BUSINESS

  CODING STRATEGY

HAPPY 50TH, OM AND CMS!

DON’T LET THE CELEBRATION OF THE PAST KEEP YOU FROM PLANNING FOR THE FUTURE

ON JULY 30, 1965, President Lyndon B. Johnson signed into law legislation that established the Medicare and Medicaid programs. For 50 years, these programs have been protecting the health and well being of millions of American families, saving lives and improving the economic security of our nation.

Though Medicare and Medicaid started as basic insurance programs for those who didn’t have health insurance, they’ve changed throughout the years to provide more and more Americans with access to the quality and affordable health care they need. In 1966, approximately 19.1 million Americans were covered by Medicare; today, that number has risen to more than 55 million . . . or so says the press release.

It’s certainly true that for the past 50 years, CMS has provided a foundation for care for individuals 65 years and older. Though optometry wasn’t formally recognized under Medicare until April 1, 1987, providing care for Medicare patients has become a large portion of the average optometrist’s patient base — and it is only going to get larger with 10,000 people per day turning 65.

TIMES ARE CHANGING

For better or worse, the Medicare of yesterday (and today) is nothing like the Medicare of tomorrow will be. The very foundation of the health care system that virtually every optometrist has become accustomed to is in the throes of a fundamental shift in regard to how physicians will be compensated and how access to patients will be determined.

As I’ve mentioned previously, the powers that be want health care to be standardized, commoditized and offered at a lower rate. Nice, politically correct and marketplace-friendly terms such as “outcome-based care” are being used; but in the end, the new system is pushing the individual practitioner to deliver higher quality outcomes, at higher volumes, for less money.

GRADING SCALE

On top of that, you, as an individual practitioner, will not be guaranteed to have access to those patients. It depends on your grade.

“What?” you ask. “My grade?” Yes, the Medicare of the future will require you to be graded on your clinical skills and your ability to provide standardized care in a fashion where your clinical outcomes with patients and your “Quality of Care” will be assessed.

This quality grade will be combined with other things, such as your ability to comply with meaningful use requirements, use of eRx, etc. This will ultimately determine something called your MIPS (Merit-Based Incentive Payment System) score. If your score isn’t up to par, you may be politely asked not to participate as a provider, and, thus, have no access to provide care to all of those covered lives — I meant patients — surrounding your practice.

HELPING HANDS

Sound bleak? It may if you haven’t been paying attention to what has been going on with the health care environment the past 10 years. But there are things that you can do. The AOA has created a registry (AOA MORE; aoa.org/more) to help assist you in complying with these confusing issues, including the following:

• Analyzing outcomes of all clinical (cumulative) data for improved patient care

• Giving each O.D. a private view of his or her benchmark performance compared to his or her peers

• Supporting the MIPS (PQRS, Meaningful Use and other clinical quality improvement measures, such as the Value Based Modifier)

GET TO WORK

There will be many things that you will have to do to adapt your practice to the current and future state of the health care delivery system in the U.S. The key is that you will have to do something rather than feigning ignorance that this transformation is not occurring. If you, as an O.D., are not proactive, I’m afraid that the flames being blown out will not be on the birthday cake of Medicare, but on the survival of your practice. OM

JOHN RUMPAKIS, O.D., M.B.A., is founder, president and CEO of Practice Resource Management, Inc., a consulting, appraisal and management firm for healthcare professionals. Email him at John@PRMI.com, or visit tinyurl.com/OMcomment to comment on this article.