Thoughts from the Eye of the Healthcare Storm Part 1: The HOPD’s Role in Reporting Quality Measures

Many wound care practitioners may not realize it, but we are currently sitting in the “eye of a healthcare storm” due to the impact of quality payment programs, MACRA, and MIPS.

Some of us residing on the Gulf Coast know what it’s like to look up into the quiet sky inside the eye of a hurricane as it passes by and experience that eerie stillness before the gale-force winds resume. Many wound care practitioners may not realize it, but we are currently sitting in the “eye of a healthcare storm.” A new method of determining advanced practitioner (AP) payment began Jan. 1 under the Medicare Access and CHIP Reauthorization Act of 2015 (MACRA). Although the final rules governing MACRA provide exhaustive detail around the Merit-Based Incentive Payment System (MIPS), there’s more to it. The goal of this new Quality Payment Program (QPP)¹ is to get all healthcare providers into Alternative Payment Models (APMs), such as accountable care organizations or patient-centered medical homes. Americans are facing “the perfect storm” that will significantly change traditional fee-for-service Medicare. In 2014, the Medicare hospital insurance (HI) trust fund went into the red by $14 billion.² Medicare trustees estimate the HI trust fund will be depleted by 2030 unless we change our course. It’s interesting to note that in 2014, $8.1 billion in trust fund assets were “redeemed” to help cover the monetary shortfall through a variety of recoupment activities targeting fraud and “improper use.” These recoupment activities directly impact wound care and hyperbaric medicine providers who are experiencing unprecedented scrutiny driven in part by the urgent need to balance Medicare’s budget. Frustratingly, some studies suggest that the highest-spending providers are probably overusing healthcare services³ and that Medicare could stay afloat another two decades without the need to ration care if we just eliminated waste. That’s why the Centers for Medicare & Medicaid Services (CMS) intends to reward “better” care rather than “more” care with the QPP. While we sit here in the eye of the storm, we have a moment to think about the challenges that will be involved in transitioning all wound care stakeholders to a value-based system.

Bundled Payments & Capitated Care 

The moves that CMS made to “package price” cellular and tissue-based products (CTPs) for skin wounds and to preauthorize nonemergent hyperbaric oxygen therapy (HBOT) are both aimed at what CMS perceives as “over-delivery” of these services. Ultimately, wound care practitioners must demonstrate that an intervention reduces total cost of care. The only way to do that is by tracking the cost of an “episode of care.” Eventually, CMS will transition outpatient payment to a system much like the current inpatient diagnosis-related groups (DRGs) that bundle charges for the treatment of a condition. That is why it’s vital for all wound care practitioners to report the same quality measures, so that performance can be compared against the aggregate. For example, we know we have “gaps in practice” that we need to correct with regard to diabetic foot ulcer (DFU) offloading.⁴ However, if one group of wound care practitioners reports a DFU offloading quality measure defined as “the percentage of DFUs prescribed any offloading one time in 12 months,” but another group reports “the percentage of DFUs prescribed evidence-based offloading at every visit,” (as defined by the U.S. Wound Registry [USWR]), the providers are not reporting the same standard of care. The USWR quality measure is the better measure of quality and is harder to pass, but the other group of physicians is more likely to have better healing rates and the lowest total cost of care. In 2016, CMS required qualified clinical data registries (QCDRs) that report offloading to “harmonize” the specifications for their measures so that DFU offloading would be reported the same way by everyone. The USWR “per-visit” offloading measure specifications will likely be accepted by all.⁵

