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The MACRA Transition — What’s Ahead for Rural Ophthalmology


As the holiday’s approach, the revised incentive programs by the Centers for Medicare and Medicaid Services (CMS) will also be here before we know it. Physicians need to figure out how their practices and patients will be impacted by the Medicare Access and Chip Reauthorization Act (MACRA) that is anticipated to replace the current Medicare payment system with the Merit-Based Incentive Payment System (MIPS) and Alternative Payment Models (APMs). Then, once those questions are answered, the solution needs to be identified.

But there’s a different conversation I want to focus on in terms of the impact of the transition to value-based healthcare, and that is of physicians in rural areas. Before that, however, let’s break down what MACRA and MIPS mean not only in definition, but how rural physicians’ day-to-day activities will be altered.


The MACRA Proposed Rule introduces a new Quality Payment Program (QPP) that is intended to simplify current Medicare reporting programs into two paths — MIPS, which covers most providers, and APMs, which only apply to providers who are part of a risk-based payment model. While timing may seem far off, the first MACRA performance period begins on January 1, 2017, with payment adjustments for that year scheduled to hit in 2019.

From a financial standpoint, MIPS is intended to advance quality based care by reimbursement. The legislation focuses on the principle that if you demonstrate higher quality than your peers, you have the chance to make more money. That said, performing below the threshold of other physicians (not only ophthalmologists) across the country can actually result in a negative adjustment. There is a lot at stake here and it will be essential that physicians do not take this legislation lightly.

While there are challenges and opportunities on the horizon for all healthcare providers, physicians in rural areas face one of the more unique paths when it comes to MACRA. This is illustrated by the fact that $100 million in technical assistance will be available to eligible providers in small practices and rural areas.

Understanding CMS’ Role in Improving Rural Area Outcomes

A recent blog post by Cara James, director of CMS Office of Minority Health, and John Hammarlund, regional administrator, goes into detail about how CMS is working towards improving and helping physicians in rural areas become better acquainted with the transition to quality based care.

In early 2016, CMS formed the Rural Health Council. The council is comprised of experts from across the agency and is focused on three main areas — ways to improve access to care for all Americans in rural settings; ways to support the unique economics of providing healthcare in rural America; and ways to make sure the healthcare innovation agenda appropriately fits rural healthcare markets.

CMS is making a targeted effort to reach clinicians in rural areas by providing technical assistance and other support for the transition to quality based care and reporting. Through the agency’s rural health coordinators and the Rural Health Council, CMS has conducted nearly two dozen listening engagements nationwide on key rural health issues, such as telemedicine, hospice and hospital support, in an effort to improve access to tools for physicians and patient care. CMS plans to use claims-based data to track some measures and simplify reporting, and physicians will be provided with different options for quality data reporting.

The MACRA rule is intended to bring more transparency to healthcare and help accelerate the transition to quality-based care. Shifting away from the established fee-for-service model, the healthcare industry will increasingly focus on a more holistic approach to population health. In addition to an augmented focus on quality, providers will need to work to eliminate costly waste and errors. MACRA will also improve information sharing among provider organizations through increased interoperability across provider organizations and electronic health record (EHR) systems.

While many are concerned about the need for increased reporting under MACRA, the goal is actually to streamline the process for small practices that may not have the tools or resources that large organizations have at their disposal. It’s extremely important for all rural ophthalmologists to fully understand what this transition means and the tools available to them.

The Vital Role Technology Plays in the Switch

Within CMS’ blog post, the authors provide a quote by Theodore Roosevelt referring to rural populations which I’d like to repeat: “the physicians are further apart and are called in later in cases of sickness, and in some districts, medical attendance is relatively more expensive.” Clearly, rural healthcare and practices have faced unique challenges since at least 1909. The good news is that we now have the technology that can overcome many of these issues.

Cloud-based, mobile EHR systems — combined with integrated practice management software — can organize clinical data in a structured format, empowering doctors to extract meaningful insights and collective wisdom at both the patient and population levels. In other words, instead of relying on any one physician’s descriptive assessment of a diagnosis or treatment, physicians that have access to an intuitive platform can reference relative findings from their peers, eliminate redundancies, automate communications and improve health outcomes.

