MACRA changes deemed likely to survive new administration

Ophthalmologists are likely to continue grappling with changes brought about by the Medicare Access and CHIPS (Children’s Health Insurance Program) Reauthorization Act (MACRA) under the administration of President Donald J. Trump, according to Ruth D. Williams, MD.

While Trump’s promise to repeal the Affordable Care Act and replace it with “something much better and much less expensive” has attracted a lot of headlines, other recent regulations affect ophthalmologists much more, said Dr. Williams of the Wheaton Eye Clinic, Wheaton, IL, at the Glaucoma 360 21^st annual Glaucoma Symposium.

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“I don’t think the ACA is the most important thing that’s changing the way we practice medicine,” she said. “The most important thing is the integration of large healthcare systems. If the ACA goes away, we’re still going to have these large healthcare systems and we function within them.”

Also, she pointed out, MACRA significantly altered requirements for physicians to be reimbursed under Medicare, and it’s not clear whether the new administration will seek changes in it.

In October 2016, President Obama’s nominee for secretary of the U.S. Department of Health and Human Services, Rep. Tom Price, MD (R-GA), expressed skepticism of the final rule for MACRA.

More from Dr. Williams: Value-Based Payment program presents potential ramifications

“We are deeply concerned about how this rule could affect the patient-doctor relationship, and I look forward to carefully reviewing it in the coming days,” said Dr. Price in a prepared statement.

Dr. Williams pointed out that MACRA passed with bipartisan support in both houses of Congress, including a 392-37 vote in the House of Representatives.

She added that no one is eager to return to the regulations for Medicare reimbursement. These included a tangle of quality-reporting requirements and the Sustainable Growth Rate, which caused physicians to constantly lobby Congress for modifications.

So for now, ophthalmologists should work under the presumption that major provisions of MACRA will remain in place, she said.

That means understanding MACRA’s underlying agenda: shifting reimbursement models from volume to value. The principle tools for that shift are Merit Based Incentive Payment System (MIPS) and Alternative Payment Models (APM).

Under one alternative payment model, physicians ophthalmologists participate in groups of healthcare providers known as accountable care organizations (ACOs). These groups in turn may participate in shared savings programs under which practices are allowed to keep some of the savings to Medicare by reduced billing.

Medicare Shared Savings program, MIPS

“You might be in a Medicare Shared Savings program ACO,” Dr. Williams said. “You might be contracted into one. And if you are, your quality reporting is through the ACO and the rules are very complicated. You still have to do MIPS but there may be a blended reporting requirement.”

Medicare Shared Savings is one example of a trend for Medicare and other payers to shift financial risk to physicians, Dr. Williams said.

MIPS does not affect ophthalmologists much in its current form, but “since the agenda is there,” ophthalmologists should understand it, Dr. Williams said.

Under MIPS, physicians could receive bonuses or penalties up to 4% of their Medicare reimbursement. This compares with bonuses or penalties that could range as high as 27% under previous regulations, Dr. Williams said. “So this is a much less onerous system.”

In its current configuration, MIPS awards 60 points for quality reporting in a system similar to the physician quality reporting system (PQRS) used before MACRA. 

It awards up to 25 points for electronic health records in a program known as “Advancing Care Information (ACI)” which takes the place of “meaningful use.”

And it awards up to 15 points for clinical practice improvement activities (CPIA).

(A fourth category, resource use, was eliminated because the Centers for Medicare and Medicaid Services (CMS) couldn’t find workable standards, said Dr. Williams.)

Quality reporting is “super easy in 2017,” Dr. Williams said.

Currently, physicians need only report on a single outcomes measure to get the full 60 points. Still practices may benefit by reporting more outcomes measures to gain a better understanding of the system, she recommended.

Practices have to report quality measures on at least 50% of their Medicare patients, and they must have at least 20 patients. They are only required to report for 90 days. But Dr. Williams has asked Wheaton Eye Clinic physicians to report for a whole year on 7 outcomes measures.

Mechanisms for reporting to MIPS vary depending on the way practices track data.

“The most elegant way” is to integrate electronic health records with the American Academy of Ophthalmology’s Intelligent Research in Sight (IRIS) registry, Dr. Williams said.

But it’s also possible to report through an electronic health records vendor.

Requirements for electronic health records are simpler than they were under meaningful use, and CMS is allowing practices to apply for exceptions to the requirement, she said.

Daunting regulations

These regulations can sound daunting, but “I’m not discouraged at all by all these changes,” Dr. Williams said.

She remembers physicians bemoaning the Resource-Based Relative Value Scale (RBRVS) when it was instituted.

And she pointed out that the American Medical Association opposed the creation of Medicare altogether.

“Physicians thought it would the end of the universe, and Medicare was actually really good for ophthalmology particularly,” she said.

The future is bright for the profession, she concluded.

“We all know the aging demographic,” she said. “We’re going to have more work than we can handle. And our real job is to take care of the growing deluge of patients coming through.”