3 Things Eye Care Providers Should Know About MIPS/MACRA

Like most bills, MACRA (the Medicare Access and CHIP Reauthorization Act of 2015) accomplishes several things, and between now and this fall, much could change—especially amid fervent lobbying by medical groups. In the meantime, here are the here-to-stay basics:

1. MACRA created the Quality Payment Program (QPP), a new framework for rewarding better quality of care (as the feds define it). It offers the choice of two payment tracks, MIPS or APM, each aimed at transitioning fee-for-service to fee-for-value, but in distinct ways.

2. The QPP is budget-neutral. This means that the losers will finance the winners.

3. MACRA fixes two additional issues important to ECPs:

  • It repeals the Sustainable Growth Rate (SGR), replacing it with 5 years of positive 0.5 percent payment updates from 2015-2019. Years 2020-2025 will have a zero percent update. From 2026 on, MIPS and APM participants receive 0.25 percent and 0.75 percent positive updates, respectively.
  • It prevents CMS from transitioning 10- and 90-day global codes to 0-day codes in 2017 and 2018, respectively. Eye care specialties were expected to be among the most negatively affected had that transition occurred.

If you performed highly and avoided penalties with the individual programs, that same performance is not guaranteed under MIPS.

Let’s cut to the chase. Should you be excited about MACRA?

It depends. MACRA seems to improve what’s in place now—but it’s far from perfect, and it’s pretty complex. And there’s one big caveat:

If you performed highly and avoided penalties with the individual programs, that same performance is not guaranteed under MIPS. 

The devil is in the details and those details may change. Right now, your best move is to focus on these big picture pros and cons:

  • The QPP aims to minimize physicians’ reporting burdens by combining individual programs (MU, PQRS, VBM) and removing redundancies, like the quality reporting component of MU.
  • It mostly removes the all-or-nothing aspects of the individual programs by offering varying levels of risk and reward. There’s one exception (we’ll get to that in a bit).
  • It gives ECs flexibility to choose the most meaningful measures and activities to report. But it also removes the Measures Group reporting options (including the Cataracts and Diabetic Retinopathy Measures Groups), potentially making reporting more burdensome for ECPs.
  • Negative adjustments are capped. The maximum downward adjustment under MIPS (beginning at 4 percent in 2019 and topping out at 9 percent in 2022 and beyond) would not equal where we are today with the individual programs until 2022.
  • The current programs offer penalties aplenty; only the VBM has incentive potential. But under the QPP, bonus potential is high.
  • The QPP offers the chance to bypass MIPS by participating in advanced APMs—but there’s little opportunity here for ECPs, at least right now. Why? Given the eligibility requirements, there are likely no advanced APMs in which ECPs can participate.
  • If you’re stuck in MIPS, you may as well make the most of it. Due to the high bonus potential, high-performing physicians stand to profit more from the MIPS track vs. the APM track, at least through 2042, says a recent Brookings Institution study. Yes, we said 2042.

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