Value-Based Payment program presents potential ramifications

Ophthalmologists need to prepare their practices for the Value-Based Payment (VBP) program for Medicare services. VBP is a strategy to promote quality and value of health care services, with providers being paid based on value-of-care-delivered rather than volume. Regardless of the perspectives, the fact remains that reimbursement can increase or decrease substantially with the VBP program.

Now is the time for ophthalmologists to take a leadership role and become engaged in preparing their practices for the forthcoming Value-Based Payment (VBP) program for Medicare services, said Ruth D. Williams, MD.

Dr. Williams explained that according to purchasers, VBP is a strategy to promote quality and value of health care services. In short, providers will be paid based on value-of-care-delivered rather than volume. However, she presented other more cynical views, including the idea that VBP is a way of cutting physician reimbursement under the guise of talking about quality. She outlined these concerns during the Glaucoma Symposium CME at the 2016 Glaucoma 360.

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Regardless of the perspective, the fact remains that reimbursement can increase or decrease substantially with the VBP program. That underscores the need for ophthalmologists to listen and learn so they can gear up and reap an increase in Medicare reimbursement. 

“You can play the quality game,” said Dr. Williams, who is in private practice in Wheaton, IL. “Although the reality part of my brain tells me it is getting harder and harder to be in an independent practice, I am confident that we will be able to make the necessary adjustments and continue to do well. The optimist’s view is that the new program is a venue for refining quality care and modeling how ophthalmology services can be provided in this era of complex health care delivery.”




Specific timelines for moving Medicare reimbursement from fee-for-service into VBP were announced in January 2015. A few months later, President Obama signed the Medicare Access and CHIP Reauthorization Act of 2015, which was celebrated by physicians because it eliminated the Sustainable Growth Rate. Overlooked in the excitement, however, was that the Merit-Based Incentive Payment System (MIPS) replaced the Sustainable Growth Rate.

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MIPS packages together the Physician Quality Reporting System (PQRS), Meaningful Use (MU), and Value-Based Modifier programs with a new and yet to be fully defined entity known as “Clinical Practice Improvement Activities.” Based on the four programs, every physician will get a composite performance score, ranging from 0 to 100, that will be used to determine payment. Unlike PQRS or MU, MIPS is a revenue-neutral program, meaning that higher-scoring doctors will benefit and take revenue away from those with low scores, whose reimbursement will decrease.

The Centers for Medicare Services (CMS) will annually set the threshold score for being a gainer versus a loser. And, there is a scaling factor for determining the maximum bonus to achieve budget neutrality, which can be as high as three-fold.

“This is why we can’t ignore MIPS,” Dr. Williams said. “You will not be judged on your absolute score, but on how you relate to everyone else. We are competing against each other and doctors who score high will move the threshold higher.”

The scores will also be available to the public on Physician Compare.

Practice impact

Dr. Williams said implementation of MIPS will bring requirements for increased reporting, and she added that to be successful, independent practices would need more help.

“Physicians in independent practices face a challenge in competing against large integrated health systems that will be able to commit resources to figure out how to systematize reporting in order to get higher scores,” she said.

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Telling her colleagues not to be discouraged by that prospect, Dr. Williams offered some constructive tips.

First, each practice should identify an individual dedicated to knowing the MIPS requirements, where the threshold will be, and the final rule when it is issued. “The final rule will not be published until sometime in the last two months of 2016, and it will be implemented on Jan. 1, 2017,” she said.

Quality Analyst


Quality Analyst

Dr. Williams said the individual should ideally be a physician. She noted that her practice has created a full-time equivalent position for a “Quality Analyst,” whose job it is to make sure all physicians are hitting their quality benchmarks and MU. This person also oversees private-payer, quality-reporting requirements, and makes sure that internal quality measures are met.

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Dr. Williams also recommended making an ongoing effort to improve MU, PQRS, and VBM modifier performance in 2016. “Don’t relax, systematize,” Dr. Williams said. “This is the year to get better and better, but you have to keep working at it,” she said.

Dr. Williams mentioned that group practices with less than 10 providers might combine with other practices to create a larger “virtual group.” The virtual group will be able to report together, and this arrangement will help to reduce the financial burden and to coordinate processes.

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Dr. Williams also said the IRIS Registry has been key for some practices that have achieved a positive update due to success with PQRS and the VBM. The IRIS Registry simplifies the reporting process for PQRS and MU.

Her final tip was to pay attention to the accountable-care organizations (ACOs) that the practice has contracted with because CMS will prioritize the quality performance reporting of the ACO over the individual’s practice.
“Be careful. You may be in an ACO that you don’t even realize you are in,” Dr. Williams said. “Some do a really good job on quality reporting, but others are not so great. This is another reason to have an expert in your practice.”


Ruth D. Williams, MD


Dr. Williams is a consultant to Allergan.