Although we do not know with certainty how legislative measures will transform the way we practice as retina specialists in the next several years, we do know that things will be different. As fellows, we are tasked with acquiring medical knowledge and surgical proficiency, so it is easy to overlook significant policy changes. Here is a primer on the 6 issues that are most likely to affect you while embarking on your first few years of practice.

ELECTRONIC HEALTH RECORDS

The electronic health record (EHR) revolution was largely spurred by the Health Information Technology for Economic and Clinical Health Act, part of the American Recovery and Reinvestment Act of 2009, which established incentive payments by Medicare and Medicaid for meaningful use of EHR systems. These benefits, topping out at $63 750 for Medicaid participants, were most significant from 2011 to 2013. More notably for current retina fellows, beginning in 2015, eligible professionals who do not demonstrate meaningful use of EHR will be subject to payment reduction of 1%, increasing yearly to a maximum of 5%. Meaningful use stage 2, effective October 2013, involves documenting 17 core objectives and 3 of 6 menu set objectives. These focus on ensuring that certified EHR technology is used to record fundamental medical information, such as demographics, vital signs, and smoking status, and to exchange that information via communications such as ePrescribing, clinical summaries transmission, and immunization status or cancer/communicable disease registry data.

HEALTH INSURANCE PORTABILITY AND ACCOUNTABLY ACT

This push toward digitizing the medical world recently led the US Department of Health and Human Services to make changes to existing policies in the Health Insurance Portability and Accountability Act (HIPAA). In the HIPAA Omnibus rule, physician practices were required to implement these provisions by September 2013. The Omnibus rule provides the public with increased protection by holding business associates and subcontractors, such as lawyers, to the same standards as physicians when it comes to disclosing patients’ personal health information. Additionally, this new regulation sets limits on how personal health information may be used for marketing and fundraising purposes. The new changes stipulate that patients may ask for a digital copy of their EHR. Also, these changes streamline authorization of health information for research purposes. Individuals who pay cash for medical services can request that their provider not disclose treatment information to their health insurance plan. Maximum penalties based on negligence in regard to patient privacy issues were raised to $1.5 million per violation. More information can be obtained at http://www.hhs.gov/ocr/privacy.

PATIENT PROTECTION AND AFFORDABLE CARE ACT

The Patient Protection and Affordable Care Act (ACA) poses both regulatory challenges and growth opportunities for retina specialists. Most notably, the digital health care marketplace is estimated to add at least 30 million Americans to the pool of insured patients, which will increase the demand for diabetic and pediatric retina care.

The Centers for Medicare and Medicaid Services (CMS) is now mandated to steer physicians’ compensation based on quality and efficiency. Between 2015 and 2017, a value-based modifier will incentivize lower resource usage and better outcomes. Those who fall outside of standard parameters will see adjustments in compensation, which can either benefit or harm a practice. Both commercial payers and the federal government are driving this payment model.

The creation of more vertically integrated health care systems, currently labeled accountable care organizations, is another cornerstone of the ACA. Larger hospital systems have sought to acquire both primary care and specialist practices. Although ophthalmologists may be minimally affected by these early developments, it is important to remain familiar with changes in referral mechanisms, patient access, and standards of care.

PHYSICIAN QUALITY REPORTING SYSTEM

For 5 years, CMS has maintained a pay-for-reporting program, now known as the Physician Quality Reporting System. Ophthalmologists or ophthalmology groups can submit data via several channels such as claims-based reporting (when processing Medicare Part B claim forms), third-party registry (such as the American Academy of Ophthalmology’s IRIS registry: www.aao.org/irisregistry), EHR (many systems are certified to submit), and the cataracts measure group (less pertinent to retina specialists).

Successful reporting can help achieve a 0.5% bonus for 2014 and avoid 1.5% and 2% payment cuts in 2015 and 2016, respectively. Successful reporting means reporting 9 measures in 3 or more quality domains (patient safety, communication and care coordination, efficiency, clinical process and effectiveness, population health, and patient and family experience) on at least 50% of patients in a given year. As fellows, it is a good idea to get in the habit of documenting some of the retina-specific measures. According to the American Academy of Ophthalmic Executives, these include dilated macular examination and counseling on antioxidant supplementation in patients with age-related macular degeneration (AMD), dilated eye exam with notation of severity of retinopathy and presence of macular edema in patients with diabetes, communication with a primary care doctor in the setting of diabetes, documentation of current medications, and screening for tobacco use with appropriate cessation intervention. These few basic components of our daily patient visits are likely to evolve into more complex outcome reporting systems in the next decade.

PHYSICIAN PAYMENTS SUNSHINE ACT

The Physician Payments Sunshine Act, enacted as part of the ACA, requires manufacturers of pharmaceuticals and medical devices to track and report payments or other transfers of value over $10 given to physicians. These reports will be publicly available online at the CMS website on September 30, 2014. In educational activities that have industry involvement, there is an increased awareness of documentation by company representatives. The American Medical Association has provided several recommendations to physicians including taking a proactive approach to tracking their personal payments and financial transfers. For this purpose, CMS created the Open Payments Mobile for Physicians, a free smartphone app available for both iOS and Android platforms. More information is available at http://www.cms.gov.

INTERNATIONAL CLASSIFICATION OF DISEASES

In 1992, the World Health Organization approved the 10th revision of the International Classification of Diseases (ICD-10). The new system increases the number of possible codes from 14 000 to approximately 69 000. Diagnosis codes were updated to include more specificity and detail, better support for quality management, and improved ability to understand risk and severity of disease.

ICD-10 codes may include up to 7 digits, starting with a letter (ophthalmic conditions typically start with H). For example, exudative AMD is H35.32. For AMD, tobacco use (Z72.0) must also be noted, if applicable. Conditions associated with systemic disease, such as diabetic retinopathy, may be listed in other chapters. In ICD-9, a patient with proliferative diabetic retinopathy would be coded 250.52 and 362.02. In ICD-10, this code would be E11.359 (type 2 diabetes mellitus with proliferative diabetic retinopathy without macular edema), found in the endocrine section. Insulin use (Z79.4) must also be noted.

PREPARING YOUR OFFICE

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Many practices are already preparing for these changes. Essential steps include verifying EHR compatibility, training office staff, and updating internal policies and paper forms. October 1, 2014, is the CMS compliance date for the transition from ICD-9 to ICD-10. Materials for provider preparation can be found by clicking the QR code below.

Gaining familiarity and experience with EHR, PQRS, ePrescribing, HIPAA policies, the Sunshine Act, and ICD-10 during retina fellowship will provide a foundation for your early years of practice. During discussions with potential employers, try to get a handle on how the practice is adapting to these changes and how it uses technology to improve patient flow. For example, many groups are already using their EHR systems to tabulate metrics for each office visit. Some can calculate the duration of each patient encounter and the likelihood that imaging will be ordered. These data can be used to optimize scheduling and decrease patient wait times, outcomes that will become more important as our health care system places more value on intelligent utilization of resources. Ultimately, physicians who will thrive in this changing environment are those who are able to maintain a patient-centered approach while striving for continued improvement in efficiency of care delivery.

John D. Pitcher III, MD; Mike Dollin, MD; and Christopher Brady, MD, are second-year vitreoretinal fellows at Wills Eye Institute in Philadelphia, PA, and members of the Retina Today Editorial Board. Dr. Pitcher may be reached at johndpitcher@gmail.com. Dr. Brady may be reached at christopherjbrady@gmail.com. Dr. Dollin may be reached at mike.dollin@gmail.com.