The concept of utilizing quality measurements in federal healthcare programs has been around since at least 2007, when the Centers for Medicare and Medicaid Services (CMS) implemented the Physician Quality Reporting System (PQRS), a program that offered incentives for healthcare providers to submit data to CMS on specified quality measures. The program evolved over time, and eventually became part of CMS’ Merit-Based Incentive Payment System (MIPS), which integrated different programs under 1 umbrella.
Under MIPS, healthcare providers are evaluated based on performance in 4 separate areas: quality, improvement activities, promoting interoperability, and cost. Since its introduction, many stakeholders have expressed concerns about various aspects of MIPS, and participation has lagged. Specialty care in particular has been slow to adopt MIPS as many of the measures are felt to concentrate on primary care metrics such as hypertension and diabetes management. CMS has responded by introducing MIPS Value Pathways (MVPs) to better align reporting with measures directly under specialists’ control. The organization is encouraging collaboration, so there are opportunities to advance value-based care by making the new MVPs more relevant to the care being delivered by a particular specialty. Now is the time for stakeholders to bring ideas to the forefront, so the new MVPs will provide a strong framework that will be meaningful and valuable long into the future.
Value Pathways Eliminate Silos
There are critical issues with MIPS as it is currently structured, as the categories are very siloed and allow participants to select activities purely based on performance or ease of participation. In particular, this has enabled clinicians to select their top performing measures within the quality category, “cherry picking” activities they perform well but may not be relevant to their clinical practice. For example, oncologists can report on a variety of primary care measures, such as diabetes care or controlling high blood pressure, when in fact these health conditions are typically managed by other clinicians. They also can report on measures such as breast cancer or colorectal cancer screening, which were most likely ordered by a primary care clinician and the patient received a cancer diagnosis as a result. Consequently, the information is of less value because it may not relate to the care provided by the actual clinician reporting the measure and is not a true indicator of the quality of care patients are receiving.
The intent of MVPs is to move away from siloed performance measures to a set of measure options more relevant to a clinician’s scope of practice that is meaningful to patient care. Essentially, MVPs are disease-state or specialty-specific subsets of measures connecting and integrating the 4 categories of MIPS. For example, instead of selecting quality measures where performance is high or improvement activities that are already currently fully implemented, MIPS participants will report on 1 MVP that relates to their area of practice, which may prove to be more relevant, meaningful, and impactful to patient care and the total cost of care delivery.
Originally scheduled for 2021, implementation of MVPs was delayed until 2023. CMS used the extra time to seek stakeholder input in an effort to collaborate and create value through meaningful participation. As part of the initial rollout, CMS identified 7 clinical areas of focus already highlighted in the 2022 CMS Final Rule, and more recently with the 2023 proposed rule, 5 additional measures were proposed, including the Advancing Cancer Care MVP (Table 1). CMS plans to continue expanding the development of MVPs into additional key areas as the program matures.
Oncology-Specific MIPS Value Pathway
In early 2021, McKesson, in collaboration with The US Oncology Network (The Network), submitted an oncology-specific MVP proposal to CMS for consideration and sought to collaborate with CMS and other key stakeholders to develop a meaningful MVP to drive improvements to cancer care. The Network, which represents more than 1400 independent physicians nationwide, played a vital role in gathering input for the proposal. Nearly all its recommendations were included in the recent 2023 proposed rule for the Advancing Cancer Care MVP, including 2 oncology-specific Qualified Clinical Data Registry (QCDR) measures developed through this collaboration.
The Advancing Cancer Care MVP focuses on areas known to help improve quality and cost that align across various value-based care initiatives. It empowers the care team to treat all patients with an enhanced suite of services under the value-based care umbrella, regardless of their participation in a particular program.
By prioritizing oncology-specific measures meaningful to oncology clinicians and care teams, the Advancing Cancer Care MVP evaluates measures that matter in the oncology space and does not hold clinicians accountable for healthcare issues better managed by other specialists or general practitioners. The Practice Insights QCDR developed through this collaboration has been approved by CMS for the MIPS program since the program’s inception. Seven custom QCDR measures were developed for use in the MIPS and other value-based care payer arrangements. The measures are chosen with a keen focus on improving the care of patients with cancer. These measures have been extremely valuable to oncology clinicians because they measure activities of interest to oncologists, care teams, and payers, increasing participation in quality programs and risk-based payer arrangements. Two QCDR measures are included in CMS’ proposed Advancing Cancer Care MVP: PIMSH2 Utilization of GCSF in Metastatic Colorectal Cancer and PIMSH8 Mutation Testing for Lung Cancer Completed Prior to Start of Targeted Therapy.
