CMS Proposes New Ophthalmology MVP, Shake Up for Cataract Surgery MIPS | AAO 2024

The 2025 proposed Quality Payment Program (QPP) rule has been announced and includes a few key adjustments that could change Merit-based Incentive Payment System (MIPS) reporting for ophthalmologists. The proposal comes with many similarities, some welcomed changes, and a few major adjustments, according to Brandy Keys, MPH, at a session held during the American Academy of Ophthalmology (AAO) annual meeting.

Brandy Keys

"Overall, there's little change in what I call the foundational elements of the MIPS program; however, there are two significant proposals related to ophthalmology specifically, and that's the complete ophthalmic care MVP and then the revisions to the cataract surgery costs measures," said Keys, the director of health policy at AAO.

Among the many changes to the cataract cost measures was a new name, which would now read: Cataract Removal with Intraocular Lens (IOL) Implantation. Additionally, the agency is adding new services to the attributive services lists, namely Dextenza (dexamethasone ophthalmic insert), Iheezo (chloroprocaine HCI ophthalmic gel), clinically relevant telehealth services, lenses, glasses and emergency visits for ocular complaints. There are also several other changes made to diagnoses codes, with some removed and others changed to risk adjustment factors.

The second big ophthalmology proposal was the introduction of a MIPS value pathway (MVP), said Keys. CMS has begun to seek feedback on this topic, including the sunsetting of traditional MIPS in favor of MVPs by 2029 or later. The proposed title for the MVP would be Complete Ophthalmic Care. The feedback from AAO on this new MVP was less than enthusiastic, with Keys noting the academy was disappointed in CMS and, in partnership with the American Medical Association (AMA), was urging them to pause this effort.

"CMS really didn't take our feedback into account in the develop of this MVP. We actually submitted a candidate MVP centered around cataract surgery earlier this year, but it was ignored," she said. "The academy has historically opposed CMS's one-size-fits-all approach to ophthalmology MVPs. We feel like the limitations of the measures that you can choose makes it impossible for some subspecialties to have a positive score on the MVP."

Outside of these major changes, other smaller adjustments are being proposed to MIPS for 2025. There are anticipated adjustments in quality measures, namely the ability to remove unneeded measures and the breaking apart of optometry and ophthalmology in the specialty measure set, which Keys said was a welcomed change.

For improvement activities, CMS is removing several frequently reported activities for ophthalmologists, including 24/7 access, population empanelment, specialist reports, and improvements for more timely test results. On the positive front, Keys said, a new scoring methodology was proposed that levels the scoring for improvement activities. Additionally, a new methodology is being proposed for cost performance category scoring, which would eliminate deciles and replace them with benchmark ranges. This change would take effect for the current year, Keys said.

In this new system, a benchmark range is created based on standard deviations from the median costs. The median would be set at 10% of the MIPS performance threshold. On average, Keys said, this would increase the mean cost performance category from 59 out of 100 to 71 out of 100. Because of this, AAO urged CMS to also apply this to 2023. "We know the cost category has been troublesome for ophthalmologists in recent history," she said.

Despite these changes, Keys noted that some concerns remain. Some of these items include the feedback received by the physician from CMS. Keys said that in many cases the reports are not useful, and the feedback has not arrived quickly enough to fully understand the measure calculation. Since the reports are not arriving on time, per the statutory requirements, AAO, and AMA, suggested reweighting of their cost category to 0%, in the instance of a significant delay. "We will continue pushing on that," said Keys.

In 2025 regardless of specialty, Keys projects 686,645 clinicians to be MIPS eligible and the proportion of physicians avoiding a penalty or earning a positive payment adjustment is projected to increase from 78.37% to 84.53%. The max negative adjustment will remain -9% and CMS expects the median positive payment will be 1.31%.

"This is because this is a budget neutral program," Keys noted. "The bonus payments are paid out from the negative adjustments. So, if fewer people are getting that penalty there's going to be less money to spread out among all those that got bonus payments."

Keys closed by updating attendees on the MIPS & IRIS registry, which is designed by AAO around continual quality improvement and open to all its members. She noted that a few important deadlines were fast approaching, with the end of the year representing the deadline for requesting a hardship exception.

"For quality measures, it just keeps getting harder and harder to get a perfect quality score, due to scoring limitations on things like top-down measures or measure with stalled benchmarks or no benchmark," said Keys. "The IRIS registry has anticipated these issues and created QCDR (Quality Care Data Registry) measures as alternatives to topped out or other QPP measures that have scoring limitations."

She closed by sharing details on the IRIS Registry Prep Kit and upcoming webinars. Final details of what will take effect in 2025 should become available in November.