UPFRONT: Creeping Change for Payments in Retina Practice


It’s better to burn out than to fade away. — Neil Young

The promise of the Medicare Access and CHIP Reauthorization Act of 2015, better known as MACRA, was to eliminate the Sustainable Growth Rate (SGR) formula — which was an enormous burden to physicians for years — and come up with a better way to pay us. The uncertainty of our payments on a year-to-year basis finally ended with the elimination of SGR. The second goal of MACRA was to stabilize physician payments. However, it appears the modest payment updates the bill provided (around 3% a year) will make our incomes drop over time due to inflation. The third goal of the bill was the most ambitious — move toward a better payment system and away from traditional fee-for-service.

The lawmakers knew that moving us from fee-for-service to the new alternative payment models (APM) would be difficult. So, they figured they would make FFS fade away by making it increasingly more difficult to avoid participation in the APMs. Every year, greater and greater penalties will be enforced on those who do not switch. There are 2 new payment models available: merit-based incentive payment system (MIPS) and advanced APM. The problem is that advanced APMs are not fully baked, and they are difficult to join as a retina specialist, leaving MIPS as the only viable option for most practices.

MIPS is a pay-for-performance system meant to reward physicians based on performance measures through a combination of quality reporting, EHR meaningful use, practice improvements, and value-based payment modifiers. But, these performance measures are not fully developed, and although practices have spent thousands of dollars tracking and reporting the measures, there is no evidence that they actually improve care or outcomes. The Cole Eye Institute is one of only a handful of organizations that tracks all retina surgical outcomes. We have been doing this for over a decade. We publish outcomes annually, good or bad. When we embarked on this endeavor, our CEO stated that the Outcomes Books were not a marketing ploy but instead a way to measure the Cleveland Clinic against other institutions. In no way have the new reporting requirements of MIPS changed our outcomes. And I am sure they never will.

That fact has never deterred the government from continuing to roll out MIPS. We will soon find out how they will publically report our performance scores and what penalties they will levy on poor performers. In this issue, we examine this incredibly important topic. With AAO just around the corner, all retina doctors should support our lobbying efforts to ensure we have some say in where MIPS is going, and how we are measured in the future. RP