Has Wound Care Lost its 'Cheese'?

I recently reread the book Who Moved My Cheese? by Spencer Johnson. It’s an allegorical tale about response to change and illustrates the way people’s attitudes can determine whether they succeed or fail when faced with changes that impact their livelihood (losing their “cheese”). Healthcare reform in the form of the Medicare Access and CHIP Reauthorization Act of 2015 (MACRA) and Merit-Based Incentive Payment System (MIPS) has moved our cheese. We can get new cheese, but we will all have to adopt new habits. Eric Lullove, DPM, CWS, FACCWS, and I will present on MIPS with a “Who moved my cheese?” theme at SAWC Spring in San Diego (April 5-9). We intend to explain, in as much detail as time allows, how practitioners can succeed with MIPS. Also at SAWC Spring, be on the lookout for a special issue of Today’s Wound Clinic (TWC) focused on reimbursement, which will be developed by Kathleen Schaum, MS, and provide more detailed information about MACRA. 

I have spent months reviewing the painful details of MIPS. It’s well publicized that clinicians can lose 4% of Medicare Part B billing if they don’t participate in 2017. What is not well known is that $500 billion has been set aside to reward “exceptional performance” with MIPS. Although the math is complicated, it’s theoretically possible for a practitioner who performs at the top of the scale to earn a bonus of 22% of Medicare Part B payments. You probably don’t know that the top-tier performers in the Physician Quality Reporting System earned 147% of their Medicare Part B payments, funded by the huge majority of physicians who failed. Under MIPS, the only way wound care practitioners can access the bonus money is through participation in a qualified clinical data registry (QCDR) that submits the usual quality measure data to the Centers for Medicare & Medicaid Services, offers “high-value” optional measures (such as patient-reported measures and risk-stratified outcome measures), and has crafted clinical practice-improvement activities that can be reported through the QCDR. The U.S. Wound Registry (USWR) offers high-value measures relevant to wound care. These measures were developed via a consensus process in 2014 with representatives from most wound care organizations, including the Association for the Advancement of Wound Care. Conference calls to develop the first suite of 14 quality measures were convened by the Alliance of Wound Care Stakeholders. I’m proud to have been part of that initial effort. However, in 2013 none of us could have known how important our efforts were going to be. MIPS began Jan. 1, 2017. Every wound care practitioner who sees Medicare patients and is not exempted from MIPS for specific reasons is already impacted by it and subject to it. Big changes continue for Medicare coverage policy affecting hyperbaric oxygen therapy (HBOT). There’s an expanded auditing program that’s part of the prepayment review of HBOT, and Helen B. Gelly, MD, FUHM, FACCWS, UHM/ABPM, offers a must-read list of items clinicians must include in their documentation in order to remain compliant for Medicare payment of HBOT. 

Compliance & HIPAA

However, there’s another kind of compliance risk we all face — the risk of HIPAA violations. Roger Shindell, MS, CHPS, CISA, authors a column on a HIPAA-related issue we face every day — texting about patients on a smartphone. Being able to text a wound photo to colleagues, particularly if you are about to place a negative pressure dressing or a total contact cast that will keep them from being able to see the wound’s progress, can be incredibly helpful. Of course, I’d much prefer to send wound photos via email directly from my electronic health record (EHR), but my hospital (like most) is worried about HIPAA violations and won’t enable the email feature on my EHR. The logical way around this barrier is to text a photo. I’d bet everyone reading this has done so. In fact, last week one of my favorite interventional cardiologists texted me the angiograms of a woman whom I referred to him urgently, in order to show me that he had saved her leg(s). She is in her 80s, lives with early-stage dementia, and has horrible bilateral ischemic rest pain that requires her to sleep in a chair. Her primary cardiologist sent her to me for lower extremity edema and draining leg ulcers. There was little I could do to fix those problems when I found her skin perfusion pressure was in the single digits on both legs (eg, 8 mmHg instead of > 40 mmHg). Thanks to a different cardiologist, she now has blood flow. The poor practices I see with regard to vascular screening never cease to amaze me, even by those who are supposed to be “experts” in the field. (By the way, vascular screening of patients living with leg ulcers is a USWR quality measure). Dr. Lullove; J.A. Mustapha, MD, FACC, FSCAI; and Audrey Moyer-Harris, BSN, RN, CWCN, MBA, have collaborated on a fantastic article on critical limb ischemia that readers may want to share with their collaborating physicians.

I’m grateful to HMP Communications and to TWC for being dedicated to the field of wound care. TWC is “getting the word out” on the impact of healthcare reform and how wound care practitioners can “survive” and even thrive under new rules. We strive to make each edition of the journal full of vital information that’s directly relevant to your patients and your practice. I hope to see you in person at SAWC! Please seek me out to give me your personal feedback regarding what you like, what you don’t like, and what you hope to get from future issues of TWC. 

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