Challenges, Perceptions, and Readiness of Oncology Clinicians for the MACRA Quality Payment Program

In addition to addressing the issue of the uninsured, the Affordable Care Act launched government programs to bend the health care cost curve by incentivizing clinicians to deliver high-quality care in a cost-effective manner. Among these programs is the Medicare Access and CHIP (Children’s Health Insurance Program) Reauthorization Act (MACRA) of 2015, which enjoyed strong bipartisan support when it was passed. With MACRA came the introduction of the Quality Payment Program (QPP), a 2-track program designed to enhance quality of care while improving patient outcomes and cost efficiency.¹ The 2 tracks are as follows: (1) the Merit-based Incentive Payment System (MIPS); and (2) Alternative Payment Models (APMs). Since most cancer diagnoses and deaths occur among Medicare patients,² the impact of the QPP on oncology care will be substantial. Successful implementation of the MACRA QPP requires a long-term strategic vision and a paradigm shift in US cancer care delivery models.

Oncologists have expressed legitimate concerns about meeting the MACRA QPP requirements while preserving the financial viability of their practices.⁴ Over 80% of cancer patients are treated in the community,³ underscoring the need to study barriers to successful implementation so that patient outcomes are optimized.

The Centers for Medicare and Medicaid Services’ proposed rule for the 2018 performance year of the QPP⁵ raises the annual threshold for MIPS to $90 000 and 200 beneficiaries. This will change little for oncologists, who routinely exceed these criteria and will universally participate, as evidenced by the 192 practices that voluntarily chose participation in the oncology APM, the Oncology Care Model (OCM).⁶ Therefore, we believe that the perceptions of oncologists about the MACRA QPP can provide valuable insights for all stakeholders in this historic transformation from volume-based to value-based health care.

Between November 1, 2016, and June 30, 2017, we conducted live meetings with 355 geographically dispersed oncologists and/or hematologists and practice administrators to examine 3 aspects of the QPP: program knowledge, challenges to implementation, and overall impact. Participants were surveyed using audience response technology that allowed more than 1 answer when appropriate.

In total, 31% (n = 110) of those surveyed were from OCM practices. When asked about familiarity with MACRA, 189 responded, and 4% (n = 8) stated that they had an in-depth knowledge; 9% (n = 16) said they had never heard of it; 43% (n = 81) indicated that they were somewhat familiar; and 44% (n = 84) indicated that they recognized the name but were not familiar with its requirements. Among 192 non-OCM practices, only 14% (n = 27) reported that their practice planned to fully participate in the MACRA QPP in 2017, while 15% (n = 29) attested to partial participation. When 56 non-OCM participants were asked about MIPS, only 13% (n = 7) described themselves as well prepared, while 20% (n = 11) were not prepared at all.

We subsequently assessed participants’ level of confidence regarding MACRA QPP effectiveness (Table 1). When asked if their practices were ready to bear financial risks of hospitalizations and/or emergency department costs, 75% (n = 54) of 72 respondents indicated no readiness. Potential reasons for lack of readiness were answered by 182 respondents: (1) concerns about drug costs (48%; n = 88); (2) human resource requirements (21%; n = 38); (3) lack of data transparency (18%; n = 32); and (4) technology hurdles (13%; n = 24). Responses to questions about overall MACRA QPP barriers and plans to manage them are provided in Table 2.

Despite the disproportionate representation of OCM participants in our survey, the depth of knowledge among respondents was found to be limited, raising concern that rank and file physicians may not be actively engaged in practice transformation, which may explain why fewer than one-third of respondents (n = 56) planned to partially or fully participate in MACRA in 2017, and 35% of 249 respondents (n = 88) admitted to having no strategy at all. Barriers to successful MACRA QPP implementation were mainly lack of knowledge and resources. Respondents clearly had doubts that the MACRA QPP would have a positive impact on their practices, patients, and health care in general. Some even suggested early retirement as an option.

Over 2 decades, oncologists have witnessed the failures of several quality and reimbursement programs, including the Medicare Modernization Act, SGR (Sustainable Growth Rate), and Meaningful Use. In the largest survey of community oncology practices about the MACRA QPP to our knowledge, we highlight critical gaps that need urgent interventions by all stakeholders to ensure success of the program in oncology, guarantee quality care, and mitigate chances of failure. While ongoing efforts by policy makers are commendable, our findings highlight a persistent gap that requires efforts to assure sustainability. Strategies to consider include regional educational seminars (in-person and virtual), practice-level financial counseling, frequent assessment of measured milestones to assure success, careful monitoring of patient outcomes, and impact on overall cost of care.

Corresponding Author: Chadi Nabhan, MD, MBA, Cardinal Health Specialty Solutions, Dublin, OH 43017 (chadi.nabhan@cardinalhealth.com).

Accepted for Publication: September 4, 2017.

Published Online: November 22, 2017. doi:10.1001/jamaoncol.2017.3773

Author Contributions: Dr Nabhan had full access to all of the data in the study and takes responsibility for the integrity of the data and the accuracy of the data analysis.

Study concept and design: Nabhan, Jeune-Smith, Kelly, Feinberg.

Acquisition, analysis, or interpretation of data: All authors.

Drafting of the manuscript: Nabhan, Jeune-Smith, Kelly, Feinberg.

Critical revision of the manuscript for important intellectual content: All authors.

Statistical analysis: Jeune-Smith.

Obtained funding: Nabhan.

Administrative, technical, or material support: Nabhan, Klinefelter, Kelly, Feinberg.

Study supervision: Nabhan, Kelly.

Conflict of Interest Disclosures: None reported.

Previous Presentation: This research was presented in part as a poster at the American Society of Clinical Oncology Annual Meeting; June 1-5, 2017; Chicago, Illinois.