So here we are—post-election America. Some are rejoicing, some are rebelling and many, if not most, are confused about how our current and future politics will affect the healthcare landscape.

As we enter into a critical time with respect to the Affordable Care Act (ACA) and the potential to “repeal and replace” looming ahead, it is important to understand that the imposed changes to our payment system—moving from quantity to quality—is unrelated to the ACA.  

What’s What

The Patient Protection and Affordable Care Act (PPACA), commonly called the ACA or Obamacare, is a federal statute enacted on March 23, 2010. It introduced mandates, subsidies and insurance exchanges intended to reduce the costs of healthcare, increase health insurance quality and affordability and lower the uninsured rate by expanding coverage. The law requires insurers accept all applicants, cover a specific list of conditions and charge the same rates regardless of pre-existing conditions or sex.¹

The Medicare Access and CHIP Reauthorization Act of 2015 (MACRA) is federal legislation signed into law on April 16, 2015. The law does many things, but most importantly it establishes new ways to pay physicians for caring for Medicare beneficiaries. The Merit Incentive Based Payment System (MIPS) is a critical component of MACRA, as it is transforming the way physicians in the United States are going to get paid moving forward.

So even if the change in government results in a change in the ACA, the conversion to a compensation system based upon quality rather than quantity will likely remain in place—and that means your practice needs to prepare because the changes happening in 2017 will start to affect how and how much you get paid in 2019 and beyond.

Preparation is Key

Every major medical carrier in the United States is migrating to a quality-based payment system, so this has the potential to greatly impact every practice, not just those who care for Medicare patients.

Luckily, CMS has made it very easy to comply with the MIPS reporting in 2017. Most importantly, if you don’t do anything, you will receive a -4% downward adjustment on your Medicare payments. So what does it take to comply? Let’s examine the various components.

There are four categories of physician performance contributing to a MIPS Composite Performance Score (CPS) of up to 100 points, based on these relative weights:

• Quality (formerly PQRS): 50%
• Advancing care information (ACI, formerly MU): 25%
• Clinical practice improvement activities (CPIA): 15%
• Resource use (based on claims data, calculated by CMS): 10%

You have four options for 2017 if you would like to avoid the -4% adjustment:

1. Report some data to avoid a negative payment adjustment (awaiting Final Rule). Even if you report on one measure on a single patient on one day, you can avoid the downward adjustment.
2. Submit full performance data (ACI, Quality and CPIA) for a reduced number of days, meaning your first performance period could begin later than January 1, and your payment could be smaller (awaiting Final Rule).
3. Move forward with a full year of reporting for maximum reimbursement potential. 
4. Participate in an advanced alternative payment model, such as a Medicare Shared Savings Track 2 or 3 ACO. This has both positive and negative financial risk and is exempt from MIPS, but most likely is not applicable to optometry, as far as we know.

There will be much more to come in the New Year, and as we know change is inevitable, I will do my best to keep you ahead of the curve; but you have to promise me one thing: don’t ignore this. In this case, ignorance is not bliss.

Send questions and comments to ROcodingconnection@gmail.com.