• The Academy has analyzed the Centers for Medicare & Medicaid Services’ proposed rules for 2019, which include an amended physician fee schedule for the Merit-Based Incentive Payment System. Read our analysis below.

    Quality Payment Program highlights

    • The number of MIPS participants in the program’s first year exceeded the agency’s expectations, with 91 percent of eligible clinicians taking part. The agency seems to be countering claims that physicians aren’t buying into the MIPS program.
    • CMS is proposing the inclusion of cost episode groups in 2019. Although we helped develop a cataract cost-episode group, we remain cautious with any cost-measurement tool that CMS proposes.
    • CMS seems serious about expanding the MIPS eligibility pool to incorporate more clinician types, i.e., audiologists and speech pathologists. This might improve the bonus pool as these practitioners are less likely to have the measure expertise to be high performers.

    The agency is lamenting a lack of data to guide its policies moving forward. This is something to watch as other organizations (i.e. MedPAC) continue to make recommendations to CMS about what it should do with the Quality Payment Program, MIPS and alternative payment models.

    Expanding the MIPS pool

    The agency seems to value a larger pool of MIPS participants after a year in which thresholds for exemptions were very high, at least by Congress’ standards. Its proposal to add more practitioners to what it defines as eligible clinicians would certainly accomplish that. In addition to physicians and other current participants, the agency would add qualified speech-language pathologists, qualified audiologists, certified nurse-midwives and registered dietitians or nutrition professionals to the MIPS pool.

    It is also adding a third tier to its low-volume threshold, though it is not making changes to the existing thresholds that helped exempt many ophthalmologists.

    Small practices lose MIPS bonus points

    The Centers for Medicare & Medicaid Services is proposing cuts to the amount of bonus points small practices can earn in the Merit-Based Incentive Payment System. The agency, in its proposed 2019 Medicare physician fee schedule, would slash the five points that are currently added to final MIPS scores for small practices. The Academy fought hard for such points, which we believe helps level the playing field for ophthalmologists who primarily operate out of small practices. We’re going to fight this change before CMS finalizes the policy this fall.

    CMS proposes adding three points to the quality score to account for this change. This would amount to 2.25 points added to physicians’ final MIPS score, due to how CMS weights the quality category.

    CMS says it does not want to “mask poor performance” in the quality category, hence this change. The Academy believes, though, that this in fact puts small practices at a greater disadvantage.

    The proposal does retain several accommodations that currently help small and solo practitioners. Among these is the small-practice hardship in promoting interoperability, MIPS’ electronic health record performance category. CMS would also still provide small practices with double credit for measures in the improvement activities category.

    The Academy will remind CMS that we support these accommodations, even as we urge the agency to forgo the proposed changes to the bonus points for small practices.

    Changes to promoting interoperability category (formerly 'advancing care information')

    The Centers for Medicare & Medicaid Services in its proposed 2019 physician fee schedule suggested a number of changes that will limit ophthalmologists’ ability to secure the points needed to pass the Merit-Based Incentive Program promoting interoperability category (formerly known as advancing care information). The agency says its intent is to simplify the category. The Academy is troubled by these proposed changes, which would be a step backward from the progress made in tying EHR use to clinical care. 

    Problematic proposed changes 

    • CMS is proposing revised scoring that harkens to meaningful use’ all-or-nothing approach. Physicians would need to do all the required measures to get any points in the promoting-interoperability category. Failure to do so would net the participant zero points. The Academy vigorously opposed this approach in meaningful use for its lack of partial credit and excessive difficulty. 
    • New burdens. One proposal would require clinical information reconciliation in your EHR. Another would tie your performance to the health information exchange measure. Particularly troubling is that the send-a-summary-of-care measure would now be worth 20 percent of physicians’ available points in the category. This is something with which physicians throughout medicine have trouble.  
    • A reliance on the latest EHR certification version, which many physicians aren’t ready to meet. The proposal would force physicians to adopt the 2015 edition of Certified EHR Technology, which some vendors have yet to support.  
    • Increased requirements to get the category points that IRIS Registry participants currently receiveThese points were especially helpful last year for ophthalmologists who participate in the IRIS Registry. Physicians would be forced to show their participation in two registries, just like under meaningful use.  

    The Academy is especially dismayed that CMS is seeking comment on its intention to step back from rewarding participants in the Academy’s IRIS® Registry in this category, along with other clinical data registry participants throughout medicine. The agency wants to hear from stakeholders on whether it should eliminate all promoting-interoperability category credit for IRIS Registry participants, beginning in 2022. 

    This would jeopardize the success of the many ophthalmologists who performed exceptionally well in MIPS in 2017 because of the IRIS Registry, with 99 percent receiving some kind of bonus. 

    In a huge change, CMS is proposing making scoring for the EHR-use section objective-based. Each objective would be all or nothing.

    Changes in scoring threshold

    CMS proposes a 30-point scoring threshold for 2019. In future years, with this progress to a higher mean and median. The exceptional-performance threshold is increased to 80 points from 70.

    Score weighting

    For the 2021 payment year, the MIPS cost category is proposed to make up 15 percent of participants’ scores. This would be up from 10 percent, a level that the Academy believes is already problematic for ophthalmologists. To rebalance the categories, quality would decrease to 45 percent.

    Measure changes

    The health information exchange measures now require clinical information, including reconciliation or incorporation of received information into a medical record.

    Some topped-out measures removed

    CMS is proposing that once a measure has reached an extremely topped out status (for example, a measure with an average mean performance within the 98th to 100th percentile range), the measure would be flagged for removal in the next rulemaking cycle. This is regardless of whether or not it is in the midst of the topped-out measure lifecycle. The Academy urged CMS to adopt this policy in previous comments we submitted.

    CMS proposal would reaffirm the IRIS Registry’s sterling reputation  

    A new federal proposal would give the Academy’s IRIS® Registry a leg up in meeting Medicare’s quality-program requirements. The Centers for Medicare & Medicaid Services last week said it would like to adopt a more stringent standard for qualifying clinical data registries.   

    CMS would require approved registries to have clinical expertise in medicine and quality measure development. The IRIS Registry meets those requirements today, which is among the reasons that it is cited by CMS leaders as the gold standard for clinical data registries. Many commercial registries that lack clinical or quality measure expertise could be disqualified, beginning in 2022.   

    The IRIS Registry not only has the most expertise related to the eye care measures, it also has an unparalleled track record of enabling ophthalmologists’ success in the Merit-Based Incentive Payment System. According to preliminary data provided to the Academy by CMS, the vast majority – 91 percent – of IRIS Registry participants with integrated EHRs achieved the exceptional performance bonus in 2017 MIPS.   

    Note: This data is preliminary as CMS must still confirm what size practice constitutes a small practice for scoring and must evaluate whether practices reported through an accountable care organization or advanced payment model.  

    The IRIS Registry also offers additional qualified clinical data registry measures for participants to select from, along with many MIPS resources and other assistance. Participation in the IRIS Registry is a free member benefit for all U.S.-based Academy members and non-ophthalmologist clinicians in their practices.  

    If you have never signed up for the IRIS Registry, you can join the more 18,000 participating providers by signing up by Oct. 31 to manually report 2018 MIPS data. Providers attending AAO 2018 in Chicago can stop by the IRIS Registry booth in the Resource Center to report a MIPS improvement activity to ensure penalty avoidance under 2018 MIPS. If you have not yet integrated your EHR system with the IRIS Registry, notify us of your intent to do so now for the 2019 reporting year by emailing irisregistry@aao.org 

    Next steps

    The Academy plans to work with CMS policymakers and members of Congress to draft a final version before the rules are issued around Nov. 1.