The Handwriting on the Wall for Wound Management

We are at an important crossroads in the field of wound management. From the perspective of new technologies, the future is bright. Unfortunately, the future of the field itself is dismal. Under Medicare’s new Quality Payment Program (QPP), wound management is not likely to be practiced by physicians. The problem is not the Merit Based Incentive Payment System (MIPS). An uncomfortable hybrid of Medicare “fee for service” and performance based payment, MIPS is only a temporary part of the QPP.  The Centers for Medicare and Medicaid Services (CMS) are rapidly moving all of us into alternative payment models (APMs). Ironically, it is the technological advances, at least in part, that doom us under APMs. Here’s why:

In 2017, MIPS Year One, Medicare compared my MIPS performance to that of my “peers,” meaning all the physicians who, like me, are board certified in family practice (FP). My perfect score in the Quality Reporting category could not compensate for the fact my Medicare Spending Per Beneficiary (MSPB) was in the top 2% of all FPs.¹ 

Why was my MSPB so much higher than that of other FPs? Because in order to care for patients with chronic non-healing wounds, I use a lot of expensive technologies like hyperbaric oxygen therapy (HBOT), negative pressure wound therapy, and cellular- and/or tissue-based products. This drove my MSPB into the stratosphere compared to the average FP. I had no way to tell Medicare I practice wound management, because it’s not a recognized specialty. CMS does know my patients are really sick. 

In this issue of Today’s Wound Clinic, Helen Gelly, MD, explains how Medicare determines patient sickness using a system called Hierarchical Classification Categories (HCCs). Every patient has an HCC score. The average HCC of all a physician’s patients determines their individual HCC score and the average HCC of all the physicians in a specialty determines the HCC score of the specialty. Although the average HCC score for an FP is 0.96, mine is nearly 4.0, about the same as a nephrologist. CMS doesn’t know the average HCC score of wound management practitioners (or their average MSPB), because we can’t be identified or grouped together without a specialty code. 

On January 1, 2019, there was one ray of hope. Undersea and hyperbaric medicine (UHM) received a specialty code designation.² It isn’t necessary to be subspecialty board certified in UHM to use that specialty code. In fact, I urged all wound management practitioners to change their specialty code to UHM even if they did not provide HBOT at all.³ Why? Soon Medicare will assess monetary penalties to practitioners whose MSPB is out of alignment with their specialty. If a wound management practitioner identifies with undersea and hyperbaric medicine, even if he or she does not practice HBOT, at least their Medicare data will be compared to practitioners who use advanced technology for chronic wounds about as often as they do. However, excessive Medicare spending per beneficiary is not why we won’t survive the QPP. 

Currently under MIPS, practitioners can report any 6 Quality measures, regardless of whether they are relevant to their particular practice. To correct this, CMS has been working with specialty societies to identify a suite of MIPS Quality measures relevant to each specialty. Even if the organizations that purport to represent wound management and hyperbaric medicine had paid attention to this important issue (they didn’t), there are no standard MIPS quality measures that represent what we do.

That’s the reason every specialty society initiated Qualified Clinical Data Registries (QCDRs), empowered by Medicare to develop specialty-specific quality measures. These specialty-specific measures are reportable through the society’s designated QCDR. Since wound management didn’t have a specialty, CMS allowed the Alliance of Wound Care Stakeholders to act in lieu of a specialty society. The Alliance partnered with the nonprofit U.S. Wound Registry (USWR) to craft a suite of wound management and hyperbaric medicine relevant quality measures that were approved by CMS.⁴ In fact, 3 of the USWR QCDR measures were chosen by CMS for depiction on Physician Compare in 2019.⁵ Technical barriers make it difficult for practitioners to report QCDR measures but truthfully the real barrier is that most practitioners don’t understand why they should. However, failure to report specialty specific quality measures is not why we won’t survive the QPP. 

Medicare positions all practitioners on a grid based on Quality Performance and MSPB.⁶ Practitioners with high quality scores but low Medicare spending can be reimbursed at a higher rate under Value Based Payment (VBP) incentives and can also negotiate better payment rates with private payers. Practitioners whose Medicare spending is high compared to peers in their specialty and who have poor or nonexistent quality data will see a reduction in reimbursement rates under VBP. That’s exactly where most wound management practitioners find themselves. They will be paid less for every office visit and procedure compared to practitioners positioned better on the grid. In fact, many private payers will not allow the “high MSPB, low quality” doctors (e.g., most wound care practitioners) to participate in their networks. Our cost and quality performance will appear to be so terrible that some payers won’t let us see their beneficiaries, and if we can see them, we will be paid less than our peers for the same services. However, bad positioning on the quality and cost grid is not why we won’t survive the QPP. 

