“Billy, your curfew is midnight!
Don’t be late!”

I was in the 12th grade; the mandate was absolute. Discussions of the consequences of tardiness were not necessary. In my mind, the mandate was clear; to disobey was unimaginable. Though I didn’t necessarily see the value, I knew what I was to do.

That was countless years ago, but it seems that now, as a physician, I deal with numerous mandates — some absolute, some ambiguously proposed— leaving much, sometimes too much, to my imagination — and much, too much, uncertainty in my practice and ASC. Let’s explore just a few mandates confronting us today.

Mandate 1

CMS proposed mandating that physician owners of ASCs participate in a survey with measures collected utilizing the Outpatient and Ambulatory Surgical Center Consumer Assessment of Health Care Providers and Systems (OAS CAHPS). The survey, we were told, should include information about Facilities and Staff, Communication About Procedure, Preparation for Discharge and Recovery, Overall Rating of Facility, and Recommendation of Facility. The surveys were originally to be operational by 2018, and ASCs were to collect 300 completed surveys to meet reporting requirements starting in January. Participation in 2018 and 2019 was to be linked to payment reimbursement beginning in 2020.

The process of administering, analyzing, collating, and reporting promises to be an expensive undertaking for the surgery center. And gearing up for the process is no easy task.

As such, many of us have taken first steps to engage a vendor and prepare our staff. Then, in July, CMS proposed that the survey program implementation be delayed and provided no guidance regarding its future. So what are we to think — and what are we to do in the meantime?

Mandate 2

CMS mandated Meaningful Use of EMR when they mandated implementation of EMR. Medicare eligible professionals were required to attest to Meaningful Use in 2016 to avoid a 4% penalty in 2018. In 2018, the Meaningful Use program will sunset. Then physicians must begin participating in the Merit-Based Incentive Payment System (MIPS). The Advancing Care Information category will become the EHR component of MIPS.

On Oct. 14, 2016, CMS released the final rule on the Quality Payment Program, which includes both MIPS and the Advanced Alternative Payment Models (APMs). The final rule requires CMS to release the criteria the agency will use to validate data submitted as part of the MIPS program in 2017. The validation criteria will be used as an element of future audits on 2017 MIPS performance. This guide summarizes the criteria CMS has released, along with information about potential audits.

• Quality: The data validation process will apply for claims and registry submissions to validate whether physicians submitted all applicable measures when submitting fewer than six measures or if the required outcome measure or high-priority measure was not submitted.
• Improvement Activities: CMS has released a list of suggested documentation examples for each of the 92 available improvement activities. For the highly weighted activities that many ophthalmic practices plan to submit, CMS will suggest appropriate documentation.

CMS indicates that the data validation criteria will be used as an element of forthcoming audits on MIPS data submissions. If a practice is contacted with an audit request, it has 10 business days to respond to CMS.

You’ve got this, right?

Mandate 3

The federal government mandated Medicaid in 1965 to assist the poor below the poverty level, seniors, people with disabilities, families with young children, pregnant women, and people without resources for long-term residential care. Since inception, the program expenditures have grown more than twice as fast as the GDP. The federal government primarily pays for Medicaid with contributions by the states. State contributions have risen from 9.5% of the total in 1990 to 19.7% today. Meanwhile, Medicaid spending has continued to consume an ever-greater percentage of the federal budget with each passing decade. In 1970, Medicaid spending was 1.4% of federal spending. In 1980, 2.4%; 1990, 3.3%; 2000, 6.6%. In 2010, 7.9%, and in 2017, 9.8%. Because of the unrestrained growth of this program, it is projected to become economically unsustainable.

We ask, what can be done about the growing cost of the Medicaid mandate and Congress debates mathematical formulas? Should Medicaid increases be tied to the CPI or the healthcare index? But the more important question might be, what should we do about the growing need for Medicaid? How do we combat the epidemics of obesity, drug abuse, teen pregnancy, and lifestyle-driven diseases, such as Type II diabetes and coronary artery disease, that plague our low-income communities and make people sick? What can we do to improve access to affordable, quality primary care and chronic disease management for low-income communities to help reduce costly emergency room visits and long-term care for chronic disease? What can we do to improve the health of people who rely on Medicaid? When we answer those questions, we bring down the cost of Medicaid and, at the same time, we build a better society. Medicaid costs are just one part of the overall healthcare reform package. We need bipartisanship and mature adults who can set aside self-interest to work for the health of the country. Is that asking too much?

These three mandates are all troublesome in their own ways. The first two compel increased overhead at a time of decreasing reimbursement. Mandate 2 proposes punishment for physicians and, by extension, their practices and ASC that “fall below the standard.” The third — and most contentious — mandate regarding Medicaid is convoluted and costly.

We are medical doctors. As such, it is our obligation to broaden our attention to the health of our country and government. Rather than a bandage, we need a complete overhaul. And that overhaul requires citizen and physician input. Through OOSS, ASCRS, AAO, and our individual efforts, we need to minimize new mandates, propose viable options, and continually work to modify outdated mandates to help benefit everyone, beginning with the patients we serve. ■