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5 EW SHOW DAILY ASCRS•ASOA Symposium & Congress, Los Angeles 2017 Providers who report all the required measures and meet the thresholds and benchmarks in each of the categories for at least 90 days, or up to a full year, have the greatest potential for a bonus and to avoid the penalty, she said. Another op- tion is to participate in an advanced APM. To avoid a penalty for 2019, a provider must score at the 2017 MIPS performance benchmark of 3 points, Ms. Madson said. Reporting one quality measure on one pa- tient, one improvement activity, or the base measures for ACI on one patient will achieve a MIPS score of 3 and avoid the penalty. Physicians can earn additional MIPS points by reporting more data for the poten- tial to earn a bonus. Additionally, a MIPS performance score of 70 or above qualifies as "exceptional performance" and is eligible for ad- ditional incentive payments. EW Editors' note: Ms. McCann and Ms. Madson have no financial interests related to their comments. IPAB; drug compounding; off-label communications; and cleaning and sterilization guidelines. Ms. McCann mentioned addi- tional legislative priorities, including the Medicare Patient Empowerment Act, which allows doctors and patients to contract privately on a case-by-case basis without opting out of Medicare, as well as the REINS Act, which requires Congressional approval for major federal rules. Two big issues relating to FDA advocacy are drug compounding and off-label communication. In terms of drug compounding, she said that the ophthalmic commu- nity is advocating for changes to office use and protecting access to repackaged Avastin (bevacizumab, Genentech, South San Francisco). Legislation is being worked on to allow traditional (503A) compound- ing pharmacies to produce drugs for office use without a patient-specific prescription. Additionally, there has been successful advocacy for ex- tended "beyond use dates" to retain access to repackaged Avastin, Ms. McCann said, but there are concerns that small facilities will not under- take the costs of sterility testing. Meanwhile, recent court decisions have caused the FDA to re-evaluate off-label policies, she said. ASCRS and the Alliance of Spe- cialty Medicine testified at the FDA. The second part of the session looked at the Merit-Based Incentive Payment System (MIPS), and Ms. Madson went into depth on specifics of the new program and options for providers. MIPS consists of giving a composite score of quality (60% for the first year); cost (0% for the first year); advancing care information, or ACI, (25%); and improvement activities (15%). MIPS streamlines PQRS, VPBM, and EHR Meaning- ful Use, and the existing penalties sunset at the end of 2018 (based on 2016 reporting). The final MACRA rule was released on Oct. 14, 2016, and it in- corporates the majority of the flexi- bility and reduced reporting burdens advocated by ASCRS and the medi- cal community in comments on the proposed rule, including a flexible and reduced first performance peri- od to avoid a penalty, reduced qual- ity reporting threshold, elimination of the cross-cutting measure require- ment, resource use was not scored in year 1, and a reduced number of ACI measures. Ms. Madson spoke about the 2017 performance period options in order to avoid a penalty in 2019, stressing that a provider can "pick your pace." To avoid the penalty, physicians can report one quality measure for one patient and not have to meet the measure bench- mark; one improvement activity; or the required base measures for advancing care information (ACI). To be eligible for a small bonus and avoid a penalty, providers can choose to report for at least 90 days: two or more quality measures on one patient and not have to meet the measure benchmarks; more than one improvement activity; or the re- quired base measures and additional performance measures for ACI. Legislative continued from page 1 Innovator's continued from page 1 by MIGS," Dr. Brown said. "I have been attempting to innovate in glaucoma surgery for more than 3 decades … most products are unfortunately on the flat part of the curve, but I have contributed to the growth," he added, pointing toward an exponential growth curve chart tracking the evolution of MIGS. At the time when he was tout- ing the possibility of glaucoma