Pay For Performance: How Will It Impact Diabetic Foot Care?

By Caroline E. Fife, MD

A dilemma of modern medicine is that reimbursement has become procedurally based. Clinicians are paid for what they do for patients, not for what they refrain from doing. Accordingly, the system, by its very nature, encourages intervention. Indeed, when one considers the combination of high patient expectations, the availability of technology, the economic pressures to generate revenue for economic survival and the litigious nature of society, the result is a higher probability of medical interventions.    For this reason, Medicare and other payors are experimenting with pay for performance and other systems that hope to reward clinicians for knowing when advanced technology is really necessary and when high quality conservative care is sufficient. Most doctors try to deliver the highest level of medical care they can. However, the late Ron Bangasser, MD, one of the architects of pay for performance in California, pointed out that while most patients rate their doctor as 4+ out of 5, they think healthcare in America is bad and they are right.    Studies show approximately 50 percent of patients do not get good quality medical care. There is also the low use of evidence-based medicine relative to national or regional benchmarks. Physicians are unable to track or even find their lab tests. Eighty-five percent of physicians in 2005 could not generate a registry list, a list of test results or a list of current medications. In addition, 33 percent of physicians repeat tests because results are unavailable; 15 percent of observed abnormal tests were not followed up; and only 18 percent of physicians have data on patient outcomes.    The fact is clinicians cannot keep track of everything they need to do for every patient. For example, in a study in which an electronic medical record (EMR) was used to provide point of service reminders, 51 percent of eligible patients got the flu vaccine versus 30 percent without a reminder. If physicians need a point of service reminder to perform one simple task for their patients, what about the myriad of practice guidelines currently available for conditions ranging from diabetic foot ulcers to neuromas?    With today’s focus on evidence-based care and practice guidelines, clinicians must retain an unmanageable amount of knowledge to deliver consistent care.1 Simple reminders generated at the moment of care in EMR systems have led to providers performing actions that would have otherwise been overlooked.2 When EMR incorporates clinical practice guidelines, it can streamline care, reduce costs and improve outcomes.

A Closer Look At Evolving Quality Improvement

Quality improvement programs began with reviewing the “bad outcome cases” and punishing the “bad” doctors. This progressed to quality improvement “protocols” (standard protocols particularly for conditions such as myocardial infarction or pneumonia that require hospitalization) and then outpatient registries (such as for registries for preventive care like mammograms).    What defines quality healthcare? According to Terris King, who is with the Office of Clinical Standards and Quality at the Centers for Medicare and Medicaid Services (CMS): “Quality health care means doing the right thing at the right time in the right way to the right person and having the best results possible.” This does not mean that all our patients get well. It does mean that we perform the right diagnostic tests, make the right diagnosis, implement the correct treatment plan and provide the best possible care in a timely fashion.    There were a variety of factors that led to the development of pay for performance. Among these factors were employer and government concern over rising healthcare costs and deficiencies in the United States healthcare system. The U.S. has a $1.7 trillion health-care industry that still largely records patient information with pen and paper.    Reportedly, only 17 percent of U.S. physicians are currently using EMRs. The Computer-based Patient Record Institute (CPRI) stated that if providers continue with their current paper systems, they will lack the tools needed to manage the quality and costs of healthcare, the scientific basis for healthcare will continue to be undermined, and healthcare reform will be impeded.3

Redefining The EMR System

Also keep in mind that the EMR offers an integration of patient information systems that captures and stores demographic, financial and medical information. They are not simply automated forms of paper charts. According to the Health Information Management Systems Society, a system meets the definition of an EMR system when it is:    •    real time (point of care documentation);    •    reliable (no downtime);    •    secure (Internet systems are unlikely to meet this standard at the present time);    •    is the legal medical record in that the system can operate in a paperless fashion;    •    assists with evidence-based care;    •    automates work flow; and    •    collects the data needed for billing and clinical research.4    While these requirements are complex and specific, in the field of wound management, they are also repetitive, relatively uniform from one patient to another, and involve a small number of procedure codes. Perhaps the most important aspect of a wound specific EMR is its effect on quality of care. For nearly two centuries, the quality of care received by a patient has been dependent on the experience of practitioner. Patients may eventually get the care they need (vascular screening, evaluation for osteomyelitis, etc.) but delays to obtaining these studies negatively affect both outcome and revenue.

How Will Pay For Performance Work For Diabetic Wound Care?

