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

Author(s): 
Caroline E. Fife, MD

   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.

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