Standardized reporting of DFU quality is vital because CMS has already begun to develop payment bundles for orthopedic procedures such as hip replacements that include all the related costs, including physician charges, acute care hospital charges, and rehabilitation costs. It will be necessary to track wound care services across the continuum of care in the same way. This will be challenging because no quality measures exist that are relevant to wound care across all of these sites. The take-home message is that “we are all in this together.” As payers move toward capitated or bundled payments and funnel both providers and institutions into APMs, we must all re-think the way we have provided care. In this scenario, it will simply not be acceptable to take a month to obtain vascular screening or two months to get offloading implemented because, in a bundled-payment world, the longer it takes to resolve a problem the more expensive it is to the providers. That means we have to reconsider our perspective on the tools of our trade. For example, in this new healthcare economy, we will provide as few HBOT treatments as possible to achieve a given outcome. However, we might decide to provide HBOT to some patients whose conditions were not covered before because, since their care is under a bundled payment, we believe HBOT might shorten their recovery, and, thus, save resources. The value proposition for HBOT and cellular products will be that they increase the chances of a desired outcome (or they reduce the time it takes to achieve the desired outcome), thereby reducing overall cost. That means our criteria for selecting a CTP will be to identify the least expensive product that can close a wound in the fewest number of treatments. In the new paradigm, multiple CTP applications are not desired and “low-bucket” products (assuming they work as well as high-bucket products) have an advantage. In fact, we will decrease the number and frequency of all interventions, including surgical debridements, to the minimum needed and focus on low-cost (but effective) treatments such as total contact casting. This author is already reviewing the cost of every product in the wound clinic and asking whether a less expensive product in the same category works just as well (or better). Sadly, although the data we need to make all these decisions are available, nobody is funding the studies needed to guide these clinical decisions.

How Can HOPDs Measure Quality of Care?

There has to be a way to measure quality for a quality-payment plan to be effective. While it’s true that we “cannot manage what we cannot measure,” measuring quality wound care is difficult. There have been numerous articles about quality of care published by Today’s Wound Clinic (TWC) directed toward the hospital-based outpatient department (HOPD). Unfortunately, of the 33 quality measures available for HOPDs to report in 2017, none are relevant to wound care.⁶ Wound care clinicians often forget that most services delivered across the United States in the outpatient payment system are delivered in the emergency department, outpatient surgery, or imaging suites. As a result, the measures available to HOPDs are entirely focused on these service lines. Of the available HOPD quality measures, only three would be worthy of consideration for wound care clinics to report to CMS: 1) the ability for providers to receive lab data electronically into an electronic health record (EHR) system as discreet, searchable data; 2) tracking clinical results between visits; and 3) influenza vaccination coverage among healthcare personnel. None of these examples measure the quality of wound care services provided by the HOPD. However, even if CMS is oblivious to the fact that more than 1,000 HOPDs focus their services on wound care, it’s still possible to develop a quality-reporting program for the HOPD, even though the data are not transmitted to CMS. Many HOPDs are creating quality programs by using USWR quality measures designed for eligible providers (EPs). Even though HOPDs cannot report the wound care quality measure data to CMS, they can report performance internally to hospital-wide quality initiatives. Given the rapid implementation of bundled payments, it makes perfect sense for HOPDs to implement the same quality measures as the APs who are responsible for the care provided in that setting. We need to develop quality measures that are relevant across all sites of care in which wound care is provided. Unfortunately, that will be difficult. In December, this author had the opportunity to serve on the National Quality Forum’s (NQF’s) Measures Applications Partnership for post-acute care.⁷ It was fascinating to observe the way in which quality measures progress from development to implementation for various sites of care. Over the two-day meeting, it became clear how many quality reporting programs received their mandate from the Accountable Care Act (ACA), a piece of legislation that’s likely to be either repealed or substantially changed by the new Congress. Regardless of where you stand politically, replacing or amending the ACA could be an opportunity for the field of wound care. The NQF staff asked committee members for suggestions regarding “cross-cutting” measures, a term used to describe quality measures that are relevant regardless of site of care. The problem with our current system is that, despite the lip service given to patient-centered care, it’s nearly impossible to develop quality measures that move with the patient across different sites of care when each site of care obtains its mandate for quality reporting in a different piece of legislation. Any legislation that replaces or amends the ACA should include a mandate for developing patient-centered quality measures across all sites of care — and patients living with chronic wounds are the perfect target for a new type of quality reporting. However, since this will literally take an act of Congress to accomplish, let’s finish discussing the currently available quality reporting landscape for wound care.

