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    Speaking Out Against Measuring “Quality”

    PQRS. For the last decade, the most maddening 4 letters in medicine. Now another 4-letter acronym—MIPS—threatens to take their place. In November, I wrote an op-ed critical of PQRS for the medical web­site KevinMD.com, titled “The Medicare Boondoggle That’s Wasting Tax Dollars and Infuriating Doctors.” It quickly went viral in the health care community, and it was clear that I’d struck a nerve. Among the many physicians who left comments or contacted me, 2 themes emerged.

    First, it was surprising to see how many doctors simply refused to participate in PQRS or EHR meaningful use programs. Second, it struck me that doctors hunger for solutions but feel powerless to effect change. Because these programs were mandated by Congress and the solutions are obviously political, medical societies like the Academy and the American Medical Association are best poised to oppose them. Hence, we should continue supporting our societies, telling our leaders that these issues bother us, and supporting medical PACs and physicians who run for office.

    What would a solution look like? I would like to see the entire quality-reporting program dismantled (PQRS has rolled over into the Merit-Based Incentive Payment System, or MIPS), and the EHR and accountable care organization requirements eliminated. There is no evidence that these govern­ment initiatives improve patient care. When a new drug is devel­oped, it must be shown to be effective before it’s approved—yet Medicare created these costly, disruptive programs without any evidence of efficacy. There’s a reason why we don’t skip over phase 1 studies and go directly to mass marketing of a drug.

    Of course, efforts to measure outcomes and quality are not going away. But these ideas should be implemented first in smaller, local markets to see if they improve care or reduce costs (think of a health system like Kaiser Permanen­te in California, for example). Seeing what works and what doesn’t in smaller settings will be not only more efficient and cost-effective but also more likely to result in changes that physicians will accept and adopt.

    Most important, physicians must become more engaged in the political process at all levels of government. Many of us continue to jump through the hoops imposed by govern­ment or insurance companies. Though these tasks annoy us, we’re generally more focused on simply making it through our busy days. However, there comes a point when govern­ment programs grow so onerous and detrimental that we, as a profession, must speak out. If we do not, we risk losing far more than a mere PQRS or MIPS payment penalty.

    Andrew Lam, MD
    Springfield, Mass.

    Response from the Academy

    The frustration you express is indeed shared by many, including the Academy. We agree that banding together in support of our advocacy efforts will help us bring about much-needed change. With Republicans in control of the White House and Congress and the appointment of Rep. Tom Price, MD, to Secretary of Department of Health & Human Services, there is a unique opportunity for simplification and for regulatory relief for physicians. Not only is the Academy helping shape the American Medical Association’s development of relief ideas, but we have also initiated our own effort.  

    These Academy advocacy efforts focus on both the new regulatory programs (primarily MIPS, which launched on Jan. 1, with your 2017 performance impacting your 2019 Medicare payments) and earlier regulatory programs, such as the Value-based Modifier (VBM) program and the electronic health record meaningful use (MU) program. Although 2016 was the last performance year for the VBM and MU programs, your performance in 2015 and 2016 will impact your 2017 and 2018 Medicare payments, respectively.

    In response to the inherently flawed approach to implementation of the mandatory VBM, the Academy will push for penalties to be substantially reduced. While not owning up to methodological problems under the VBM, the Centers for Medicare & Medicaid Services (CMS) agreed to zero out the impact for cost/resource use under the 2017 performance year of MIPS because they felt physicians needed more time to understand the program during this inaugural year. Physicians certainly didn’t understand the program in 2015 and 2016, which will lead to unfair penalties in 2017 and 2018. (With the 4% penalty from VBM, physicians will experience negative adjustments of a total of 9% and 10% in penalties in 2017 and 2018.) Claims-based quality measures such as hospital readmissions and hospitalization rates are not relevant for many ambulatory specialties. The flawed attribution methodology of the VBM assigns patients with chronic eye disease to the eye care specialist when a primary care provider sees the patient for fewer visits, yet the patient is hospitalized for chronic obstructive pulmonary disease COPD.

    While the penalty amounts for the MU program are legislatively set, this should be revisited where possible such as expanding hardship exemptions to provide additional relief for physicians from a program that has proven to be less than meaningful to physicians and their patients. Additional exemptions should be granted for 2017 and 2018.

