From The Editor

By noon on Monday, June 27, I felt like I had passed a kidney stone because that’s when I finally submitted my nine-page comment letter on the Medicare Access and CHIP Reauthorization Act (MACRA) of 2015. Writing a comment letter on MACRA was an agonizing project that entailed wading through the 900-page proposed rule that provided exhaustive details about how eligible clinicians will participate in what is now being called the “Quality Payment Program” via the Merit-Based Incentive Payment System (MIPS). Unless implementation is delayed, the rules that determine physician payment are due to take effect Jan. 1, 2017. In case you hadn’t noticed, that is less than six months away and the details are not yet final. The performance period is set to begin in calendar year (CY) 2017 so that the Centers for Medicare & Medicaid Services can use those data upon which to base providers’ CY 2019 payments.

As I have discussed before in this column, MIPS rolls all three of the current quality programs into one big incentive program in which practitioners will be rated on a point score of 0-100. In Year No. 1, the “quality” category (largely based on the current Physician Quality Reporting System) will count for 50% of the total score while the “Meaningful Use” category will be renamed “advancing care information” (and will contribute 25%) and the “cost or resource use” category will contribute 10%. However, there is a completely new category known as “clinical practice improvement activities” (CPIA) that will contribute 15% of the total score in the first year. I’ll focus on the CPIA in this editorial.

CPIA Subcategories 

MACRA specified six subcategories of activities that comprise CPIA:

1. expanded practice access,

2. beneficiary engagement,

3. population management,

4. patient safety and practice assessment,

5. care coordination, and

6. participation in an advanced practice model, including a medical home.

However, three additional subcategories were also suggested in the “proposed rule”:

7. achieving health equity,

8. emergency preparedness and response, and

9. integrated behavioral and mental health.

More than 90 different activities were listed in the proposed rule, each one classified as “high weight” (worth 20 points each) or “medium weight” (worth 10 points each). To get full credit for the CPIA category, a provider needs 60 total points comprised of activities from any combination of categories. However, as can be seen from reviewing only the nine broad subcategories listed above without even knowing the details of specific activities, many are not relevant to a wound care practitioner or will be extremely difficult for a practitioner to achieve working in a hospital-based outpatient center, long-term care facility, nursing home, or anywhere that is not a private-practice setting. For example, expanded patient access refers to evening or weekend services. Many activities are focused on primary care, such as integrating behavioral and mental health, care coordination, and participation in an advanced practice model or medical home. Yet, there are some CPIAs that are highly relevant to wound care practitioners, particularly those that can be reported through a qualified clinical data registry (QCDR) like the US Wound Registry (USWR). In a future article I will explain in detail how the USWR will introduce CPIA activities relevant to wound care practitioners. However, I write this column as we near our monthly publication deadline, now that all my 4th of July barbeque guests have gone home. I am thinking about one of the conversations that took place at the party when a seasoned teacher asked a young guest what grade she was in. My friend commented how nice it was that in her particular grade, she wouldn’t have to go through standardized testing and that she would have a much nicer year of school not having to spend time preparing for that test.  A few minutes later, my friend mentioned that she was tutoring a police officer in fractions because he failed that part of a math exam that he needed to pass for a job promotion.  

As I prepared my MACRA comments, I read those 90 CPIA projects and asked myself, “Is there any way we can make these useful to wound care practitioners? Or, will these projects end up being like those ridiculous standardized tests we took in school that didn’t seem to be useful for anything at all, but we had to do them because it was the law?”

CPIAs & QCDRs

Here are a few CPIAs that can be performed via a QCDR, and soon we will be discussing exactly how the USWR will provide them:

1. Use a QCDR to generate regular feedback reports that summarize local practice patterns and treatment outcomes.
2. Use QCDR data for quality improvement.
3. Participate in a QCDR that promotes the use of patient engagement tools.
4. Participate in a QCDR that uses data on patient experience.
5. Use QCDR data for ongoing practice assessment and improvements in patient safety.
6. Participate in a QCDR that uses standardized patient questionnaires.

We know there are wound care practitioners who still do not reliably provide vascular screening or diabetic foot ulcer offloading — that is the equivalent of a high school graduate who cannot do math fractions even when his job depends on it. So, while it may be true that MACRA is ridiculously complex and some of these requirements seem irrelevant, it is also true that some practitioners are still underperforming. The question before us is, “Can we design CPIAs that actually improve clinical practice?” 

I intend to see that we do.