It is generally agreed that healthcare providers should perform certain clinical interventions for certain medical problems, in certain patients, and within a specific time or in a specific sequence. Implementing this requires the following things:    •    an agreement regarding what care one ought to provide for a given clinical problem (clinical practice guidelines);    •    the selection of specific performance criteria to decide upon the care provided; and    •    a method of clinical surveillance to determine if the performance criteria were met.    Most pay for performance strategies focus on various aspects of primary care. However, when reviewing a list of the 10 diagnoses for which CMS expends the largest amount of its budget, three of them are related to diabetes. It is estimated that $8.5 billion is spent for wound care products and services, according to the transcript of the March 29, 2005 Medical Carrier Advisory Meeting (MCAC). Two percent of all chronic ulcerations are caused by diabetes. The prevalence of diabetes in the population is increasing at 14 percent per year and diabetic wounds represent 80 percent of all chronic wound costs. It seems inevitable that pay for performance will reach diabetic wound care in the near future.    At this time, several national organizations have established evidence-based guidelines, all of which are available online. Those created by the Wound Ostomy Continence Nurses (WOCN) are available at The National Quality Forum is an organization that endorses national consensus standards for measuring and publicly reporting on performance. The National Quality Forum endorsed standards will become the primary standards used to measure the quality of health care in the United States. At this time, there are only a few standards pertaining to diabetes.5-7 For an abbreviation of the WOCN guidelines for diabetic foot ulcer care, see “Basic Interventions For Diabetic Foot Ulcer Care” below.

How Can You Meet The Challenge Of Pay For Performance?

Clinicians cannot meet the challenge of pay for performance without a level 4 EMR. This will require an information technology (IT) investment. While this is a barrier to participation initially, EMRs will soon be known as the IT investment needed for bonus calculation.    There are several pay for performance opportunities for clinicians. Pay for performance offers a quality incentive based on money saved. Improved quality means less litigation and pay for performance offers increased clarity about what is reimbursed. In addition, there is also feedback about clinical outcomes, which allows learning and improves outcomes. Pay for performance leads to increased consistency of care between both between clinicians and across settings.    In preparing for pay for performance in wound care and ensuring appropriate treatment of patients at risk for developing a wound, one should emphasize the following:    •    consistent evaluation and treatment plans;    •    disease management to lower chronic wound risk;    •    consistent measurement and reporting of outcomes; and    •    consistent documentation of care; For patients with wounds, one should:    •    stop causes of pain and tissue deterioration;    •    optimize the healing environment    •    reduce pain and infection (associated with gauze use); and    •    remove devitalized tissue which can be an infection focus.    Physician payment is about to undergo a paradigm shift. While dramatic changes like this are difficult, pay for performance represents an opportunity for clinicians to improve patient care. Dr. Fife is an Associate Professor in the Department of Anesthesiology at the University of Texas Health Science Center in Houston. She is the Director of Clinical Research at the Memorial Hermann Center for Wound Care. She is also the President of Intellicure, a wound specific EMR provider. Dr. Steinberg (pictured at left) is an Assistant Professor in the Department of Plastic Surgery at the Georgetown University School of Medicine in Washington, D.C.



References 1.    Siwicki B. Outpatient electronic records. Tackling the challenges. Health Data Management, May 1997, 5: 66-68, 70, 74, 76-78, 81. 2.     Khoury A. Support of Quality and Business Goals by an Ambulatory Automated Medical Record System in Kaiser Permanente of Ohio. Effective Clinical Practice, October/November 1998, 1: 73-82. 3.     CPRI Workgroup. Valuing CPR Systems: A Business Planning Methodology. Schaumburg, IL: Computer-based Patient Record Institute, 1997. 4.     HIMSS Electronic Health Record Definitional Model Version 1.0 2004. 5.     Adult diabetes: percentage of smokers who were recommended or offered an intervention for smoking cessation (i.e., counseling or pharmacologic therapy). National Diabetes Quality Improvement Alliance 2003 May. NQMC:000616. Accessed at 6.    Adult diabetes: percentage of patients receiving at least one complete foot examination (visual inspection, sensory exam with monofilament, and pulse exam). National Diabetes Quality Improvement Alliance 2003 May. NQMC:000610. Accessed at 7.     Adult diabetes: percentage of patients receiving one or more A1c test(s). National Diabetes Quality Improvement Alliance 2003 May. NQMC:000596. Accessed at Additional References 8.     Shortliffe EH. The evolution of electronic medical records, Academic Medicine 1999;74(4):414-419. 9.     Dassenko D, Slowinski T. Using the CPR to benefit a business office. Healthcare Financial Management, July 1995, 49: 68-70, 72-73. 10.    Mildon J, Cohen T. Drivers in the electronics medical records market. Health Manage Tech, May 2001;22: 14-6, 18. 11.    Fife CE, Walker D, Farrow W, Otto GH. Wound center facility billing: a retrospective analysis of time, wound size, and acuity scoring for determining facility level of service. Ostomy Wound Manage 53(1); 34-44, 2007.


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