as a surgical disease, it was a contrarian opinion, Dr. Brown said. Glaucoma was thought of as a medical disease and surgery too risky. But the hard reality, he said, is that medical ther- apy carries the issues of non-com- pliance, side effects, and long-term expense. When you compare eyes on drops to eyes that have had sur- gery, the proof is in the pictures. Dr. Brown first worked with a device, originally designed by anoth- er physician as a vitreous cutter, modified into the glaucoma me- chanical trephine, or "trabecufine." The device allowed for an ab-interno trabeculectomy. However, there were issues with the outcomes—trouble with the hole, scarring—and Dr. Brown said it was abandoned before viscoelastic and mitomycin-C could have helped it along. "What we needed was a device to keep the hole open and control flow. I couldn't accept that blebs were going to be key to glaucoma surgery," Dr. Brown said. Along this vein, Dr. Brown patented a tack, which he called the glaucoma faucet, that could control pressure from the cornea. Looking for support, Dr. Brown pitched the idea to two companies and was ultimately rejected. This device laid the groundwork for the MicroOptx Brown Glaucoma Implant (Maple Grove, Minnesota), which is begin- ning FDA trials. In 1995, Dr. Brown and his wife developed a technique for a 360-de- gree trabeculotomy in congenital glaucoma patients. This was the precursor for gonioscopy-assisted transluminal trabeculotomy (GATT). Next, Dr. Brown developed a T-tube, a trabecular bypass device to improve outflow in both direc- tions into scleral collector channels. This device called EyePass—similar in mechanism to iStent (Glaukos, San Clemente, California)—was eventually abandoned after several FDA trials when its sponsor ran into financial trouble. Why did iStent succeed while EyePass did not? Dr. Brown asked. He called it the Columbus effect. "The first person often misun- derstands the real market and misses the opportunity," he said. While EyePass was looking at refractory glaucoma, hoping to replace trabeculectomy, went surgi- cally from the outside in, and was not combined with cataract, iStent targeted mild to moderate glaucoma, sought to reduce medications, went ab-interno, and was combined with cataract surgery. With iStent, other recently approved MIGS devices, and those in the pipeline, are we there yet, is glaucoma now a surgical disease? Dr. Brown asked. While it's certainly moving in that direction, Dr. Brown said cur- rent MIGS rely on passive pressure to lower pressure. While this is safe, he thinks we need active flow, a pump. "Nature's pump is cilia, and they're everywhere and they're amazing," he said, going on to describe research on the develop- ment of a pseudo-cilia, powered by magnets, that could someday be lined up in rows and used as a pump in conjunction with MIGS. "If this is like our other prod- ucts, it will be a product in 10 to 15 years by someone else," Dr. Brown quipped. "We need more innovation, and MIGS has been great, but one of the finest things about MIGS is it gives us hope for the future that one day we will solve glaucoma," Dr. Brown concluded. Ahead of Dr. Brown's lecture, David Parke II, MD, CEO, American Academy of Ophthalmology, San Francisco, discussed how big data could drive ophthalmic innovation. Sean Ianchulev, MD, New York, presented micro-interventional endocapsular lens fragmentation for low-energy phaco surgery using the miLoop (IanTECH, Reno, Nevada). Shin Yamane, MD, PhD, Yoko- hama, Japan, presented flanged IOL fixation in the sclera using a double-needle technique. Richard Lindstrom, MD, Minneapolis, high- lighted research about an eye drop (EV06, Novartis, Basel, Switzerland) that reverses crosslinking effects in the lens for the treatment of pres- byopia, while Brian Francis, MD, Fountain Valley, California, present- ed on the benefits that aqueous an- giography could provide to surgical glaucoma and the current state of that technology. EW Editors' note: Dr. Brown has finan- cial interests with Allergan (Dublin, Ireland), Rhein Medical (St. Petersburg, Florida), and Glaukos. Dr. Ianchulev has financial interests with IanTECH. Dr. Lindstrom has financial interests with Novartis. Drs. Parke, Yamane, and Francis have no financial interests related to their comments.

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