-making in oncology (which has historically exhibited wide inter-provider variances in course and cost of care).

In doing so, they seek to standardize the course of care to the point that apples-to-apples cost comparisons can be made between providers, to measure their value and performance.

Alignment and decision-making support are critical to your practice’s success.

Most providers now participating in value-based care models are implementing, or seeking to implement, support pathways for clinical decision-making.

These seem to be crucial to achieving the value-based performance thresholds necessary to avoid reimbursement penalties and/or financial losses.

And, the more streamlined decision-making becomes, the less likely providers are to get caught up in the pitfalls of poor reporting.

Oncology practices should make sure that they take time to consider all the value-based options available to them.

Once a program is chosen, executives and physicians need to ensure that they mutually understand its requirements and goals, that they’re working together to invest in the tech and infrastructure that will be necessary to achieve success, and that they’re well-aligned going forward.

Without such alignment, patient outcomes are likely to suffer. And improving patient outcomes is, after all, the overarching reason for the shift toward value-based care.