The Affordable Care Act (ACA), which the Supreme Court recently upheld, creates a new value-based payment modifier. Starting in 2015, this payment modifier will provide differential payments to doctors based on quality and cost of care. Since the payment adjustments are to be budget neutral, some physicians will receive bonuses and others penalties under this provision. It is likely that payment based on quality measures will soon represent a substantial portion of a physician’s income.
For more than a decade, multiple stakeholders have worked to create reliable and valid measures of care to be used in public reporting, provider profiling and value-based payment. Practitioners who treat diabetic foot wounds and wound care manufacturers need to hear the message that “value-based purchasing” is here. Clinicians who practice wound care must find a way to participate in this system or they will be unable to get reimbursement for their services as healthcare reform moves away from the “fee-for-service” model.
The movement away from fee-for-service began in earnest in 2006 when President Bush signed the Tax Relief and Health Care Act, which authorized the Centers for Medicare and Medicaid Services (CMS) to establish and implement a physician quality reporting system. In response to the mandate, the CMS created the Physician Quality Reporting Initiative, also known as “Pay for Performance.” The Medicare Improvements for Patients and Providers Act of 2008 authorized a 2 percent bonus for those who successfully reported quality measures and this increased to 4 percent in 2011 (2 percent for the Physician Quality Reporting Initiative plus 2 percent for electronic prescribing).
Initially, physicians reported measures using their claims. This method was not very successful because it was complex and required a lot of work to be done by hand. Accordingly, in April 2008, the CMS expanded the data collection process to include reporting data via qualified patient registries.
However, the real goal is to have every physician report his or her data directly from their electronic health records. Eventually, all physicians will send their raw data to the CMS and the CMS will calculate whether they passed the quality measure.
Participating in the Physician Quality Reporting Initiative (now called the Physician Quality Reporting System or PQRS) has been challenging for wound care clinicians. At the outset, there were no measures directly applicable to wound care clinicians. Subsequently, there was one measure that specifically addressed the percentage of patients with venous ulcers who were prescribed (any type of) compression once in the year in which they were treated. Since it was necessary to report at least three measures successfully to get the bonus money, wound care physicians had to select some other measures to report that were not directly applicable to wound care (e.g. screening for fall risk, tobacco cessation counseling, diabetic blood pressure control, etc.).
The Affordable Care Act makes a number of changes to the Physician Quality Reporting System. Eligible professionals who do not satisfactorily report data on quality measures for the Jan. 1, 2013 to Dec. 31, 2013 reporting period will see a reduction in their Medicare fee schedule payments of 1.5 percent in 2015 and will lose 2 percent in 2016 and each subsequent year.
Who Would Take The Lead On Wound Care Quality Measures?
The National Quality Forum is charged with endorsing national consensus standards for measuring and publicly reporting on performance. The American Medical Association (AMA) convened the Physician Consortium for Performance Improvement more than a decade ago.1
Specialty societies have also worked hard to develop measures relevant to their patients and their practitioners. The fragmentation of wound care among many different organizations substantially weakens its ability to develop measures since membership dues often support quality initiatives. Furthermore, since there are numerous wound care societies, no one organization is poised to take the lead in this endeavor.
Questioning The Current Quality Measures Specific To Wound Care
When the AMA decided to look at wound care as part of its Physician Consortium for Performance Improvement project, it went to the American Academy of Plastic Surgery for guidance since that group limits its voting members to groups with seats on the AMA House of Delegates. The AMA does not recognize “wound care” as a medical specialty so wound care clinicians do not have representation in the Physician Consortium for Performance Improvement.
The seven wound care quality measures this group developed are posted on the AHRQ National Quality Measures Clearinghouse Web site.2 Only one of these measures (offloading a diabetic foot ulcer) would likely have ever been developed by clinicians who were in the full time practice of wound care.
The CMS selected two of these measures to add to the PQRS program. It selected the two “overuse measures.” This is likely due to the CMS trying to reduce overuse of resources in general.
A physician would “pass” these measures by not performing a swab culture of a wound and not using a saline wet-to-dry dressing. However, there is a mistake with the way that the swab culture measure was designed in that the “denominator,” rather than being “all wounds which were cultured,” is “all chronic wounds.”3
The effect of this design flaw is that physicians would pass the measure if they never performed a wound culture at all on any wound.
It is best to read the definition of the measures in detail. However, here is a brief summary of the current PQRS measures relevant to wound care.
• A venous ulcer measure passes if the physician prescribes venous compression one time in a 12-month period. (This is certainly insufficient to actually heal an ulcer.)
• There is a measure of patient education on the need for venous compression (but it has nothing to do with the actual care of a venous ulcer).
• There is a measure of patient education on diabetic foot care, which does not actually measure physician care of diabetic foot ulcers.
• Another measure is not performing saline wet to dry dressings of a wound. (Accordingly, any other wound dressing will pass the measure, regardless of whether the dressing is indicated in that particular wound or ulcer.)
