MACRA: What Optometrists Should Know About Medicare Payment Reform

Posted by Deborah Pinnock on May 2, 2016 11:33:56 AM



The American Optometry Association considers MACRA (Medicare Access and CHIP Reauthorization Act of 2015), a fairly recent healthcare payment reform, to be a big win for optometrists. Why? Because it distinguishes optometrists as physicians. Why is this important? It means that while optometrists are subject to the quality standards established by the new legislation, they are also eligible for the incentives that will be awarded to clinicians who meet the standards. As a result, it’s important for optometrists to understand this reform, the criteria that’s used to evaluate the overall quality of a physician’s services and the two avenues they can use to grow their payments from this federal health insurance program. 



MACRA Basics

At its most basic, MACRA is a relatively recent healthcare reform, signed into law on April 16, 2015, that changes the basis on which, and the avenues through which, this program’s physicians get compensated. Instead of being reimbursed based on the quantity of services they provide, doctors will now be paid according to the quality and value of the services they provide. One of the immediate impacts of the new law and a major win for these providers, is the fact that it revokes the Sustainable Growth Rate (SGR) provisions, a law many medical professionals opposed. SGR was used to regulate the program’s spending on physician services. At times, this method resulted in payment cuts for doctors.

How physicians get compensated also changed. With the passing of the new law, there are now two main pathways for eligible physicians to increase their payments. They are the Merit-Based Incentive Payment System (MIPS) and Alternative Payment Models (APMs).



MIPS (Merit-Based Incentive Payment System)

MIPS combines three existing quality reporting programs, creating a new system to evaluate the quality of a physician’s services. The building blocks of the new MIPS are the following reporting programs:

  • Physician Quality Reporting System (PQRS)
  • Value-Based Payment Modifier (VBPM)
  • Meaningful Use (MU)
  • Clinical Practice Improvement Activities (CPIA-a new program)

Using these programs as a foundation, a performance score, based on the following criteria, is used to evaluate the quality of a clinician’s services:

  • Quality – (tied to PQRS)
  • Clinical practice improvement activities (tied to CPIA)
  • Meaningful use of Certified EHR (Electronic Health Records) (tied to CPIA and MU)
  • Resource use (tied to VBPM)

Impact of MIPS

Depending on the clinician’s performance, he or she may receive a payment adjustment in the form of an increase or decrease in payment, or no payment at all. These payment adjustments will start in 2019 at four percent and progress to nine percent by 2022. 




APM (Alternative Payment Models)

The second component of the MACRA, the Alternative Payment Models (APM), establishes alternative, incentivized ways for physicians to receive payment. They include:

  • A Medicare Shared Savings Program (MSSP) accountable care organization (ACO)
  • An expanded, innovative payment model, created by the Center for Medicare & Medicaid Innovation (CMMI)
  • A Medicare Acute Care Episode Demonstration Program or Medicare Health Care Quality Demonstration program
  • Other demonstration programs necessary per the federal law

Impact of APM

Physicians that participate in some APMs may be eligible for certain incentives. For example, clinicians labeled as “Qualifying APM participants” will get a lump sum incentive payment, equivalent to five percent of the previous year’s appropriate combined expenses and based on the applicable fee schedule. This incentive payment will begin in 2019 and extend to 2024. Additionally, physicians that qualify as APM participants will not be impacted by the MIPS adjustments.  

In conclusion, “Quality is never an accident; it is always the result of high intention, sincere effort, intelligent direction and skillful execution; it represents the wise choice of many alternatives.” This quote, by William A. Foster, represents MACRA’s aim—quality. Every aspect of this program is intentionally designed to achieve this end. Being aware of this law, the avenues to obtain incentives and the fact that optometrists, a role typically associated with ancillary benefits, now have the opportunity to benefit from this reform, positions you to build your revenue stream by taking advantage of incentives associated with the quality work you do every day.  


Check out our provider blog that features informative content for vision and dental providers. 

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Topics: medicare, MACRA

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