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MACRA changes are part of volume-to-value shift


The Medicare Access and CHIP Reauthorization Act of 2015 and its Merit Based Incentive Payments System are here to stay for the foreseeable future and are likely to significantly impact reimbursement for ophthalmologists as part of a shift away from traditional fee for service medicine. In this changing landscape, eye care practitioners need to understand the basics of the system, such as reporting requirements, and begin to consider new models of care.


By Nancy Groves; Reviewed by David W. Parke II, MD

Barring any legislative action, MACRA (Medicare Access and CHIP Reauthorization Act of 2015) and MIPS (Merit Based Incentive Payments System) will continue to be part of life for ophthalmologists for years to come. While the American Academy of Ophthalmology continues to assess the goals and guidelines within MACRA and evaluate options such as alternative payment models (APMs), Academy CEO David W. Parke, II, MD, urged ophthalmologists to fully participate in the MIPS reporting program and to avail themselves of resources to learn more about its complexities.

The premise of the changes set in motion by MACRA is a shift from volume to value. “The key thing to me, and this is always worth remembering, is that value is defined as the healthcare outcomes achieved per total dollars spent on any given set of services,” Dr. Parke said.

The intent is to drive physicians out of traditional fee for service medicine through either the MIPS or APM pathway. However, APMs, particularly advanced APMs, have little to offer most specialists unless they are engaged in a large, integrated system or accountable care organization, Parke said, adding that data suggest that the vast majority of physicians will still be in MIPS for the foreseeable future. APMs have not been developed for most specialties that comply with MACRA program requirements and are clinically valid and relevant.

In 2017, the highest weighted component of MIPS was quality measurement (60%), while resource use accounted for 0% of the final performance score; clinical practice improvement activities and advancing clinical information made up the remaining 40%. However, the policy goal is for quality measurement and resource use to ultimately become the two most significant components of payment.

Dr. Parke urged physicians to report quality measures for a full year in 2018 and to report on at least two outcomes to reduce the likelihood of financial penalties and increase the possibility of a bonus. Although reporting on just one patient a year qualifies for 2018 reporting, this gives physicians no margin of error, he added, recommending more substantive participation.


Reminding physicians how much is at stake through MIPS incentives, Dr. Parke noted that the maximum adjustment factor for 2019 is ±4% based on 2017 performance, rising to ±9% in 2022 based on 2020 performance. Additional adjustments up to 10% are possible based on exceptional performance from 2019 to 2024, but “don’t count on it” was Dr. Parke’s assessment of that prospect.

While MACRA, MIPS, and APMs may seem simple, the reality is that the new system is extraordinarily complex and somewhat fluid. A few of the questions surrounding the system include who determines quality, are the metrics clinically relevant, and are they risk adjusted? Are costs correctly attributed? How is the data collected and by whom? There is still a lot of confusion about this program in the medical community, Dr. Parke said, adding that some physicians have not even heard of it.

The policy goals are to correct overvalued services, and there is also an effort to reduce physician income disparity both at a social level and within the physician community by eliminating the intensity component, re-evaluating times, and providing bonuses to underpaid specialties, largely primary care.

As to how MACRA might affect retina specialists, Dr. Parke referred to statistics for intravitreal injections in Medicare, which saw a 3500% increase over a 10-year period starting in 2005. More specifically, intravitreal injection (CPT 67028), which requires 22 minutes of physician work, is the second highest intensity payment per minute after emergency intubation. Combined Part B payments for ranibizumab and aflibercept totaled $2.5 billion in fee for service Medicare in 2015.

“These figures make intravitreal injections and Part B drugs a continued target for payment scrutiny and demand continual advocacy activity by the Academy,” noted Dr. Parke.

It’s worth asking whether MIPS is in danger despite the bipartisan support for MACRA when it was passed in 2015. The Medicare Payment Advisory Commission has suggested that physicians should move as much as possible to APMs such as accountable care organizations (ACOs) or medical homes. However, most of today’s ACOs do not have bimodal risk, Dr. Parke said.


Retina-specific advanced APMs are a theoretical option to MIPS. They required evidence of downside risk-taking-typically greater than 3% of payments-as well as critical bundle size, such as 35% of Medicare revenue and patients in 2019 and 50% in 2021. Dr. Parke said that the Academy continues to model and investigate this approach because of advantages in bonus payments but has yet to define a model which it believes is clinically applicable.

He also reminded physicians that commercial as well as federal payers are keenly interested in moving from volume to value and are exploring non-traditional payment systems including reference-based pricing, bundles, and two-sided risk arrangements.  

Facing challenges from multiple directions, ophthalmologists and particularly retina specialists have to acknowledge that their chosen specialty and subspecialty make up a very small part of the “house of medicine,” Dr. Parke said. “As we try to move the payment needle in what we consider to be the appropriate and right direction, the key thing is to work together as a whole specialty. Retina alone constitutes less than 0.3% of American physicians.”

More information about MIPS is available on the academy website.


David W. Parke II, MD

e: dparke@aao.org

This article was adapted from Dr. Parke’s presentation during Retina Subspecialty Day at the 2017 meeting of the American Academy of Ophthalmology. He does not have any relevant conflicts of interest.


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