Quality Reporting for SNFs & Nursing Homes

Skilled-nursing facilities (SNFs) have one wound care-relevant quality measure they can report to CMS (NQF No. 0678): the percentage of residents or patients living with pressure ulcers that are new or worsened (short stay).⁸ This quality measure reports the percentage of patients or short-stay residents living with stages II, III, or IV pressure ulcers that are new or worsened since admission. The pressure ulcer measure has also been implemented in nursing homes and is currently publicly reported on CMS’ Nursing Home Compare website.⁹ The measure is intended to encourage SNFs, nursing homes, and long-term care hospitals to prevent pressure ulcer development or to keep them from worsening. Thus, the motivation behind it is laudable. However, the measure itself is not focused on any intervention that would actually prevent or treat pressure ulcers. While pressure ulcers are worthy targets for a measure across all sites of care, this flawed pressure ulcer measure is not the answer. We are in much need of wound care-relevant quality measures that can transition across all sites of care and that will actually facilitate improved care. 

Home Health Quality Reporting

Home health agencies have their data publicly reported as part of CMS’ Quality of Patient Care Star Rating system based on the Outcome and Assessment Information Set assessments and Medicare claims data. There is also Patient Survey Star Ratings based on the “patient experience of care measures.” The Quality of Patient Care Star Rating includes nine of the 24 current home health quality measures: 1) timely initiation of care; 2) drug education on all medications provided to patients/caregivers; 3) influenza immunization received for current flu season; 4) improvement in ambulation; 5) improvement in bed transferring; 6) improvement in bathing; 7) improvement in pain interfering with activity; 8) improvement in shortness of breath; and 9) acute care hospitalization.¹⁰ Home health agencies report no measures relevant to wound care, despite the high percentage of patients for whom they provide wound care.

Quality Reporting & The Advanced Practitioner

All APs who see Medicare patients are subject to MIPS. Unless the provider is excluded from MIPS (eg, bills less than $30,000 per year under Medicare, is in certain APMs), APs who do not participate will lose 4% of their 2017 Medicare Part B payments. Many TWC articles and editorials have explained MIPS.¹¹ There are more than 300 quality measures currently recognized by CMS for MIPS participation, none of which are directly relevant to wound care, although some are indirectly relevant (eg, control of hemoglobin A1c, screening for tobacco use, assessing for appropriate footwear in diabetes).¹² Providers must report on all patients, which means the capture of quality measure data must happen inside the EHR; there is no mechanism for “hand entering” data as in the past. Providers need only report one quality measure to keep all 2017 billing, but bonus payments from 4-12% are possible and there is an additional 10% bonus for “exceptional performance” under MIPS. Also, remember that, as of December 2016, every Medicare EP’s quality performance data became publicly available on Physician Compare.¹³ Since wound care is not a specialty, wound care practitioners won’t be distinguishable as a group on Physician Compare. The generic measures that most wound care APs will report under MIPS means their quality performance will be compared to that of general practitioners around the U.S. Whether a provider is penalized or obtains a bonus depends on his or her score in relation to the other providers who reported the same measures. This is a test graded on a curve, and if you are not in the top quartile of performance on each measure being reported the chances of getting a bonus payment are significantly reduced. So, when wound care providers report hemoglobin A1c control, they will be competing for the highest performance rate against every primary care physician, internist, and endocrinologist in the U.S. reporting that measure. The same is true for blood pressure control, etc. Because wound care practitioners do not treat these conditions (but only report the measured values), it’s not likely they will outperform the specialists for whom these areas actually do measure their quality of care. However, if APs report the wound care-specific quality measures available in USWR’s QCDR, at least they will have their quality data compared against other wound care clinicians. Data from the USWR show that in 2016, under the old Physician Quality Reporting System (PQRS) rules, the average wound care practitioner lost nearly $8,000, although he/she will not experience this payment reduction until 2018. Current estimates suggest MIPS will result in a decrease in payment, to about 80% of solo practitioners and small-group practices; so the pressure will increase for clinicians to form real or virtual groups in which they can demonstrate improved patient outcomes at lower costs in order to maintain the current reimbursement rate. Reporting quality data through the USWR’s QCDR provides a mechanism by which wound care practitioners can form a “virtual group.” (See more details in Part 2 of this article on page 24).

