Adapting to Change

  It was Viktor Frankl, PhD, MD, the late best-selling author and Holocaust survivor who once said, “When we are no longer able to change a situation, we are challenged to change ourselves.” Frankl, an Austrian psychiatrist, believed it was both possible and necessary to find meaning in even the most difficult circumstances.

  Today, we are in the middle of a fundamental restructuring of outpatient payment policy. That upheaval shouldn’t be classed with what Frankl endured, but it is certainly an event that we as individuals can’t control. The only thing we can do about healthcare reform is change ourselves and the way our wound centers operate. This issue of Today’s Wound Clinic (TWC) is devoted to helping readers reassess their wound centers and adapt to inevitable change.

  In fact, these changes bring some exciting new opportunities for wound care professionals willing to approach healthcare differently. If you are a regular TWC reader, you know the outpatient payment system is moving away from one based on volume to one based on value. At the upcoming Symposium on Advanced Wound Care, Guy Clifton, MD, author of the book Flatlined: Resuscitating American Medicine, will tell us what he learned as a health policy fellow at Robert Wood Johnson University Hospital, New Brunswick, NJ. (Hear Dr. Clifton in Session No. 15 on Oct. 17 at 9 a.m.)

  In previous articles I have detailed the need for quality measures (QMs) and the seven frustrating years I spent trying to get wound care and hyperbaric QMs into the Physician Quality Reporting System (PQRS). The reason that QMs are so important is this is the last year in which eligible professionals can obtain bonus money for PQRS reporting. Beginning in 2015, penalties for non-reporting begin with the loss of a percentage of Medicare payments. The Affordable Care Act will shift an even larger percentage of payments for both practitioners and hospitals to a value-based payment system. This transition will not be gradual. It could be complete in five years. And, it’s a zero-sum game, so the money for individuals who report will be taken from the individuals who do not report. We don’t just need “something” to report, we need real measures that assess whether clinicians are following clinical practice guidelines. The way the measures are designed may determine not only how we are reimbursed for years to come but how our patient care is publicly compared to our peers. Ask yourself: Upon which clinical activities or interventions would you like to be compared to your peers if that data were visible on the Internet?

  Just as I had about given up on the fight for wound care quality measures, the American Taxpayer Relief Act was passed by Congress Jan. 1, 2013. Press coverage has focused on the fact that it averted the “fiscal cliff” and blocked a scheduled 26% cut to physician payments. However, buried deep in the bill is important language recognizing the value of clinical data registries. Section 601(b) of the legislation outlines a new process through which physicians will be able to satisfy federal quality reporting requirements under PQRS by participating in a qualified clinical data registry (QCDR) as of 2014. Most important to the wound care industry, QCDRs do not have to use quality measures endorsed by the National Quality Forum, allowing us to circumvent this expensive and bureaucratic process. A QCDR must possess benchmarking capacity, allowing it to measure the quality of care that a clinician provides in comparison to other EPs, and it must be able to stratify patients by severity or risk. Risk adjustment is a corrective tool used to level the playing field in the reporting of patient outcomes, adjusting for the differences in severity among specific patients and making it possible to compare performance fairly. QCDR measures must cross three National Quality Strategy domains. And while a QCDR may report on process measures, at least one measure must be outcome-based and the outcome measure has to be risk adjusted.

  The US Wound Registry (USWR) is one of many specialty registries developed and operated by the Chronic Disease Registry. It became a PQRS registry at the outset of the registry process in 2008 and is one of the most experienced PQRS registries.

  As a nonprofit organization focused on quality of care for patients living with chronic diseases, USWR has helped shed light on “gaps in practice,” such as poorly implemented compression for venous ulcers and poorly implemented offloading in diabetic foot ulcers.^1,2 Building on this work, USWR started a “Do the Right Thing”TM project to pilot test QMs it developed (eg, venous ulcer compression, vascular assessment for leg ulcers, diabetic offloading).³ USWR worked with the Institute for Clinical Outcomes Research to develop the Wound Healing Index (WHI) to stratify patients by severity in order to provide a more fair way to report healing outcomes.⁴

  The wound care community can’t continue to report “98% healing rates,” which are patently ridiculous. Like other specialty societies, the only way to demonstrate the value of our interventions is by reporting the percentage of patients we heal who were expected to fail based on their risk – not by excluding sick patients from the dataset. (Trauma surgeons do not measure success by simply reporting, “everyone lives!”; instead, they report survival according to the patient’s likelihood of death based on the severity of injuries.) The USWR has a history of developing wound care QMs, testing them in practice, using them to improve patient quality of care, and being alone in understanding the need for risk stratification in outcomes reporting.

