• The Centers for Medicare and Medicaid Services has published its finalized policy for how it will implement Medicare’s new physician payment system. This policy, released Oct. 14, is a requirement of the Medicare Access and CHIP Reauthorization Act of 2015, known as MACRA, the law that repealed the sustainable growth rate formula in 2015. Key details:

    • New Medicare physician payment system takes effect with physician reporting beginning Jan. 1, 2017, to affect 2019 payments.
    • CMS accedes to advocacy led by the Academy and others to provide simplified program and first-year flexibility via the “Pick Your Pace” initiative.
    • Academy members have access to ophthalmology’s best resources for understanding the program, preparing for transition and succeeding in its requirements: aao.org/medicare.
    • AAO 2016 features a comprehensive program of live-learning opportunities at AAO 2016 for physicians and their practice management staff.
    • The Academy will host a live webinar on Nov. 18 to help you and your practice understand what your next steps are.

    Background

    The rule formally establishes the Quality Payment Program, a system that emphasizes quality of care over volume of services. The system goes into effect with physicians reporting in 2017. It will impact your payments beginning in 2019. The program features two pathways for physicians: the Merit-Based Incentive Payment System and advanced alternative payment models. For 2017, most ophthalmologists will likely use the Merit-Based Incentive Payment System, Medicare’s new fee-for-service option.

    Physicians Can Easily Avoid Penalties Under ‘Pick Your Pace’ Initiative

    Months of Academy advocacy for simplified requirements to ease the transition to the new system netted a major win for physicians. CMS developed the “Pick Your Pace” initiative to help physicians avoid penalties, or in some cases, qualify for bonuses with a minimal amount of reporting.

    • This increased flexibility lets physicians completely avoid a penalty for 2019 by reporting on a single measure or clinical practice improvement activity.
    • Physicians who want to earn a bonus can qualify by reporting on a 90-day period at any point in 2017.

    The Academy pressed for such changes as a means for enabling all ophthalmologists, including those in small practices, to avoid the 4 percent financial penalty in 2019, which stems from the first year reporting year of MIPS.

    MIPS Still the Likely Pathway for Ophthalmologists

    Under the MIPS fee-for-service option, CMS measures physician performance in four categories: quality, which replaces the Physician Quality Reporting System; advancing care information, which replaces meaningful use; clinical practice improvement activities; and resource use.

    In 2017, each category is weighted as follows:

    • Quality – 60 percent
    • Resource use – 0 percent
    • Advancing care information – 25 percent
    • Clinical practice improvement activities – 15 percent.

    Beyond 2017, these numbers will likely change.

    CMS also significantly increased its low-volume threshold to exempt from MIPS providers whose Part B billing charges are less than or equal to $30,000 annually, or see fewer than 100 Medicare Part B beneficiaries. This will exempt more than 30 percent of physicians and other clinicians from the program.

    Problematic Resource Use Category is Neutralized

    Of the four categories in the Merit-Based Incentive Payment System, resource presented the most difficulty for ophthalmologists. The Academy believes its measures are unfair to subspecialists because it compares them with comprehensive ophthalmologist. CMS has neutralized any anticipated issues with this measurement category by weighting resource use as 0 percent of physicians’ overall score in the program’s transition year.

    This 0 percent weight won't last, and is slated to increase in future years. The Academy will work to compel CMS to delay this increase until the agency can develop more appropriate ways to measure cost – especially for surgical specialties like ophthalmology.

    For informational purposes, CMS will provide ophthalmologists with feedback for performance in lens and cataract episodes, but this data will not impact your score.

    Reduced Thresholds in Quality Category, but Still No Measures Groups

    Despite the Academy’s ongoing objections, CMS eliminated measures groups as possible reporting options, including those for cataracts and diabetic retinopathy.  However, CMS lowered the patient reporting thresholds -- a positive development for ophthalmology. Rather than requiring physicians to report quality measures on 80 or 90 percent of their applicable patients, as previously proposed, CMS will require physicians to report on 50 percent. The agency also finalized its proposal requiring physicians to report on six quality measures in order to receive full credit in this category. This requirement applies to providers who wish to be eligible to earn a larger bonus in 2019.

    EHR Use Requirements Reduced in Advancing Care Information Category

    The Academy celebrates several changes made to advancing care information by CMS. These changes, which are intended to reduce the burden for providers, include reducing the number of required measures from 11 to five. The agency is also made several difficult-to-reach measures optional. For example, the measure requiring patients to download or transmit their health data using an online portal is now optional.

    In another significant victory for Academy members, CMS removed the computerized provider order entry measure. This measure requires physicians to use an EHR to order medication, labs and imaging tests. The requirement has traditionally been problematic for ophthalmologists because it included office imaging tests, such as optical coherence tomography, or OCT. It also required offices to have their medical staff certified, with practices shouldering the financial burden. By removing this measure, practices no longer face this requirement for practices.

    In addition, CMS increased the amount of credit physicians can earn for electronically participating in the Academy’s IRIS Registry. Participants in ophthalmology’s clinical data registry can now be credited for 5 percent of total advancing care information initiatives. Previously, they would earn only one bonus point.

    Big Gains for Small Practices in Clinical Practice Improvement Category

    The Academy is heartened by CMS’ reduction of the required number of clinical practice improvement activities on which providers must report. Small practices with 15 or fewer clinicians can report just one activity to earn full credit for this category. Those in larger practices must report on two high-weight activities or four medium-weight activities to be eligible for a larger bonus.

    CMS also finalized a simplified attestation approach for this new category. As a result, several of the approved activities appear to be attainable for most ophthalmologists. Participants in the Academy’s IRIS Registry will find their use of ophthalmology’s clinical data registry will count for several activities.

    Alternative Payment Models Remain Unlikely Option for Ophthalmologists

    CMS includes additional models as “advanced” alternative payment models, but most remain unlikely options of for our profession. As a result, the Academy continues to believe that MIPS will be the pathway for the majority of ophthalmologists in the first year of the program.

    CMS’ additions include the Medicare Accountable Care Organization Track 1 Plus (1+) for 2018. This brand-new model will have limited down-sided risk, softening a previous requirement that physicians assume greater financial liability. The agency may also reopen applications for current alternative payment models, or modify current options, such as the Maryland All-Payer Model and the Comprehensive Care for Joint Replacement model. CMS will release a finalized list of advanced alternative payment models by Jan. 1.

    The agency also says it still does not consider Medicare Advantage as a potential advanced APM. It will, however, consider Medicare Advantage plans as other payer advanced APMs.

    Next Steps

    The Academy will provide its community of U.S. members with the resources you need to succeed in this new program. We’re updating aao.org/medicare with new analysis, new resources and helpful information.

    • We’re also holding a live webinar on Nov. 18 to help you and your practice understand what your next steps are. Plan to attend this important online event, which will feature analysis and a question-and-answer session with the Academy’s physician leaders and health policy experts.
    • AAO 2016 attendees can take advantage of numerous live-learning opportunities in Chicago. This is a timely and unmatched opportunity to participate in the most comprehensive live programming and resources created specifically for the ophthalmology profession on Medicare’s new physician payment system. Policy, coding, compliance and practice management experts will lead several presentations explaining the various Academy tools and resources member ophthalmologists and their practice management staff have at their disposal to ensure a successful transition to the system

    The Academy will also use the agency’s 60-day comment period to continue our push to refine any policies that need adjustment, with support for ophthalmologists at the forefront of our advocacy.

    Resources