Caroline Helwick

November 14, 2017

NEW ORLEANS  — Ophthalmologists' voices are going to be heard in Washington, DC, and the regulatory burdens that are dragging down their practices are going to be eased, Seema Verma, MPH, the new administrator of the Centers for Medicare & Medicaid Services (CMS), told attendees at the American Academy of Ophthalmology (AAO) 2017 Annual Meeting here.

In her keynote address, Verma said "regulatory burdens" is a recurring theme among physicians and it's an area in which CMS plans to make positive changes. This was music to attendees' ears. 

"If I could tell CMS one thing, it would be to 'simplify,'" Michael X. Repka, MD, the AAO's medical director for governmental affairs and professor of ophthalmology at Johns Hopkins University, Baltimore, Maryland, told Medscape Medical News.

Dr Repka and Daniel Briceland, MD, from Scottsdale, Arizona, the AAO's senior secretary for advocacy, said they have already sensed a change. "She said to bring our ideas and she will listen. We have received an invitation, and we are hopeful," Dr Briceland commented, while Dr Repka added, "I think CMS may be more doctor-friendly now. I think there is greater access and we are being listened to."

Verma began her talk by acknowledging the failures and shortcomings of the US healthcare system. "Even though we undeniably have among the world's best health care systems, that doesn't mean — as you're well aware — that it is without problems," she said. CMS has prioritized a few issues that contribute to the problems, she said, including reducing paperwork for physicians and lowering the cost of prescription medications. They will be rolling out programs intended to help.

Patients Over Paperwork

"The array of regulations that govern healthcare is overwhelming," Verma acknowledged. CMS announced last month an initiative they are calling Patients Over Paperwork. CMS will review all regulations that currently exist within CMS, and for each one it will ask following:

  • What's the purpose?

  • Is it required by Congress?

  • Does it make sense?

  • Does it help us prevent fraud and abuse?

  • Does it meaningfully impact patient care and safety or improve outcomes?

"When regulations no longer advance the goal of putting patients first, we must improve or eliminate them," Verma said.

Meaningful Measures Initiative

Also launched last month by CMS is the Meaningful Measures initiative. The purpose of this program is to review and revise quality measures across all CMS programs, including the Merit-Based Incentive Pay System (MIPS), which has numerous reporting requirements.  

"There is a financial cost to physicians of reporting an array of measures to different payers. It's also taking time away from your patients," she told the audience.

Under Verma's leadership, CMS wants fewer quality measures and ones that assess meaningful outcomes, such as documented improvement in vision after a procedure The aim is to ensure that quality measures are "streamlined, outcomes-based, and meaningful to doctors and patients," she explained. "Until we get to a smaller set of more impactful measures that assess outcomes rather than processes, the burden associated with reporting measures will run the risk of outweighing their intended purpose."

The AAO's IRIS Registry can help identify good quality measures in ophthalmology, as it has already identified many that are important to eye care providers. IRIS is also yielding the type of "big data" that will benefit patient care, she said.

Simplifying MACRA, Rethinking CMMI  

The Center for Medicare and Medicaid Innovation (CMMI) is testing a variety of alternative payment models, though Verma acknowledged that one specifically designed for ophthalmology practices has not yet been designed. CMS expects to get more creative, and it welcomes input from ophthalmologists, she said.

"MACRA [Medicare Access and CHIP Reauthorization Act] is a complex new system of paying doctors who participate in Medicare. It introduced extensive reporting requirements and more burdens. We are trying to implement it in a way that will be easier for you," she told listeners.

For example, smaller practices are now exempt from MACRA requirements, "but we need a system that is working for all providers," she emphasized. "Otherwise, this could push doctors out of the Medicare system."

Dr Repka agreed that MACRA is something of a headache and should be revised.  "I've tried to understand the MACRA program and to explain it colleagues in my own practice, and it's impossible," he told Medscape Medical News. "It's too complex. No physician wants to spend time figuring it out, so they ignore it, and yet that could have disastrous consequences in terms of penalties.

"The hope is that CMS can make the program work in an understandable fashion. The program, as it's been rolled out in the first 2 years, makes sense on a MACRA basis. It does not make sense on an implementation basis," he said.

Verma hopes to change this. "We're leading CMMI in a new direction, one that will promote flexibility and patient engagement," she said. "We recently issued a Request for Information to collect ideas on the best path forward for the Innovation Center. We're moving away from the idea that those in Washington can engineer a more efficient healthcare system. Washington is not at the center of private market innovation!"

Ophthalmologists are encouraged to suggest ideas, and the AAO intends to do so, Dr Repka said.  

Tackling Cost Concerns

Spending on prescription drugs now exceeds $142 billion in this country, accounting for more than 22% of total Medicare spending. Ophthalmologists are second only to oncologists in numbers of prescriptions written. CMS is trying to tackle the cost of these drugs through various approaches, including the following:

  • Increasing competition in Medicare Part B and Part D, as well as within the Medicaid program. The idea is to "help market forces lower drug costs," she said.

  • Encouraging the development and use of lower-cost biosimilars. Biologics will have their own payment code.

  • Modernizing payment models. One way may be through transitioning to value-based reimbursement, especially for expensive drugs, which will dictate payment based on the clinical outcomes achieved. "This requires buy-in from all stakeholders," she pointed out.

Lowering the cost of drugs will require coming at it from many angles, Verma continued. "There's not a silver bullet to controlling costs across the board." 

One thing that Verma did not address, however, was an issue of great concern to ophthalmologists: declining reimbursement for the treatment of Medicaid and Medicare patients, for which she had no predictions for the future.

Verma concluded by calling on eye care providers to offer their input about these important CMS efforts. "We know that we can't do it alone," she said. "We need your input and ideas; we need you to work with us; we need you to challenge us."

Ms Verma is employed by the US government. Dr Repka and Dr Briceland have disclosed no relevant financial relationships.

American Academy of Ophthalmology (AAO) 2017 Annual Meeting.  Presented November 12, 2017.

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