In 2021, Medicare will implement MIPS Value Pathways (MVPs). CMS has indicated that they do not plan to include specialty specific QCDR measures in MVPs. If CMS limits all specialties to standard MIPS measures, then hyperbaric medicine and wound management physicians will be forced to report the quality measures assigned to their primary specialty. That means the Quality Performance of a wound care practitioner like me whose primary board is family practice will be determined by whether they order mammograms and perform colon cancer screening, measures which I would certainly fail. Those who practice UHM, a recognized subspecialty, might have gone to CMS and lobbied for the creation of a MIPS Value Pathway relevant to UHM. Doing so could have helped not only UHM but all wound management practitioners. Unfortunately, neither of the hyperbaric medicine clinical associations engaged with CMS on this vital issue, so there will not be a relevant MVP for us to use. Our cost and quality performance will be tied to our primary specialty, likely with disastrous results. However, even that is not why we won’t survive the QPP. 

We needed to establish the average HCC score and MSPB for practitioners in our field. CMS tried to help by making participation in a clinical data registry one of the ways to satisfy mandatory clinical data exchange requirements under the MIPS category of “Promoting Interoperability.”⁸ To satisfy this requirement through the USWR, practitioners did not have to submit any data, report QCDR measures, or even pay any money. Specialty registry participation with the USWR is free and only requires a practitioner to log on electronically and sign up.⁹ Had wound management practitioners done this, USWR QCDR participation could have acted as a sort of “surrogate” for their missing subspecialty designation. The USWR QCDR could also have provided accurate data for the field of hyperbaric medicine despite the fact that most hyperbaric practitioners didn’t change their specialty code. Unfortunately, individual practitioners have focused their energy on ways to avoid the MIPS specialty registry requirement instead of leveraging it to save the field. Failure to establish the average HCC and MSPB in wound management and hyperbaric medicine is a big reason why we won’t survive the QPP, but there’s a bigger one.

Medicare is designing value-based, episode-based payment models around the most expensive conditions so practitioners will manage them more efficiently.¹⁰ Episode-based payment committees are tasked with identifying all the procedures and services that will be incorporated into payment models for diseases like peripheral arterial disease, diabetes and renal failure. Unfortunately, neither CMS nor the specialists in those fields understand that a common symptom of these diseases is a chronic wound. As a result, the episode-based payment committees are not including the cost of wound management (meaning, the cost of advanced technologies) in the disease models. The exclusion of wound management and hyperbaric medicine services from the episode-based payment models is the main reason we won’t survive the QPP. 

There’s a Biblical story about King Belshazzar of Babylon, who was so busy congratulating himself on his accomplishments that he failed to notice the Persian army surrounding his city. While he partied, an invisible hand inscribed a message on the wall translated as, “You have been weighed in the balance and found wanting.” Since the fall of Babylon, we’ve admonished people to “heed the handwriting on the wall.” 

The end of wound care and hyperbaric medicine has been written in the Federal Register, posted on the CMS website and detailed your MIPS reports. Physician organizations have been busy holding scientific meetings about advances in technology while ignoring the forces that threaten to end the field. They should be meeting with CMS in Baltimore and not with each other in Las Vegas or Chicago. As an individual practitioner, you could help save yourself if you change your specialty code to UHM, volunteer for an episode-based payment committee and sign up for free with the USWR. 

While that’s a good way to start 2020, we won’t save the field unless the clinical associations wholeheartedly endorse participation in the USWR QCDR so we get the data we need, and unless manufacturers fund the analysis of registry data so we have the information CMS wants. 

We live in an era of great technological advances. Unfortunately, the handwriting on the wall says we won’t be around to use it. n 

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

1. Fife C. Counting the cost and a roadmap to survival. Available at https://tinyurl.com/qrq7v7q.  

2. CMS. New Physician Specialty Code for Undersea and Hyperbaric Medicine MLN Matters Number: MM10666. Available at https://tinyurl.com/ssdat64.

3. Fife C. Hyperbaric medicine physician specialty code–instructions on how to change your taxonomy. Available at https://tinyurl.com/uhy65tu. 

4. US Wound Registry Quality Measures. Available at https://tinyurl.com/wpvcbzl   

5. Fife CE, Nusgart M. Three wound care quality performance measures are now public: why it matters. Adv Skin Wound Care. 2019; 32(12):538–9. 

6. Fife C. The cost and quality grid. Available at https://tinyurl.com/tbnqcuj.  

7. CMS. MIPS Value Pathways. Available at https://tinyurl.com/vpkx3pe.

8. CMS. 2019 Medicare Promoting Interoperability Program Scoring Methodology Fact Sheet. Available at https://tinyurl.com/we34x9o .

9. U.S. Wound Registry.  Available at https://www.uswoundregistry.app/

10. CMS. Value Based Bundled Payment. Available at https://tinyurl.com/ycfz3fry.