While there continues to be much public discussion about the importance of patient-reported outcomes in wound care, only the USWR has developed patient-reported measures relevant to wound care. Despite all the lip service about the topic of patient- centered care, between 2014 and 2016, under PQRS, only a handful of APs used those existing patient-reported measures, such as “wound-related quality of life.” This year, the USWR submitted a “patient-reported nutritional screening” measure for consideration under MIPS.¹⁴ Nutrition has always seemed to this author to be the logical choice for a cross-cutting measure because it’s universally important and relevant to all sites of care. USWR quality measure specifications, including all the patient-reported measures, are available as electronic clinical quality measures (eCQMs)⁵ that can be downloaded freely from the USWR website and installed into any certified EHR, making participation vendor neutral. Let’s hope that in 2017 there will be less talk about patient reported measures in wound care and more actual reporting of available measures.

Getting Into the Same Boat with Registry Reporting 

In 2016, specialty registry reporting was mandatory as part of the Meaningful Use (MU) of an EHR. Depending on where providers stood with regard to the MU program, some needed to report to two registries or lose 4% of their Medicare Part B payments. Under MIPS, registry reporting is among the 11 quality measures that comprise “Advancing Care Information” (ACI). Providers must report five ACI measures. Reporting data to a registry provides bonus points for this category of MIPS. Last year, more than 2,000 wound care practitioners joined the nearly 400 EPs who were already participating in the USWR. In turn, the USWR sponsored several specialty registries, including those for HBOT, negative pressure wound therapy, CTPs, DFUs, venous leg ulcers, and podiatry.¹⁵ All are listed on the National Institutes of Health clinical trials website (visit www.nih.gov/health-information/nih-clinical-research-trials-you). EPs can participate simply by transmitting continuity of care documents (CCDs) on their patients. CCDs contain demographics, diagnoses (by ICD-9-CM and ICD-10), all medications, all allergies, procedures, and labs. Transmitting a CCD is an inherent capability of any certified EHR. 

Why do registries matter? In 2016, HBOT registry data were vital during the analysis of the physician work component for the supervision of HBOT. The American Medical Association’s Relative Value Scale Update Committee needed data to understand the average number of comorbid medical conditions present among HBOT patients, as well as the average number of medications taken. Using HBOT registry data, within three hours it was determined that the average number of comorbid conditions was 10 and the average number of medications was 12 (among 11,240 discreet HBOT patients).¹⁶ No other organization had the needed data on hyperbaric patients. Had registry data not been readily available, physician reimbursement for hyperbaric chamber supervision would likely have been dramatically reduced. Registry reporting is the future of wound care and is extremely valuable for the HOPD. The USWR can provide national benchmarking data that can help HOPDs understand how sick their patients are in relation to the rest of the country, and how their use of debridement, HBOT, CTPs, and other interventions compare to the national norm. For example: Recently, USWR data confirmed the impact of visit frequency on patient outcomes. The data showed that lower visit frequencies were associated with lower probabilities of wound healing. Thanks to the structured data transmitted to the USWR, Dr. Marissa Carter was able to create cohorts matched in more specific detail than any prior wound care publication.¹⁷ This mechanism of registry participation requires no secondary data entry and is the way forward for comparative effectiveness research (CER), which is how we will likely obtain the information we need to “survive” bundled payments because we will at last be able to determine which therapies have the most impact on real-world patients. Remember, in the future it’s likely that the provider and the hospital will be negotiating a shared payment for services. So, understanding the comparative effectiveness of products and the provider’s quality performance will be vital.

