Medicare Payment Changes Make it Easy to Avoid Penalties

Marcia Frellick

October 16, 2016

CHICAGO — Changes to the rule that overhauls physicians' pay under Medicare, announced two days ago, mean that the vast majority of ophthalmologists will not incur penalties in 2017 and 2018.

"It will be hard to get penalized," said Michael Repka, MD, from the Johns Hopkins Wilmer Eye Institute in Baltimore, who is clinical spokesperson for the American Academy of Ophthalmology (AAO).

Ophthalmologists have been waiting for the Medicare Access and CHIP Reauthorization Act of 2015 (MACRA) final rule, because a large percentage of their patients are enrolled in Medicare.

"When 65% or so of your practice is in this program, you need to care about the details, and a penalty would be an important percentage," Dr Repka told Medscape Medical News.

The Quality Payment Program (QPP) will be used to shift Medicare reimbursement from fee for service to pay for value. Of the two QPP tracks, the Merit-Based Incentive Payment System (MIPS), which combines three current incentive programs, is the most pertinent to ophthalmologists.

The final rule establishes a threshold for quality-improvement measures. Above that threshold, you get a bonus; below that threshold, you incur a penalty.

Every physician can find something they can do to avoid the penalty.

It was anticipated that the threshold would be a score of about 50 or 60; instead, it is a score of 3 on a 100-point scale. "Basically, if you do any one thing — you don't have to do it right, you just have to do it — you will get enough points to not get a penalty," Dr Repka explained. "Every physician can find something they can do to avoid the penalty."

It is important to remember this is a transition period. It is likely that the Centers for Medicare & Medicaid Services (CMS), which issued the rule, realized physicians would not be ready for a monumental change in 60 days, he explained.

"The bill is still coming, it's just delayed," he said. "The penalties are still in play, and they're even higher in the next measurement year."

According to an AAO alert sent to members, the lower threshold will last through 2018.

"We anticipate making proposals on the parameters of this second transition year through rule-making in 2017," the academy stated.

The final rule comes with a long to-do list, and many of the items "don't make common sense," Dr Repka said. "Some things will appear to not really advance care."

It's very reasonable to expect that the principles of MACRA will extend into the commercial space.

The changes currently pertain only to Medicare fee for service, David Parke II, MD, chief executive officer of the AAO, explained during a press conference here at the AAO 2016 Annual Meeting. However, soon commercial payers and Medicare Advantage will likely move to the value-based payment system.

"It's very reasonable to expect that the principles of MACRA will extend into the commercial space and into the Medicare Advantage space because, ultimately, employers and the patient community are expecting that outcomes of care and control over costs will be a part of the payment system," he said.

Ophthalmologists who use the IRIS Registry will have a leg up when it comes to the new payment model, said David Glasser, MD, assistant professor of ophthalmology at the Johns Hopkins School of Medicine in Baltimore, who is chair of academic health policy at the AAO.

The registry can connect with electronic health records (EHRs) and automate data collection. All the data captured from outpatient visits can be fed into the quality-improvement and the clinical-practice-improvement portions, and "can even earn bonus points for the EHR advancing-care-information portion of the MIPS program," Dr Glasser explained.

The next step in the transition to value-based payment will be determining how ophthalmologists can take the non-MIPS Alternative Payment Models (APM) pathway, Dr Repka said.

"That's the pathway CMS really wants doctors in," he reported. "This MIPS program is not meant to be the final place, but currently there are no options for ophthalmologists in the APM pathway."

Dr Repka and Dr Glasser have disclosed no relevant financial relationships. Dr Parke reports receiving consultant fees from the OMIC-Ophthalmic Mutual Insurance Company.

American Academy of Ophthalmology (AAO) 2016 Annual Meeting. Presented October 15, 2016.


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