Quality Measures And Value-Based Payment: What Wound Care Clinicians Should Know

Author(s): 
Caroline E. Fife, MD

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

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