Risk-Stratified Outcome Reporting

The first step to linking payment to patient outcome is to accurately report patient outcomes, and doing so requires a method to “risk stratify” patients. Risk stratification levels the playing field so that clinicians who care for the sickest patients are not penalized by having outcomes that appear to be worse than that of their peers. Data from the USWR were used to create a series of mathematical models known as the Wound Healing Index (WHI), which can be used to predict the likelihood that a wound of a given type will heal.^17,18 The USWR has several risk-stratified DFU and venous ulcer outcome measures. It’s no longer acceptable for clinicians to artificially inflate healing rates (eg, touting a 95% healing rate) by not reporting the outcome of patients who fail to heal. Wound care clinicians who say they achieve healing rates greater than 90% can only do so by not reporting a large percentage of patients. This misrepresentation of healing rates was due to the inability to stratify patients according to their risk of failure. It’s now possible to use the WHI to report provider-specific wound healing outcomes in relation to the predicted likelihood of healing. This means wound care providers can actually boast that they heal only 50% of patients (for example) when the WHI predicted that only 25% of them would have healed. Anyone can heal a wound that was going to heal anyway. The way to demonstrate your expertise is to heal the hardest-to-treat wounds, meaning the ones predicted to fail. This type of truthful outcome reporting is vital to surviving in the world of bundled payments and accountable care because payers will allocate higher reimbursement rates for the most challenging patients, thus, we will need to be able to identify them on the first day of treatment.

Risk stratification of outcomes using the WHI enables CER in wound care. The WHI combines both wound and patient factors to predict likelihood of healing. The model can run if clinicians input the answers to a few simple questions. There is a nominal charge to use the WHI model because, although KCI/Acelity (San Antonio, TX) funded some of its development, most of the cost was borne by the USWR and Susan D. Horn, PhD (University of Utah School of Medicine). Unfortunately, there’s no wound care specialty society to fund this work and federal agencies do not consider wound care a healthcare priority. So far, wound care organizations and manufacturers have not adequately supported the analytic work needed to ensure wound care practitioners “survive” the QPP transition. Unless that changes, the costs must be borne by the practitioners. The DFU and the venous ulcer models have been incorporated into risk-stratified outcome measures available in the USWR. Under MIPS, reporting risk-stratified outcome measures earns bonus points to APs and increases their likelihood of bonus payments.

Too Late to Evacuate

Right now, HOPDs have no wound care quality measures to report to CMS; subacute sites of care have only one flawed pressure ulcer measure that focuses on counting and staging pressure ulcers (but not on prevention or treatment); home health agencies have no wound care measures at all; and EPs have no wound care quality measures among the standard CMS measure list. While much has been said about quality of care in the wound center, HOPDs have no reportable quality measures relevant to the wound care services they provide. Our one small life raft is that APs have access to 21 wound care-relevant QCDR measures in the USWR (all available as eCQMs that can be installed in any certified EHR), as well as a validated wound risk-stratification system (ie, the WHI). HOPDs can report these measures internally, but not to CMS. 

If wound care reimbursement is going to be tied to outcome and quality in the QPP, and outpatient payment is going to be bundled within episodes of care, we have a long way to go to build a workable system that properly incentivizes clinicians and hospitals and that actually improves the quality of care for patients living with wounds. Since federally funded quality programs continue to ignore wound care (for the time being), the best plan for HOPDs is probably a four-pronged approach: 1) assist the APs who work in HOPDs to participate in MIPS successfully; 2) commit information technology resources to install and internally report the available USWR wound care quality measures that will allow national benchmarking; 3) develop more QCDR wound care measures and attempt to get them recognized by CMS for use across other sites of care; and 4) work with CMS to develop episode of care “resource use” measures for various wound diagnoses. It’s too late to evacuate because healthcare payment reform is already making landfall. If HOPDs don’t benchmark their quality performance and help their APs survive MIPS, they will not be prepared for an even stronger storm headed our way — APMs. 

