Nagging Questions About Government Plans for Ophthalmology

Laird Harrison


April 14, 2016

In This Article

Rewarding Outcomes Instead of Treatments

MACRA takes the place of the Sustainable Growth Rate (SGR) formula that limited Medicare's growth in spending on physician reimbursement to the growth in the nation's gross domestic product. Though Congress suspended enforcement of the SGR every year, the threat of these cuts had hung over physicians' wallets since 1997.

Through MACRA, Congress and the president are trying a different approach to cost efficiency through "value-based" payments. The idea is that the traditional model of paying physicians a fee for service encourages overtreatment. The new models are meant to reward outcomes instead.

The idea isn't a new one. For years, providers treating patients through Medicare have faced penalties and bonuses aimed at encouraging them to:

  • Report data about outcomes through the Physician Quality Reporting System (PQRS);

  • Improve care and control costs through the Value-Based Payment Modifier; and

  • Make "meaningful use" of electronic health records (EHRs).

These programs have always posed problems for ophthalmologists, says David Glasser, MD, a spokesperson for the American Academy of Ophthalmology (AAO) and assistant professor of ophthalmology at Johns Hopkins School of Medicine in Baltimore, Maryland. For example, physicians who have signed contracts with accountable care organizations (ACOs) could be penalized if the organizations don't report PQRS data. "It can be complicated in a large practice," he says.

And the EHR initiative has flopped, as far as Dr Glasser is concerned. "The requirements for successful attestation are increasing," he says. "The number of physicians successfully attesting is decreasing. And there is no evidence for improved outcomes."

One problem is that competing EHRs are often incompatible, he says. If doctors in the same ACO don't have complete records on the same patients, updated in real time, because their EHRs can't exchange data on those patients, cost-effective patient care is difficult to achieve.

But ophthalmologists still struggling to go digital may have some breathing room, Dr Glasser says. "Medicare did not announce [the latest] requirements for meaningful use until late last year," he says. "The year was more than three-fourths over when the requirements were announced, so they liberalized the ability to claim a hardship exemption. We think anyone who asks for it has a good likelihood of getting it."

Then in January, CMS Acting Administrator Andy Slavitt said that the meaningful-use program would likely be retired this year. Why? Because MACRA, which stresses merit-based incentive payments and alternative payment models like ACOs, needs a new streamlined regulatory approach, he said, without offering any details.[1] Stay tuned.

Problems Ahead for Some Ophthalmologists?

Starting in 2019, CMS will roll PQRS, the Value-Based Payment Modifier, and the EHR requirement (or whatever replaces it) all into one program: the Merit-Based Incentive Payment System (MIPS). Under MIPS, CMS will give physicians a composite score according to quality, resource use, clinical practice improvement activities, and (for the time being) meaningful use of EHRs.

On the basis of their MIPS score, CMS will impose 4% penalties for those who fall short of its standards or pay 4% rewards for those who exceed them. The penalties or rewards will rise each year for 5 years, reaching 9% in 2022.

For at least some ophthalmologists, MIPS could pose problems if the system does not make fine-enough distinctions among the types of patients and conditions being treated.

"I think retina doctors are vulnerable under MIPS," says Geoff Emerson, MD, PhD, a retina specialist at the Retina Center in Minneapolis, Minnesota, and a spokesperson for the American Society of Retina Specialists (ASRS). "Retina doctors tend to use more resources than other specialists because of these high-cost drugs."

Details on how MIPS awards and penalties would actually be applied, and to whom, are pending. But the AAO is hoping to make life easier on ophthalmologists through its Intelligent Research in Sight (IRIS) registry. Ophthalmologists enter data on their own outcomes into this database, and they can compare their practices with AAO member benchmarks.

IRIS can already automatically extract and submit data for PQRS measures to CMS on a practice's behalf, and the AAO hopes that ophthalmologists will be able to use IRIS to comply with the new MIPS requirements as well.

"The registry does what all of these other programs are supposed to do, which is improve quality," says Dr Glasser.


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