Thoughts From the Eye of the Healthcare Storm Part 2: The Wound Care Clinician’s Road Map to MACRA & MIPS

This article provides direction for wound clinic providers who may need help finding their way through today’s new reimbursement and payment rules.

The goal of the new Quality Payment Program (QPP) by the Centers for Medicare & Medicaid Services (CMS) is to reward advanced practitioners (APs) and hospitals on the basis of patient outcomes. The QPP began Jan. 1, and approximately 80% of clinicians in the United States, including most wound care practitioners, are currently subject to the Merit-Based Incentive Payment System (MIPS). Practitioners who bill Medicare less than $30,000 per year or see fewer than 100 Medicare patients per year are among those excluded. How will MIPS work for the wound care practitioner? This article will discuss that topic, the specific impact of MIPS on practitioner payment, and provide a plan of suggested action to help practitioners navigate what’s coming (and what’s already here) for our industry. 

It’s helpful to remember that the QPP was passed with bipartisan support and is not linked to the Affordable Care Act (ACA). The legislation that initiated the QPP is the Medicare Access and CHIP Reauthorization Act of 2015 (MACRA). Unlike the ACA, there is no movement in the government to change or repeal MACRA, because MACRA replaced the sustainable growth rate (SGR) formula that was going to require a 21% cut in Medicare Part B payments to all APs in 2015. So, to those practitioners who are worried about the effect that MIPS will have on their bottom line, remember that MIPS replaced something with more severe financial implications. It’s also important to remember that MIPS is only a temporary program (even if “temporary” means a decade). The long-term plan is to get every physician and hospital into an Alternative Payment Model, such as an accountable care organization. In those scenarios, both the AP and the hospital will be financially “at risk” for the care of patients. There will be some fixed reimbursement to both entities, and the path to financial success will be based on how much money is saved, not on how much is billed. Hospitals and practitioners are in this together, so now is a good time for us all to learn to coordinate our quality reporting, which will be the engine of success moving forward. You may be thinking, “MIPS only affects my Medicare payments, so income from private-payer reimbursement will not be affected.” That is incorrect. At the 2016 National Quality Forum (NQF) annual meeting, under the theme, “Re-engineering Quality Data for Value,” Marilyn Tavenner, former CMS administrator and current chief executive officer of AHIP (America’s Health Insurance Plans), announced that private payers were going to use the same quality measures and the same quality system as Medicare.

MACRA replaced (and combined) several different and separate incentive programs, specifically: the Physician Quality Reporting System (PQRS), Meaningful Use (MU), and value- based payment. MIPS is a blend of these three programs, with MU renamed “Advancing Care Information” (ACI), plus a new category known as “Clinical Practice Improvement Activities” (CPIA). Unlike the prior system, MACRA does not offer the option for providers to “opt out” of reporting by simply paying a penalty, meaning that any practitioner who accepts Medicare patients must comply. However, there’s good news: MIPS eases the burden of reporting by combining the three prior programs into one program. Furthermore, under the previous programs (PQRS and MU), by 2015 the best one could do was avoid a penalty; the incentive programs that provided “bonus money” had ended. Also, in 2016, under the old program, the maximum downward adjustment was -8%. Under the new rules of MIPS, the maximum downward adjustment a provider can experience (at least the first year) is only -4%. The penalties increase as the years go by under MIPS, but the worst penalty is still only -7% in 2021. Because MIPS incorporates aspects of previous programs (eg, PQRS) in which wound care providers have already been engaged, we can predict the way wound care practitioners are going to fare under it in 2017 by looking at PQRS performance in 2016. In 2016, a handful of large physician groups received the benefit of engaging fully in the 2014 PQRS/value payment program. Keep in mind there is a lag time of two years from the time a practitioner reports quality data and the time the negative or positive financial implications are realized. In 2016, under PQRS, the top tier of practitioners (in terms of scores on PQRS measures) earned 147% of Medicare allowable charges. Think about that number. With Medicare headed for insolvency, at a time when all practitioners were facing a 21% Medicare pay cut under the SGR, how was it possible for Medicare to give some practitioners a 47% pay increase? The answer is, a huge bonus payment was possible to a few top-tier providers because it was funded by a $74 million transfer of wealth from physicians who either did not participate at all or did not participate successfully. The losers include most wound care practitioners. We reviewed the U.S. Wound Registry (USWR) data of about 500 wound care practitioners (see Figure 1). 

The average wound care practitioner lost nearly $8,000 in 2016 under PQRS. Medicare expects a similar transfer of wealth under MIPS. If you consider CMS’ (now infamous) Table 64  from the MACRA rule, CMS estimates 87% of solo practitioners will have a negative payment adjustment, as well as 70% of small groups with fewer than 10 practitioners. 