    The Academy is the leading source of expert knowledge on eye health, so it is critical that we share our expertise with lawmakers. Effectively advocating for ophthalmology and our patients takes both a strong Academy and an even stronger grassroots program built on the efforts of our members. Get involved and connect the dots for lawmakers between the policies they write and the work you’re doing in the field. And your support of OphthPAC ensures ophthalmology has a seat at the table when policies are being discussed at a federal level.

    Editor’s note: Reducing your regulatory burden is an Academy priority. What can you do? Help the Academy in its advocacy efforts (aao.org/advocacy) and take advantage of the Academy’s MIPS reporting tools (aao.org/iris-registry/medicare-reporting).

    Continuing the Discussion on Concussion Care

    As noted in Annie Stuart’s excellent article “Concussion Care” (Feature, December 2016), the importance of related visual dysfunction is becoming increasingly apparent. Ne­glected in most concussion discussions is an evolving under­standing that idiosyncratic responses by the migraine brain are often contributory. As with headaches, slowed thinking, and sleep disturbances, postconcussion visual symptoms are similar to those occurring with migraine. These include photophobia, convergence insufficiency, accommodative insufficiency, chronically blurred vision, and vestibular migraine with vestibulo-ocular dysfunction.

    Posttraumatic headache (PTH) is the most frequent post­concussion symptom.1 PTHs are associated with a variably disabling postconcussion syndrome (PCS) in a small per­centage of those concussions that remain symptomatic for more than 1 week.2 Preinjury primary headaches represent a significant PTH risk factor. Migraine and probable migraine (as classified in ICHD-3 beta) are the most frequent pri­mary headaches identified, and there are no symptoms that distinguish trauma-triggered migraine from concussion. The presence of the migraine comorbidities of depression and anxiety are risk factors for developing persistent PTHs and PCS.3,4 Familial migraine is a biomarker for postconcussion migraine.5-9

    Researchers are beginning to find explanations for these responses in the migraine brain. Cortical spreading depres­sion is induced by brain trauma and is also the pathophysio­logic correlate of migraine aura.10,11 Nitric oxide synthase, pain-signaling molecules, and calcitonin gene–related pep­tide (CGRP) are common to the pathophysiology of both migraine and PCS.12 Possible contributory postconcussion cerebral alterations include neuroinflammation; augment­ed pain perception from malfunction of the intrinsic pain modulation system; and elevation of the level of comorbid depression, anxiety, and sleep disturbances.13 The mapping of task-specific cortical activity using brain network activation analysis is different in migraine patients who are expected to develop PTHs.14

    By including an accurate migraine history in concussion data collection, the significance of the relationship between migraine and the visual symptoms of PCS will be better ap­preciated and lead to improved concussion care. I agree with Dr. Galetta’s comment, “We need ophthalmology involved.” We may even consider prospective identification of young athletes at risk for developing more severe postconcussion symptoms due to migraine.15

    Alfred J. Cossari, MD
    Port Jefferson, N.Y.

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    1 Heyer GL et al. Cephalalgia. 2016;36(4):309-316.

    2 Morgan CD et al. J Neurosurg Pediatr. 2015;15(6):589-598.

    3 Morgan CD et al. Neurosurgery. 2014;61(suppl 1):196.

    4 Kerr HA. Pediatr Ann. 2014;43(12):e309-315.

    5 Abu-Arafeh I et al. Pain Manag. 2014;4(4):303-308.

    6 Lucas S. Characterization and management of headache after mild traumatic brain injury. 2015. www.ncbi.nlm.nih.gov/books/NBK299177/. Accessed Feb. 13, 2017.

    7 Pinchefsky E et al. Pediatr Neurol. 2015;52(3):263-269.

    8 Lucas S. Curr Pain Headache Rep. 2015;19(10):48.

    9 Lords Q et al. Sports Health. 2014;6(5):406-409.

    10 van der Veek EM et al. Neuropediatrics. 2015;46(2):116-122.

    11 Tang YT et al. J Neurophysiol. 2014;112(10):2572-2579.

    12 Daiutolo BV et al. J Neurotrauma. 2016;33(8):748-760.

    13 Ruff RL et al. F1000Res. 2016;5.

    14 Kontos AP et al. Brain Imaging Behav. 2016;10(2):594-603.

    15 Anderson K et al. Behav Neurol. 2015;2015:693925.

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