Preparing for a Quality-Based Payment System

  On Jan. 27, the Obama administration released its goals for overhauling the US healthcare payment system. For readers of Today’s Wound Clinic, discussion related to the shift from volume-based payment to a system based on care quality has been ongoing. The traditional Medicare fee-for-service system cost taxpayers $362 billion last year. Data show that resources are often overused and misused with almost no relationship between spending and quality of care. The 2010 Affordable Care Act expanded payment models that reward providers for the value of care provided, including bundled payments for certain episodes of care and the creation of accountable care organizations (ACOs) in which provider groups share the savings – or the losses – for managing patients on a budget. These alternative payment structures currently represent about 20% of Medicare payments. With the recent announcement made by US Health & Human Services (HHS), we now have a “clear timeline” for moving from volume to value in Medicare. HHS plans to tie 30% of traditional payments to quality or value through alternative payment models such as ACOs before 2017. The ultimate goal is for 50-90% of all payments to be “value based” by 2018. To accomplish this, HHS is creating the Health Care Payment Learning and Action Network to help expand value-based payment within the private sector as well as to state Medicaid systems. About 20% of provider payments by Blue Cross® Blue Shield® insurers are already through contracts that prioritize quality over quantity. Aetna® officials say 28% of their reimbursements are in valued-based contracts and they expect 75% by 2020.

Effects on Wound Care Reimbursement

  It is still unclear how wound clinics and wound care clinicians will experience this titanic change. We do know the discussion about value-based payment is no longer theoretical. Within three years more than half of Medicare payments will be value-based. Within five years virtually all Medicare payments and nearly all private insurance payments will be value-based. Whether wound care reimbursement reform is achieved through bundled payments, capitated payments, outpatient diagnosis related groups, or ACOs, it will be dependent on the availability of well-designed quality measures. Seeing this on the horizon, in 2014 the Alliance of Wound Care Stakeholders and the nonprofit US Wound Registry (USWR) began to craft wound care-related quality measures as part of the USWR Qualified Clinical Data Registry (QCDR). This year, the Undersea and Hyperbaric Medical Society (UHMS) and the USWR collaborated to submit seven new hyperbaric oxygen therapy measures to the Centers for Medicare and Medicaid Services (CMS). Eligible providers (EPs) can use USWR’s QCDR measures to obtain credit for participating in the Physician Quality Reporting System (PQRS). These seven new measures, if accepted by CMS, will be developed as electronic clinical quality measures (eCQMs) to facilitate reporting by any electronic health record (EHR) certified for stage II Meaningful Use. UHMS is to be commended for its commitment to the wound care field and the foresight in recognizing that quality measures have become top priority. These new QCDR measures, which had been under development for months, were submitted to CMS exactly four days after HHS announced its plan to link 50% of reimbursement to quality metrics in three years.

What Does Everything Mean?

  EPs need to participate in PQRS and will be able to provide the USWR 2016 wound and hyperbaric eCQMs to all EHR vendors. Reporting quality measures should be easy for all EHRs. Those with wound care-related specialty societies who have not developed quality measures relevant to one’s field should develop them by 2016. If your hospital or practice is involved in any network using quality measures to track or incentivize performance, let the organization know that relevant measures are available within the USWR. Manufacturers in the wound care space should financially support measure development so that eCQMs are available for easy reporting by any EHR vendor. We have fewer than three years to get ready.