As an example, Boca-Raton based Modernizing Medicine’s EHR platform, EMA™, is a system within the modmed Ophthalmology™ suite of products and services that helps ophthalmologists manage the transition by providing quality data and reporting capabilities. Specifically, the platform can provide functionality for automated quality data capture, population health registries, real patient engagement and analytical tools and interoperability.

Additionally, EMA also includes Grand Rounds™ — a tool within the software that allows ophthalmologists to access top treatment information not just from colleagues in their practice, but from a larger nationwide pool of treatment data. This is especially useful for rural ophthalmologists who may not see the same number of patients and breadth of diseases as compared to physicians in a more populated metropolitan area. In Grand Rounds, they can draw from millions of patient encounters to discover top treatments from rare conditions to common cases that resist first or second treatments. In seconds they can have medical knowledge beyond the walls of their practice and drill down beyond general populations to specific population criteria and disease specifications.

Today’s technology can enable a more simplified, collaborative and accessible model for care. The ultimate goal of mandates such as MACRA is to advance quality in healthcare, and technology will continue to be a critical contributor to its success. While emerging technologies like telemedicine have the ability to advance care in rural areas, having the right EHR system in place is the important first step for rural physicians who want to achieve financial success under MACRA and MIPS.

MACRA Integration: Tips to Help You Achieve Your Financial Goals

Specialty care has always faced its challenges in rural areas, and the move towards quality care presents additional hurdles that can be addressed successfully if physicians have the right tools and resources. With the latest technology, education and understanding of what’s to come in 2017, your practice will be well informed and ready to face the upcoming deployment. Here are a few tips to better prepare your rural practice for the MACRA rollout in January 2017:

  • Avoid penalties — To avoid 2018 financial penalties, it’s important to successfully report to the Physician Quality Reporting System (PQRS), the Medicare Electronic Health Record (EHR) Incentive Program (formerly “Meaningful Use”) and the Value Modifier. Performance data from 2017 will determine your practices’ payment for 2019.
  • Review your Quality and Resource Use Reports (QRUR)The QRUR report indicates your practices’ performance on quality and cost. You can obtain your previous reports via CMS’ website. This will inform you of the changes your practice needs to make to avoid the penalty phase of the MACRA composite score.
  • Data accuracy is key — With MACRA, your performance is compared with similar groups across the country, therefore, the data you enter needs to be accurate to ensure adequate measurement. With solutions like modmed Ophthalmology, quality data is automatically integrated into your system as you go through your patients’ appointments, so research systems that best suit your ophthalmic workflow.
  • Meet your performance marker — It is important for ophthalmologists to review quality measure benchmarks and understand what is required for above-average performance. To do this, put practice strategies and clinical workflows in place to help meet vital criteria, and ensure that your EHR system supports specialty measures.
  • Keep up with ICD-10 — ICD-10 is and will continue to be a crucial part in the transition as we move towards quality reporting. Accuracy on the highest level needs to be maintained and up-to-date. EMA, for example, automatically enters in my codes using a 3D anatomical atlas as I notate an appointment with my patient. This creates a peace of mind for me and my patients, as well as relieves much of the heavy lifting reporting creates for me and my staff.

As rural ophthalmologists begin to navigate the unsettled waters of the MIPS transition, they must first understand how their practice can and will be impacted if it is not prepared, and how to not only avoid penalties but also receive maximum reimbursements. While CMS recognizes the difficulties rural physicians will face with the legislation and are putting certain actions into play to help alleviate those stressors, a successful transition relies on actions taken by the practices themselves. To that end, it is essential to adopt the right EHR system and workflow processes in order to be prepared for the volume to value transition.

Without the proper tools, education and strategies, rural providers will find it difficult to engage in population health management programs, risk stratification and preventative health strategies — all major proponents of data-driven, value-based services.

By: David A. Goldman, MD on in News