MACRA’s Evolving Impact on Retina

Despite significant regulatory rollback this year, retinal physicians remain vulnerable to penalties.


The slow roll-out policy that characterized the first year of the Medicare Access and CHIP Reauthorization Act (MACRA) appears set to continue next year as well. Citing the need to “move the program further in the least burdensome manner,” CMS officials under the new administration eased regulatory thresholds for participation, penalties, EHR use, and other MACRA benchmarks.

Most important to the retina world, throughout 2018 cost containment will remain excluded from calculating Medicare penalties and bonuses. This gives the subspecialty another year to persuade CMS that the law’s payment structure should not penalize retina physicians for the high cost of administering anti-VEGF drugs.

Not only would assessing Medicare Part B drugs likely put most retinal surgeons in line for penalties, but under the “buy and bill” system by which most private practices operate, reimbursement for the drugs themselves would also be subject to those same penalties. One study suggested this could cause some retinal physicians to lose money on every injection.

“The Academy believes this is unfair,” says George A. Williams, MD, AAO secretary of federal affairs and president-elect, who has advocated for ophthalmology’s interests. “We don’t set the prices of these drugs. And there are many indications where the more expensive drug is clearly the drug of choice. So, we will continue to push on that issue.”

Here is a look at MACRA and some other ways the retina community might shape its impact.


Designed to incentivize health care away from fee-for-service billing and toward value-based care, MACRA creates a Medicare payment structure that rewards improved outcomes and cost savings and penalizes poor outcomes and cost overruns. Practitioners subject to the law will fall into 1 of 3 payment groups: the Merit-Based Incentive Payment System (MIPS), the Alternative Payment Model (APM), or the Advanced Alternative Payment Model (AAPM).

Most physicians fall into the MIPS or APM category and will receive a score between 0 and 100 to determine bonuses and penalties. Four factors establish the score: patient outcomes, use of EHR, practice improvement activities, and cost. Each will be weighed differently each year; as mentioned above, cost will count for 0% in 2018. Bonuses and penalties begin at ±4% in 2019 (based on 2017 performance) and rise to ±9% in 2024.

Under “buy and bill,” CMS reimburses Medicare Part B drugs’ cost, plus 4.3% — extra money that goes toward upkeep, not profit, according to a comment letter ASRS sent CMS in August. “These costs can be significant,” the letter explains, “particularly for biologics, and include shipping and handling, taxes, storage space, monitored refrigeration, maintenance, inventory tracking, disposal, loss, general staff time, and other indirect costs.”

The letter cites an ASRS-commissioned study that concluded smaller practices might be unable to afford branded anti-VEGF drugs under MACRA. In such cases, their patients would be forced to travel to hospitals to receive injections, the ASRS warned.

Dr. Williams is optimistic that lobbying efforts will convince CMS to exclude Part B drugs. After all, the Physician Quality Reporting System and other legacy programs that served as MACRA’s prototypes omitted them. However, he notes that even discounting drugs, retina will still bear the liabilities of high patient volumes and expensive imaging costs.

Part of the problem lies in the subspecialty’s distaste for self-promotion, according to Pravin Dugel, MD, of Retinal Consultants of Arizona. “For the last 20 years, we’ve spent so much time on clinical innovation that we never stopped to assess the value, monetary or otherwise, of all the things we’ve accomplished.”

He remembers when standard of care included lasering the fovea, creating 20/200 vision, and then trying to explain to patients how a smaller but immediate scotoma would actually help them in the long run. “To go from that to having a 90% chance of preserving vision with anti-VEGF injections is miraculous,” he says.

The retinal community should lobby CMS to add quality measures that better reflect its contributions. How many falls were prevented? How many cases of low vision support were averted? Dr. Pravin cites statin drugs as an exemplar: “There’s a lot of literature about the monetary value of statins. The result is people simply don’t question the value of stains.”


The Intelligent Research in Sight (IRIS) system, an AAO software package launched 3 years ago, represents a potential bright spot. Compatible with 40 different EHR systems and free to academy members, IRIS can access a practice’s electronic records, pull the required MACRA information, and report the data to CMS. While other specialties scramble to add staff or contract with third-party vendors, IRIS offers eye care a much smoother transition into the new payment model.

By all accounts, the system functions as advertised. McKesson Specialty Health Consultant Linda Pottinger, MBA, who has worked in other specialties, has experience with IRIS and was impressed. She attributes its proficiency to the AAO’s having had the foresight to cut the system’s teeth on PQRS before launching it for MACRA.

Pottinger encourages her clients to take a proactive stance toward MACRA. Few practitioners realize it, but they can band together and pitch their own alternative payment models to an entity called the Physician-Focused Payment Model Technical Advisory Committee. Given retina physicians’ independent, do-it-yourself streak, practices may find creating their own payment model in conjunction with a nearby hospital or ACO congenial, she suggests.

Whatever path retinal physicians choose, the clock is ticking. Unlike many other health care matters, MACRA enjoys widespread bipartisan support and is unlikely to be repealed any time soon. Furthermore, CMS will not keep the bar for avoiding penalties this low forever. And the 9% penalties scheduled for 2024 could easily mean tens of thousands of dollars in lost revenue per physician.

If you are reading this in 2017, there is still time to participate and avoid penalties in 2019. It could take as little as 5 minutes, experts say. Dr. Dugel summarizes the lowered regulatory standards with a sports metaphor: “This is the equivalent of being able to play a golf course for free before you actually have to play in a tournament. Why would you not take that opportunity?” RP