Editor’s Note: Part 2 of this article addresses the “road map” by which wound care practitioners can participate in MIPS and possibly earn bonus money. Click here. 

References

1. Delivery System Reform, Medicare Payment Reform. CMS. Accessed online: www.cms.gov/medicare/quality-initiatives-patient-assessment-instruments/value-based-programs/macra-mips-and-apms/macra-mips-and-apms.html

2. 2015 Annual Report of the Boards of Trustees of the Federal Hospital Insurance and Federal Supplementary Medical Insurance Trust Funds. CMS. Accessed online: www.cms.gov/research-statistics-data-and-systems/statistics-trends-and-reports/reportstrustfunds/downloads/tr2015.pdf

3. Baicker K, Chandra A. Medicare spending, the physician workforce, and beneficiaries’ quality of care. Health Aff (Millwood). 2004;Jan-Jun;Suppl Web Exclusives:W4-184-97. 

4. Fife CE, Carter MJ, Walker D, Thomson B, Eckert K. Diabetic foot ulcer off-loading: the gap between evidence and practice. Data from the US Wound Registry. Adv Skin Wound Care. 2014;27(7):310-6. 

5. Quality Measures. USWR. Accessed online: https://uswoundregistry.com/qualitymeasures

6. Hospital Outpatient Quality Reporting (OQR) Program Overview. QualityNet. Accessed online: www.qualitynet.org/dcs/ContentServer?c=Page&pagename=QnetPublic%2FPage%2FQnetTier2&cid=1191255879384

7. MAP Post-Acute Care/Long-Term Care Workgroup. NQF. Accessed online: www.qualityforum.org/project_pages/map_post-acute_carelong-term_care_workgroup.aspx

8. Development of the Skilled Nursing Facility Readmission Measure (SNFRM): August 2012 Technical Expert Panel Report. CMS. Accessed online: www.cms.gov/medicare/quality-initiatives-patient-assessment-instruments/nursinghomequalityinits/downloads/development-of-the-skilled-nursing-facility-readmission-measure-snfrm-august-2012-technical-expert-panel-report.pdf 

9. Nursing Home Compare. Medicare. Accessed online: www.medicare.gov/nursinghomecompare/search.html

10. Home Health Star Ratings. CMS. Accessed online: https://www.cms.gov/medicare/quality-initiatives-patient-assessment-instruments/homehealthqualityinits/hhqihomehealthstarratings.html

11. Fife CE. From the editor. TWC. 2017;11(2):4. 

12. Measures Codes. CMS. Accessed online: www.cms.gov/medicare/quality-initiatives-patient-assessment-instruments/pqrs/measurescodes.html

13. Physician Compare. Medicare. Accessed online: www.medicare.gov/physiciancompare/search.html

14. Fife CE. Taking ‘our own medicine’ through the nutritional screening quality measure & quality payment program. TWC. 2017;11(1):21-32.

15. U.S. Podiatry Registry. USWR. Accessed online: www.uspodiatryregistry.com

16. Fife CE, Gelly H, Walker D, Eckert KA. Rapid analysis of hyperbaric oxygen therapy registry data for reimbursement purposes: technical communication. Undersea Hyperb Med. 2016;43(6):627-34. 

17. 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):823-32.

18. Horn SD, Barrett RS, Fife CE, Thomson B. A predictive model for pressure ulcer outcome: the wound healing index. Adv Skin Wound Care. 2015;28(12):560-72.