• Another measure is not performing a swab culture of a wound. (This is incorrectly designed as a physician passes the measure by never performing a wound culture at all.)
• There is a measure for the prescription of diabetic foot ulcer offloading.
There are some other measures that are indirectly relevant to wound care such as hemoglobin A1C measurement and smoking cessation.
Clearly, practitioners of advanced wound care need to develop better measures that reflect the care they provide to patients. However, if quality measures are a large component of physician payment, even bad measures are better than none at all.
Theoretically, there are four different ways that an eligible provider can submit data to the CMS. These approaches are: claims-based, registry-based, electronic health records (EHR) direct and group practice reporting. However, since neither the group practice nor the EHR direct options include any of the wound care measures, wound care clinicians can, by default, use only claims-based or registry-based reporting right now. To become eligible for an incentive, an eligible professional must submit each measure on 80 percent of eligible beneficiaries, and no measure or measures group can have a 0 percent performance rate.
A Closer Look At The Financial Incentives For Meaningful Use Of EHR
I hope you are getting the picture that while this process is about improving the quality of care for patients in the U.S., it is also about developing a nationwide program of data transmission to CMS regarding clinician adherence to practice standards.
The move toward nationwide transmission of healthcare data took a giant step forward with the passage of the piece of legislation known as the Health Information Technology for Economic and Clinical Health Act (HITECH Act), which President Obama signed into law in February 2009 as part of the economic stimulus bill.
The Medicare EHR Incentive Program pays up to a $44,000 bonus to each eligible provider who adopts and “meaningfully uses” an electronic medical record. One major component of demonstrating meaningful use is the calculation and reporting of Clinical Quality Measures. Eligible providers must submit three core measures and three additional Clinical Quality Measures from a set of 38. Clinicians can submit three alternate core measures if data are insufficient for the three core measures.
Let us review these confusing initiatives and how they relate (or don’t relate) to wound care clinicians. Under the HITECH Act, the “meaningful use” of an electronic health record requires a practitioner to submit three Core Clinical Quality Measures or three alternate quality measures plus three “additional measures” for a total of six. If you do this, you are on track for your HITECH bonus money.
Under PQRS in 2013, there are 265 quality measures, of which you must submit at least three in order to get a 0.5 percent bonus or avoid a 1.5 percent “adjustment.” The CMS worked with the National Quality Forum to retool 113 of the 265 PQRS measures for 2013 into “electronic measures” and of those, CMS selected 51 to be part of the “EHR Direct” program. Given that those 51 EHR measures contain all 44 of the HITECH measures (six core + the 38 menu), you can use the “EHR Direct Pilot” program to meet both the HITECH meaningful use requirements and PQRS. When you submit your measures through EHR Direct, you get your 0.5 percent PQRS bonus, you avoid your 1.5 percent adjustment (the reduction in your total Medicare billing for not reporting), and you have met part of the requirement for your HITECH adoption money.
Here is the problem for wound care doctors: None of the “EHR measures” are relevant to wound care. There are no electronic measures that relate to wound care.
How Can We Move Forward To Truly Measure Quality In Wound Care?
Wound care practitioners need to consider the types of quality measures by which they would like to be measured. What measures would improve patient outcomes, decrease cost and reflect the quality of care provided? Most of us would agree that the current measures do not do this but the answer to the problem is not to refuse to participate.
The answer is to work collectively to develop and test better measures. We must begin to act like the specialists we believe we are if we want to continue to care for patients in the face of healthcare reform. The measure development and testing process to meet CMS standards is not a simple process. Wound care organizations and manufacturers need to combine their resources to create and test electronic measures. This will require substantial funding.
If we begin working now, we might have wound care quality measures ready by 2015 when value-based purchasing is a reality. If we do not create and test wound care quality measures within the next 12 months, the wound care industry may not survive the next decade.
Dr. Fife recently retired after serving as a Professor of Medicine in the Division of Cardiology and the Director of Clinical Research at the University of Texas Health Science Center in Houston. She is now in the private practice of wound care and hyperbaric medicine in The Woodlands, Texas. Dr. Fife is also the Chief Medical Officer of Intellicure.
1. Available at http://www.ama-assn.org/ama/pub/physician-resources/physician-consortium... . Accessed Aug. 10, 2012.
2. Available at http://www.qualitymeasures.ahrq.gov/browse/by-organization-indiv.aspx?ob... . Accessed Aug. 10, 2012.
3. Available at http://www.qualitymeasures.ahrq.gov/content.aspx?id=27944 . Accessed Aug. 10, 2012.
For further reading, see “Pay For Performance: How Will It Impact Diabetic Foot Care?” in the June 2007 issue of Podiatry Today, “Turning Evidence Into Practice: A Guide To Treating Chronic Wounds In The Diabetic Foot” in the September 2007 issue or “A Guide To Achieving CMS ‘Meaningful Use’ Standards” in the October 2011 issue.