Nurses play a vital role in the activities included in the proposed MVP, as essentially nursing practice tends to be patient-centered, ultimately supporting the tenets of value-based care. Relying heavily on a balance of improving quality while lowering costs, value-based care attempts to reduce costs without sacrificing quality. A critical part of the equation requires that the patient remains informed and actively involved in care and treatment decisions. Consequently, the MVP prioritizes patient involvement and highlights the patient voice as essential to optimizing patient-centered oncology care. Patient-reported outcomes-based measures and activities are integrated throughout the proposal, as there is great value in measuring matters that have a direct impact on patient care, or the perception patients have about their care. This approach brings to the forefront the concept of improving patient mindsets to impact health outcomes, a promising new area of research that holds much potential for patients with cancer.
Mindsets — core assumptions a patient has about how things work — not only have a physiological impact on a patient’s experience or perception of their care, but may actually influence outcomes as well.1 Targeted psychological interventions aimed at encouraging more adaptive mindsets have the potential to transform supportive care in oncology.1 Nurses can educate patients on how much their mindset plays a role in their overall care and outcome, helping them reframe their outlook to one of having more control over their situation, potentially leading to improved outcomes.
There are many other opportunities built into the MVP for nurses to drive improvement in patient care and outcomes. For example, pain management is a measure central to the MVP and is undoubtedly a key area in all patients’ care. The World Health Organization (WHO) reports that pain is experienced by 55% of patients with cancer undergoing treatment and by 66% of patients who have advanced, metastatic, or terminal disease.2 Patients should be regularly asked about their pain, and treatment modified accordingly to reduce pain, avoid potential complications associated with pain, and improve quality of life. Typically, patients are asked their pain score upon rooming during nearly all visits. However, critical next steps to reduce elevated pain levels are often missed without careful follow-up.
Although CMS’ Advancing Cancer Care MVP includes pain assessment, The Network continues to encourage CMS to include additional measures aimed to optimize patient-centered oncology care. Patient-centered measures drive the core concepts of value-based care, where patients take an active role in care decisions and receive more coordinated, cost-efficient care focused on enhanced services and appropriate targeted treatment. One of the key areas to improving cancer care is improving pain management. This can be assessed by the Practice Insights QCDR measure that is a patient-reported outcomes measure for assessing pain improvement within 30 days. This encourages the care team to heed closer attention to those patients who may need additional follow-up or recall to the practice to ensure their pain is adequately managed. Patient detail reports, along with targeted worklists available through the QCDR, can serve as useful tools for identifying patients with elevated pain levels who require additional outreach and intervention. The worklists also serve as a tool for care team huddles, flagging patient charts for follow-up, or implementing post visit check-ins with high-risk patients.
The QCDR quality measure for pain improvement can help clinicians assess the effectiveness of their pain management practices, as well as benchmark their performance against their peers.
Another common thread within the Advancing Cancer Care MVP is the importance of advance care planning (ACP). Central to this is ensuring patients with advanced disease have meaningful discussions about their cancer treatment and end-of-life care so decisions are based on the patient’s wishes. Although all patients should have ACP discussions, The Network continues to encourage CMS to expand the MVP to include a QCDR quality measure to ensure that ACP discussions occur for patients with metastatic disease within 6 months of diagnosis. Along with this, several improvement activities support implementing workflows that prioritize ACP discussions for these higher-risk patients. Prioritization of these patients’ values and wishes is critical, especially during advanced disease.
A Path Forward
The new MIPS Value Pathways, and CMS’ support of stakeholder collaboration, present an opportunity for oncology care providers to continue to engage in value-based care. For oncologists, the new MVP approach represents an opportunity for oncology care teams to participate in the MIPS program and to be assessed on a core set of measures and activities that are meaningful and relevant to the care they deliver.
A successful oncology-specific MVP that will have the most value is one that is patient-centric and designed to help patients efficiently navigate their often-complex cancer journey. Undoubtedly, oncology nurses will play a key role, as their many contributions are critical to the holistic approach necessary for value-based care to thrive.
- Zion SR, Schapira L, Crum AJ. Targeting mindsets, not just tumors. Trends Cancer. 2019;5(10):573-576. doi:10.1016/j.trecan.2019.08.001
- WHO Guidelines for the Pharmacological and Radiotherapeutic Management of Cancer Pain in Adults and Adolescents. Geneva, Switzerland: World Health Organization; 2018. Accessed June 14, 2022. https://www.who.int/publications/i/item/9789241550390