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A look at how MIPS will affect every ophthalmologist
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The Merit-based Incentive Payment System, or MIPS, was scheduled to take effect Jan. 1. It will not be repealed by the incoming Republican Congress as it helped design it and voted for it.
A few big picture thoughts. If you receive reimbursement from Medicare Part B, you are subject to MIPS. That is 95% of American members of the American Academy of Ophthalmology and 98% of American members of the American Society of Cataract and Refractive Surgery, so just about everyone. One major positive: MIPS is consistent with a fee-for-service-based Medicare, and President-elect Donald Trump, the proposed HHS Secretary Tom Price, MD, an orthopedic surgeon who is a good friend to ophthalmology and specialty care, and the anticipated Republican Congress support retaining a fee-for-service-based Medicare option. So, the march toward capitated care and single payer is likely delayed. For most of us, that is good.
Another positive in the Medicare Access and CHIP Reauthorization Act and MIPS is that the SGR was repealed, which is good for physicians. That sword of Damocles no longer hangs over our head. However, Medicare total payment growth has been capped at 0.5% for 2016 to 2020, 0% from 2020 to 2025 and then somewhere between 0.25% to 0.75% thereafter. That is bad, as our practice costs are likely to increase at a faster rate than 0.5% and certainly faster than 0%, so we will need to manage our practices well or see our net incomes decline. The best solution to flat reimbursement besides the usual caveat to manage expenses carefully is to plan to see a few more patients each week and year or see patients with a higher reimbursement per unit of care, especially those in the cash-pay sector. For most ophthalmologists, this is an easy adaptation. We have been doing it for decades, and we will keep doing it.
MIPS says it is going to rate every ophthalmologist from 0 to 100, and each of us will be given a score every year. Patients will also be able to access each individual doctor’s MIPS score. It looks like it will be a no-brainer to achieve a score of 50, and while no one knows, a score of something like 70 to 75 might make you average. You will be scored on quality of care with a 50% weighting. This will include reporting on six quality measures, much like those many of us have been doing in the Physician Quality Reporting System. This looks pretty straightforward to me, and AAO and ASCRS have done a nice job getting us reasonable reporting metrics. The AAO Intelligent Research in Sight (IRIS) Registry should be quite useful here for reporting and documentation. I encourage every ophthalmologist to sign up for IRIS.
The next heaviest weighting goes to advanced eye information at 25%. My interpretation of these parameters is that they pretty much require electronic health records, so if you do not have EHR today and do not want to be penalized in this category, you will need to incorporate EHR into your practice. Fortunately, the EHR available to ophthalmologists today has improved significantly. Unfortunately, the government financial incentives to adopt EHR have expired.
Third is a category called clinical practice improvement, and it will be weighted at 15% in your MIPS score. These parameters are being sorted out but also look achievable. They include things such as patient recall systems and interprofessional communication.
Finally, at number four is resource use, which really translates to cost per unit of care as compared with your colleagues. This is fortunately only 10%.
So, why is every doctor’s MIPS score important? Because your 2019 reimbursement from Medicare will be modified by your MIPS score. In 2019, you can be penalized 4% or rewarded 12%, depending on your MIPS score. Every year through 2022, the penalty increases as does the reward. In 2020, it will range from –5% to +15%, in 2021, –7% to +21%, and in 2022 and thereafter, –9% to +27% (presuming no changes to the regulations, which we all know is highly unlikely). Most doctors, I suspect around 70%, will likely be in the no-penalty/no-reward bucket, but a few will be heavily penalized and a likely small number of spectacular performers highly rewarded. It is, in my opinion, definitely worth avoiding the heavily penalized group. Looking at the requirements, this should be fairly easy for any ophthalmologist with EHR who reports on their quality and improvement metrics and has reasonable costs.
The exciting opportunity and challenge for well-managed practices is to get into the highly rewarded group. Let’s say in 2022 in your locality, average surgeon reimbursement for cataract surgery is $640 per eye. The ophthalmologist with a maximum penalty would be reimbursed $582 per eye, and depending on the rewards available to distribute, the best performer with the highest MIPS score could get paid as much as $812. That is a $230 per cataract surgery difference, or for a practice that does 500 cataracts a year, $115,000. For the ophthalmologist earning $500,000 in Medicare revenue, the worst performer to best performer gap is $180,000 per year. Because the overhead to do the work will likely be similar for each ophthalmologist, that $180,000 will translate nearly 100% into increased take-home pay. At $500,000 in Medicare revenues, every 1% penalty or bonus translates to $5,000 in decreased or increased net take-home income.
The bottom line: Understanding and managing one’s MIPS score will be important, and while the carrot or stick does not hit until 2019, the behaviors that will lead to our first MIPS score start now. Both AAO and ASCRS have done exemplary work protecting and preparing the American ophthalmologist for this significant change in Medicare reimbursement. But it is up to the individual doctor to get educated and incorporate into their practice the necessary practice patterns and reporting needed to avoid the potential significant penalties or reap the potentially even greater rewards.