  Thanks to QCDR legislation, registries that had been in existence for at least one year (since Jan. 1, 2013) can create their own QMs. At last, the door to wound care and hyperbaric measures opened to us — but we only had a few days to design up to 20 measures, a process that normally takes months. In addition, the QCDR legislation was really directed at specialty societies. However, since “wound care” is not recognized by the American Board of Medical Specialties, who would provide the imprimatur for all the measures that the field of wound healing needed?

  The Alliance of Wound Care Stakeholders convened a conference call with the Centers for Medicare & Medicaid Services (CMS) to request that, given its unique role as an umbrella organization for so many professional societies, the Alliance be allowed to function as a de facto specialty society for the field of wound care. CMS readily agreed.

  During that call, Alliance members also explained to CMS why “process” measures were important to the field of wound healing. Although CMS might only want “outcomes” (eg, healing rates) for many therapies, “healing” is not the ultimate goal. As a result of USWR publications demonstrating gaps in practice for compression and offloading, CMS agreed to allow process measures in the field of wound care.

  The Alliance and its member organizations have worked diligently with USWR to craft a suite of 12 QMs. The American Podiatric Medical Association was also particularly helpful, providing detailed measures relevant to the diabetic foot.

  Specifications for all measures developed can be viewed at: www.uswoundregistry.com/specifications.aspx. Providers using any certified electronic health record (EHR) can report QMs through the USWR by providing these specifications to their EHR vendors. CMS has specifically discouraged the idea of “vendor specific” QCDRs. The USWR can receive QM data from any EHR certified for stage II of Meaningful Use. For 2014, eligible professionals who satisfactorily report data on nine wound care QMs through the USWR are eligible to receive an incentive equal to 0.5% of the total estimated Medicare Part B-allowed charges for all covered professional services furnished during the applicable reporting period. Eligible providers who don’t satisfactorily report data on QMs in 2014 will experience a 2% loss of Medicare billing in 2016. Transmission of data to the USWR can also be used to meet the registry reporting option for stage II of Meaningful Use.

  While the shift from our current payment model is difficult, it is possible to use well-designed QMs within USWR as opportunities. Individual providers can publicly demonstrate clinical excellence using USWR measures. Thanks to the WHI, we can stratify patients by risk (severity) and begin reporting outcomes based on predicted likelihood of failure. It is now possible for clinicians to report, for example, that in the category of wounds with only a 25% likelihood of healing, 50% of wounds were healed. That is how we demonstrate the real value of services. If you are looking for a clinician to care for a loved one with a poor prognosis, you choose a provider who has good outcomes with very sick patients. Wound care providers who report USWR “appropriate use” measures can demonstrate to payers that they implement advanced therapeutics wisely and may be able to negotiate insurance contracts on that basis. USWR data can be used to create national benchmarks for patient risk as well as demonstrate the value of a variety of clinical interventions. USWR, in conjunction with the Alliance, is continuing to develop new QMs based on clinical evidence. We can’t change our situation, but we can change our practice and the way our facilities operate.

  Caroline E. Fife is chief medical officer at Intellicure Inc.; executive director of USWR; medical director of St. Luke’s Wound Clinic, The Woodlands, TX; and co-chair of the Alliance of Wound Care Stakeholders.

References

1. Fife CE, Carter M, Walker D. Why is it so hard to do the right thing in wound care? Wound Rep Reg. 2010.18;154–158.

2. Fife CE, Carter MJ, Walker D, Thomson B, Eckert KA. Diabetic foot ulcer offloading: The gap between evidence and practice. Data from the US Wound Registry. Adv Skin Wound Care. 2014. 27:7;310-316.

3. Horn SD, Fife CE, Smout RJ, Barrett RS, Thomson B. Development of a wound healing index for patients with chronic wounds. Wound Repair Regen. 2013. 21:6;823-832.

4. Fife CE, Walker D, Thomson B. Electronic health records, registries, and quality measures: What? Why? How? Adv Wound Care. 2013. 2:10;598-604.

5. Fife CE, Carey D, Spong K, Strba B, Wall V. Remote medical quality management: Improving physician practice standards in wound care by telemedicine. 2013. 20;46-50.