June 2019


How the new 2019 MIPS cataract episode-based cost measure will impact you

by Ellen Stodola EyeWorld Senior Staff Writer/Meetings Editor

In 2019, the Merit-Based Incentive Payment System (MIPS) includes a new cataract surgery episode-based cost measure in the Cost category. Following the MACRA technical corrections enacted in early 2018, CMS is continuing the MIPS transition period by keeping the weight of the Cost category low, at 15% of the final MIPS score. 2019 performance in MIPS impacts 2021 payments.

MIPS episode-based cost measures and the cataract episode measure

In addition to the existing population-based cost measures in the Cost category—total per capita costs and Medicare spending per beneficiary—CMS has included several new episode-based cost measures that seek to measure the total costs of patient care related to a specific “episode,” such as a surgical procedure or inpatient hospital stay for a particular condition. Cataract surgery is included as a procedural measure and will be attributed to cataract surgeons with 10 cases that meet the attribution criteria. ASCRS served on a technical expert panel (TEP) convened by CMS and the contractor developing the measure, Acumen, to provide input on the development.
Episode-based measures were developed in addition to existing population-based measures, which were first used in the Value-Based Modifier Program and continued into MIPS. Population-based measures seek to measure the total cost of care for a patient in a year and may hold physicians responsible for the cost of care they did not provide.
ASCRS, ASOA, and others in the medical community have long advocated for the development of episode-based measures to ensure that physicians are only evaluated on the costs of care that they can influence.

Costs included in the cataract episode measure

The cataract surgery measure new in 2019 measures the costs 60 days prior to the surgery and 90 days following, including preoperative care, the surgery itself, the facility payment, anesthesia costs, and any separately billable services furnished in the global period, such as the cost of surgery related to complications. Some measures may include separately payable drugs. In the case of the cataract surgery measure, there is one drug currently on pass-through, injection of phenylephrine and ketorolac (Omidria, Omeros), and several Medicare Part B drugs used postoperatively to treat endophthalmitis. The list of included drugs will be updated on an annual basis.
ASCRS and ASOA oppose the inclusion of any drug on pass-through in the episode measure and are advocating to have it removed because it defeats the purpose of pass-through to provide separate payment for certain higher-cost new and innovative drugs administered during a surgical procedure and to provide time to introduce the drug into the marketplace. “ASCRS is concerned that including pass-through drugs in the cost measure could stifle innovation,” said Parag Parekh, MD.
Following the 3-year pass-through period, CMS measures the drug’s utilization, adjusts the facility fee using a formula to account for the drug’s cost based on its use and other factors, and bundles the drug into the facility fee. ASCRS and ASOA think including pass-through drugs in the episode measure will inappropriately influence the utilization data for new drugs and are advocating that no pass-through drug be included in the episode measure. “This could end up being penny-wise and pound-foolish for CMS and bad for high quality patient care,” Dr. Parekh said. He added, “If a drug given during surgery can reduce the need for medications after surgery, then CMS ought to encourage that. Postop medications can be onerous to patients; they are hard to put in correctly, they are a nuisance for patients and doctors, and they are expensive to the patient and CMS.”

Cataract episode-based measure attribution

Ophthalmologists will be attributed the cataract surgery episode measure if they perform uncomplicated cataract surgery on a Medicare Part B patient during the performance year. Surgeons must have at least 10 cases that meet the attribution criteria to be attributed and scored on this measure.
This includes only surgeries billed with CPT code 66984. No other cataract surgeries, such as 66982 complex cataract surgery, will be included in the measure.
In addition, ASCRS was successful in advocating for excluding any patients with significant ocular comorbidities from this measure. “Sicker patients are typically more expensive to care for, and if CMS attributes that added cost to a given ophthalmologist, we will have a system that penalizes doctors for treating the sickest among us,” Dr. Parekh said. These comorbidity exclusions are identical to the exclusionary criteria for the cataract quality measure 191, 20/40 or Better Visual Acuity 90 Days following cataract surgery.
Using the current pass-through drug on a patient otherwise excluded from the measure, such as through complex surgery or because of an exclusionary comorbidity, will not be included and therefore will not impact the episode measure score.

Cataract surgery episode sub-groups

Because the cost of cataract surgery varies greatly depending on whether it is performed in an ASC or an HOPD, the cataract episode separates surgeries into sub-groups to compare the cost of similar surgeries in similar contexts. “ASCRS insisted that the cost measure be a fair, apples-to-apples comparison,” Dr. Parekh said. To further sub-divide the episodes, there are sub-groups for whether one surgery was performed within the 90-day window of the measure (unilateral) or if the second eye was operated on within the 90-day global of the first surgery (bilateral).
Therefore, the measure assigns each episode to one of four sub-groups: ASC, unilateral; ASC, bilateral; HOPD, unilateral; and HOPD, bilateral.

Cataract episode measure score

To calculate the total measure score, CMS will evaluate each surgery, or episode, and calculate an “observed” cost and compare it to the national average “expected” cost for its sub-group. This is done by dividing the observed cost of the episode by its expected cost, which expresses the observed cost’s deviation from the expected cost as a ratio. CMS will add all the episodes’ ratios together, across all sub-groups, and divide that sum by the total number of episodes to determine the total average of the surgeon’s episodes’ deviations from the expected costs. That figure is then multiplied by a national average total cost to represent the surgeon’s average deviation from expected costs as a dollar figure. If the surgeon is reporting MIPS as part of a group, the group’s combined average cost is calculated.
CMS then compares the physician’s or group’s average cost to a benchmark and assigns the measure a score of 1 to 10 points. The benchmark will be determined based on cost data from the performance period. The lower the average cost of the cataract episode, the higher the measure score will be.
Once the cataract episode measure is scored, CMS then determines the Cost category MIPS score for the physician or group.

About the doctor
Parag Parekh, MD
Chair ASCRS Government Relations Committee

Online resources from ASCRS

Members-Only Guide on the Cataract Surgery Episode-Based Cost Measure

MACRA Center

MIPS Category: Cost

Contact information
: parag2020@gmail.com
Nancey McCann: nmaccann@ascrs.org

Cataract Awareness Month

Several vision health organizations recognize June as Cataract Awareness Month. The nonprofit Prevent Blindness estimates that the number of cataract cases—already the leading cause of blindness in the world—will increase 78% by 2050. During this month, inform patients about the risk factors that can lead to cataracts (age, certain diseases, exposure to UV sunlight, etc.), the symptoms of cataracts (blurry/cloudy vision, glare, poor night vision), and about the safety and efficacy of cataract surgery. The National Eye Institute reports better vision after cataract surgery in 90%
of cases.

How the new 2019 MIPS cataract episode-based cost measure will impact you How the new 2019 MIPS cataract episode-based cost measure will impact you
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