MIPS: New Rules, New Money

If you play nice you may see bonus reimbursement, but if you take your ball and go home, you will likely see a reduction.

By Linda Pottinger, MBA

The goal of Medicare physician payment reform is to move toward a system based on quality patient care and improved outcomes while reducing costs. Whether tied to reform or not, the improvement of patient care is an effort all retina specialists can support and one that many have already been working to address.

The wait is over. Medicare’s first major move toward value-based care was implemented on January 1, 2017. The final rule for the Quality Payment Program authorized by the Medicare Access and CHIP Reauthorization Act of 2015 (MACRA) was released in late 2016 and combined the Physician Quality Reporting System (PQRS), Meaningful Use (MU), and the Value-Based Payment Modifier (VBPM) into a single program called the Merit-Based Incentive Payment System (MIPS). MIPS is a budget neutral initiative, meaning funds to pay positive payment adjustments for top performers will come from penalties assessed to poor performers, and data reported in 2017 will impact 2019 payments.


• MIPS combines physician quality measures many retina doctors are already familiar with, MU measures using certified EHR technology, and Cost and Improvement activities into one program for Medicare reimbursement.

• There are various degrees to which doctors can comply with MIPS requirements in 2017, all of which will affect 2019 payments. Negative payment adjustments in 2019 can be avoided by minimum (test) participation in 2017.

• Some practices may need to make minor adjustments in 2017 to comply with reporting requirements.

In 2017, MIPS will measure physicians’ and groups’ performance in the following categories:

• Quality: replaces PQRS; 60% of MIPS composite score

• Advancing Care Information (ACI): replaces MU; 25% of MIPS composite score

• Improvement Activities (IAs): a new category; 15% of MIPS composite score


The MIPS final rule gives practices several options for participation in 2017, enabling them to transition to value-based care at a pace that meets their readiness. Below is a review of your options, ranking them from best to worst.

Full Participation

Submit data for all required measures in all categories for the full year and be eligible for a larger positive payment adjustment. Practices interested in this option should have already started documenting and collecting MIPS data. Clinicians who achieve a score of 70 to 100 are eligible for an additional adjustment from a $500 million bonus pool.

Getting Started

• The American Society of Retina Specialists website houses a number of MIPS explanations on its advocacy page.

• The American Academy of Ophthalmology has similar resources online, plus an FAQ that retina practices might find handy.

• The Centers for Medicare and Medicaid Services (QPP.CMS.gov) may also serve as a helpful tool.

Partial Participation

Report a minimum of 90 days of data for all required measures in all categories to be eligible for a small positive payment adjustment.

Test Participation

If a practice does not have an electronic health record (EHR) capable of MIPS reporting or is not ready to participate fully, it can avoid a negative MIPS payment adjustment by reporting on at least one measure in the quality category, one IA, or the required number of ACI measures.

Do Not Participate

Practices should not consider this as an option because those that do not participate at all in 2017 will receive a 4% negative payment adjustment in 2019.


Now that MIPS is in effect, retina practices should develop an action plan to ensure they are well positioned for success. The following are key areas retina practices should consider.

Technology for MIPS Readiness

One of the first steps every practice must take is to verify that its EHR is certified for MU, now known as ACI. This will likely require engaging with an EHR vendor to determine whether the quality and performance measures the practice wants to track for MIPS submissions are available in the EHR. Practices already participating in MU will be a step ahead by virtue of having an EHR in place and being familiar with the technology requirements. However, it is still important to confirm to what extent a practice’s technology will enable MIPS reporting and when the functionality will be available.


In addition to many nonspecialty specific measures, some retina-specific quality measures include:

• Adult primary rhegmatogenous retinal detachment surgery: No return to the OR within 90 days of surgery

• Adult primary rhegmatogenous retinal detachment surgery: Visual acuity improvement within 90 days of surgery

• Age-related macular degeneration: Counseling on antioxidant supplement

Review Practice-Relevant Quality Measures

There are more than 20 quality measures related to ophthalmology, with several being specific to retina (see MIPS for Retina Doctors Only). Practices that have performed well in PQRS are in a good place to transition to MIPS because many of the quality measures for MIPS are an extension of PQRS. Unlike PQRS, which required providers simply to report on certain measures, practices under the MIPS program will have to demonstrate improved quality annually, with 2017 results serving as a baseline. Measures submitted electronically through an EHR or other qualified clinical data registry are eligible to earn bonus points, up to 10% of the total available points in the quality category.

Identify IAs That Are a Good Fit for the Practice

The goal of clinical practice IAs is to drive innovation that benefits both patients and the practice. There are nearly 100 IAs to choose from, so it should not be hard to find several that are a good match for a practice. Look for measures that the practice is already meeting or that require only small process or documentation changes. Ultimately, practices can maximize their scores by considering activities that improve their efficiency and effectiveness in providing quality patient care.

Designate a Practice Champion to Drive MIPS Participation

Whether a practice is large or small, identify a MIPS program owner. This leader will be responsible for managing the MIPS participation process, verifying readiness of the EHR, and ensuring that the staff is fully engaged as the practice transitions to new documentation and reporting processes. Change is not easy. However, embracing a team approach and helping the entire staff understand the positive impact that participation brings to patients and to the practice will demonstrate that the change is worthwhile.

Linda Pottinger, MBA
• director of payer initiatives for Innovative Practice Services at McKesson Specialty Health in The Woodlands, Texas


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About Retina Today

Retina Today is a publication that delivers the latest research and clinical developments from areas such as medical retina, retinal surgery, vitreous, diabetes, retinal imaging, posterior segment oncology and ocular trauma. Each issue provides insight from well-respected specialists on cutting-edge therapies and surgical techniques that are currently in use and on the horizon.