• Opinion

    How to Avoid Death by a Thousand Cuts

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    Ruth D. Williams, MD

    By Ruth D. Williams, MD, Chief Medical Editor, EyeNet

    My retina colleague, Mark Daily, recently compared our many reimbursement decreases to a notorious ancient form of punishment, “death by a thousand cuts.” In his 1895 memoir, The Peoples and Politics of the Far East, Henry Norman described such an execution and noted that this penalty was reserved “for culprits who commit triple murder and for parricides.”1 Ophthalmologists have suffered multiple reimbursement cuts, not for committing terrible acts but while providing high-quality eye care.

    Recent reimbursement decreases include the automatic 2% sequestration cut initiated in 2013. Cataract surgery reimbursement was reduced by a dramatic 13.6% in 2013. This year retina and glaucoma services were unfairly slashed, as CMS implemented significant cuts beyond those recommended by the Relative Value Scale Update Committee (RUC), and several of these procedures are slated for even more cuts in 2017. Many physicians were hit with the Value-Based Modifier (VBM) penalty, and 40% of practices with 10 or more physicians got a double whammy this year: 2% penalty for failing PQRS, which is a prerequisite for the VBM (a further 2%-4% cut).

    While these accumulating reimbursement cuts are discouraging, the news is not all dismal. Some practices gained an increase in 2016, as a result of performing well on the VBM—for example, a number of ophthalmology practices received an increase up to 16%. How can your practice capture an increase in Medicare rates instead of constant decreases?

    CMS’ evolving quality program, the Merit-Based Incentive Payment System (MIPS), provides an opportunity for a payment uptick. This new quality and value program, to be implemented in 2019 (based on 2017 data), represents the evolution and consolidation of existing programs, including the PQRS, meaningful use (MU), and VBM. As a central component of the Medicare Access and CHIP Reauthorization Act of 2015, MIPS became the principal pathway forward for fee-for-service Medicare. MIPS differs from the current PQRS and MU programs in that penalties or bonuses are not meted out on an all-or-nothing basis, but are on a continuum, and each physician will be given a score from 0 to 100. Ophthalmologists can earn ±4% in 2017 (reflected in the 2019 fee schedule) and up to ±9% in 2020 (in the 2022 fee schedule). Because the MIPS program is revenue neutral, there will be winners and losers in the quality game.

    Here are some things you can do now to improve your chances of a reimbursement increase under MIPS.

    • First, and most important, every ophthalmologist must pass PQRS, which is a requirement for obtaining the VBM. While both are not part of MIPS, the new program will have similar processes.
    • Second, practices should commit to the process of quality measurement and reporting. MIPS, or its next iteration, is the future of reimbursement.
    • Third, practices should continue to refine internal administrative processes related to quality reporting, MU, and efficiency. While MIPS will not be implemented until 2019, now is the time to work on improving these processes, since the data collection begins in 2017.
    • Fourth, every practice should cultivate at least one ophthalmologist and one staff member to be MIPS experts. The proposed MIPS rule, published April 27, includes Quality Reporting (formerly PQRS), Advancing Clinical Information (formerly MU), Clinical Practice Improvement Activities (new), and Resource Use. Every practice needs to know these regulations, which are due to be finalized by November.
    • Finally, the IRIS Registry is a powerful tool for reporting and improving quality and for simplifying the process.

    MIPS doesn’t need to be a painful “death by a thousand cuts.” Although the details are pending, it will provide an opportunity for a real payment increase. We must make a sustained commitment to quality reporting, efficiency, and the technology of data sharing. We do not have a choice.


    1 Norman H. New York: Scribner’s; 1895: p. 225.