Eyeworld

147 March 2018 EW MEETING REPORTER 50% to 60%; improvement scores incorporated into the quality and cost categories; low volume thresh- old increased to $90,000 in allowed Part B charges or 200 patients; and virtual groups were implemented. CMS set the 2018 MIPS perfor- mance threshold at 15 points, up from 3 points in 2017, Ms. McCann said. Scores above are eligible for a bonus, scores at the threshold (15) receive no bonus or penalty, and scores below the threshold receive a penalty up to 5%. The exception- al performance threshold remains 70 points. You can earn MIPS final score bonus points (either 5 bonus points for those in a small practice of 15 or fewer eligible clinicians or a complex patient bonus of up to 5 points). Ms. McCann highlighted ways in which ASCRS and the medical community are still advocating for changes in MACRA and MIPS. She shared some of ASCRS' key recom- mendations for 2018 and beyond. These include retaining performance period flexibility for 2018 and beyond (3 more years); eliminat- ing the inclusion of Part B drugs; simplifying and streamlining the MIPS program and scoring; defining group size by number of MIPS-eligi- ble clinicians and not eligible clini- cians; reinstating quality measures groups; reducing the weight of the cost category for three additional years; resolving the attribution, risk adjustment, and cost methodology issues in the cost category; address- ing topped-out measures; having transparency and accountability with CME and the contractors, with the development of episode-based measures; and having more trans- parency and accountability with CMMI, with alternative payment models for specialties. Editors' note: Ms. McCann has no financial interests related to her presentation. Ocular surface disease CME program An EyeWorld CME program on ocular surface disease was supported by grants from Shire (Lexington, performance and offers two pay- ment pathways: a modified fee-for service model (MIPS) and advanced alternative payment models (APMs). "Our road in ophthalmology is MIPS," Ms. McCann said. MIPS, or the merit-based incentive payment system, consol- idates the current quality reporting programs (PQRS, VBPM, and Mean- ingful Use, which will sunset) and adds clinical practice improvement activities into a new program, which began in 2017 and impacts 2019 payment. MIPS is comprised of a compos- ite score from four categories: quali- ty (50%), cost (10%), advancing care information (25%), and improve- ment activities (15%). Participants will receive a final performance score of 0–100, based on their performance in the four categories. The final score will be compared to a performance threshold. In some cases, CMS may determine a provid- er is excluded from one or more of the other MIPS categories and will reweigh the individual provider's quality performance score to make up the difference. "You will have a positive, neg- ative, or neutral adjustment based on the composite score," she said. The negative adjustment is capped at 5% in 2020, 7% in 2021, and 9% in 2022. Ms. McCann highlighted some key changes for MIPS in 2018. It continues the transition flexibili- ty for year 2, and participants can avoid a penalty by submitting mini- mal data. The performance period will be for a full year for the quality and cost components and at least 90 days for the improvement activities and ACI components. Ms. McCann highlighted major changes from 2017: the cost category weight increased to 10%; policies to reduce the burden for small practices of 15 or fewer eligible clinicians were added (including 5 bonus points to the final score, ACI hardship exemption, reduced reporting for improvement activities, and quality scoring accommodation); increased quality reporting threshold from cause visual surprises. Dr. Charles pointed out that many critical macular diseases may be invisible without the use of spectral domain OCT. These macular diseases seen only with OCT include vitreomac- ular schisis, vitreomacular traction syndrome, subretinal fluid without bleeding with small CNV in early AMD, central serous retinopathy, and transparent epimacular mem- branes. Dr. Charles said that A-scan ultrasound axial length may be inac- curate with any of these conditions, and optical measurement from RPE is mandatory. Editors' note: Drs. Charles and Weikert have no financial interests related to their presentations. MIPS update Nancey McCann, ASCRS director of government relations, Fairfax, Virginia, gave an update on MIPS, MACRA, and APMs for 2018. The Medicare Access and CHIP Reauthorization Act (MACRA) was developed in a bipartisan, bicameral process over 2+ years; it permanent- ly eliminates the sustainable growth rate (SGR), which had been produc- ing Medicare physician payment cuts annually since 2002, and it provides for 5 years of 0.5% updates. It also implements a new payment system that ties reimbursement to anterior surface. Manifest refraction may provide insight into the astig- matic component of the posterior cornea, he said. Dr. Weikert questioned if surgically induced astigmatism is important. He suggested using ap- proximately 0.1 D for temporal clear corneal incisions ≤2.4 mm. Dr. Weikert highlighted the calculators available, stressing that while no calculator is perfect, they keep getting better. He mentioned the Baylor nomogram but also noted that this is a nomogram and not a calculator, so it provides guidelines intended to leave a little residual with-the-rule astigmatism, and surgi- cally induced astigmatism needs to be factored in. Dr. Weikert finished by discuss- ing if IOL toricity is "one size fits all." For patients with short eyes, he said, these eyes require high IOL powers, formulas often overesti- mate required IOL power, and they are prone to myopic errors, among other issues. Dr. Weikert said toricity suffers from similar issues, and he suggested a conservative approach to selection of toricity magnitude. High IOL powers may exhibit greater toric effect. Steve Charles, MD, Memphis, Tennessee, presented on several ret- ina topics, stressing that insufficient preoperative macular evaluation can View videos from the 2018 Surgical Summit: EWrePlay.org Alan Crandall, MD, discusses strategies for reducing surgical complications related to pseudoexfoliation. continued on page 148

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