On the other hand, CMS estimates that among physicians belonging to large groups (100+), 81.3% will have a positive payment adjustment. This is a zero-sum game. The bonus money paid under MIPS to a few physicians will be funded by the huge pool of practitioners who are assessed penalties. Did Medicare intend to advantage large group practices? No, it’s because large groups have the infrastructure to figure out how to maximize their performance, which is akin to being the first player in Tic-Tac-Toe: The player who makes the first move can ensure they win. MIPS is more like chess in terms of the complexity of its rules. However, MIPS is still a game that anyone can learn and which is more likely to be won among those who have excellent coaching and are making the first move. Moving forward, this article will provide some coaching that wound care practitioners need to win the MIPS “game.” Math will be required.

The Fine Print of MIPS

The aggregated MIPS performance score is a total of performance in four categories: quality measures, ACI, CPIA, and resource use. Each of those categories contributes a certain number of points, but each category is worth a different percentage of the aggregate score. In 2017 (Year 1), resource use (defined as the amount of money Medicare spends on a patient) is not going to be considered. However, data on resource use are still being collected for future use. In 2017, the points from resource use have been given to quality measure performance, so, in 2017, the quality measure category determines 60% of the total score, with ACI contributing 25% and CPIA 15%. Every practitioner in the U.S. will be rated on a point scale from 0-100. Figure 2 above is a graphic depiction, but think of it this way: Quality measure score “X” (0.6) + ACI score “X” (0.25) + CPIA score “X” (0.15) = aggregate MIPS score (0-100). Despite the fact that the “final rule” for MACRA did not come out until late November 2016, CMS still began its implementation Jan. 1, 2017. This gave practitioners less than one month to get their processes in place for MIPS before they became subject to its reporting requirements. 

To mollify the thousands of voices calling for a delay in MIPS, CMS created greater confusion by creating “pick-your-pace” options in 2017, allowing providers to decide how much participation they wanted to have with MIPS requirements the first year. Practitioners who do nothing will lose 4% of their Medicare Part B payments. Participating even a little bit (submitting “test data”) would allow practitioners to keep all of their Medicare Part B payments (but have no chance at a bonus). The definition of test data is submitting one quality measure, or submitting two ACI measures, or submitting one CPIA. There are also two participation options that allow a provider a chance at a bonus payment. Both of these options actually involve the same data submission. The only difference is the timeframe over which the provider reports. If providers report only 90 days of patient data in 2017, they may qualify for a small bonus in 2019. If they participate “all in” for the entire year, with patient data starting Jan. 1, 2017, they qualify for a “modest bonus.” However, there is some fine print that has not been widely publicized. Under MIPS, there is a multiplier for “exceptional performance.” A total of $500 million (yes, that is half a billion dollars) has been set aside to provide an extra 10% bonus for the highest performers. Providers who want to get into exceptional-performance territory must get the highest possible MIPS score (> 70). Remember that MIPS is “graded on a curve.” During college or professional school, most practitioners had the experience of taking a difficult exam and scoring, for example, a 50, only to find that a 50 was a “B+” because the passing rate on the test was so low. That’s when students realized the real key to academic success is getting a higher grade than the majority of the other students in the class. In other words, MIPS success is relative to one’s peers. Wound care practitioners are competing against the brightest doctors in the U.S. (who see Medicare patients) and the biggest physician groups that have dedicated teams to help them succeed. As a result of their lack of practice infrastructure to facilitate reporting, wound care providers are at a big disadvantage. This author has called a few large group practices that specialize in wound care and found nobody prepared to help their practitioners obtain bonus money in MIPS.

Participating Fully in MIPS

In the quality-performance category, providers must report six quality measures chosen from a “MIPS-approved” list of about 200. In 2017, quality measure performance contributes 60% of the total MIPS composite score. As this author has discussed in previous articles, there are no wound care-relevant quality measures in the list.^1,2 Wound care providers will be reporting measures such as tobacco screening, hemoglobin A1c control, body mass index measurement and follow up, medication reconciliation, and blood pressure control. Remember that if providers want to get bonus money, a passing score is not good enough; they must be in the top quartile of each measure. The exact score required in order to position a doctor in the top quartile of any specific measure will change each year, because everything depends on the scores of all the doctors reporting particular measures. Figure 3 shows a reproduced graph from this author’s personal quality and resource use report (QRUR) and depicts the point distribution of all the physicians who reported these same quality measures in 2014. The horizontal axis depicts the provider scores in quality reporting. The vertical axis depicts their scores in “resource use,” which is calculated by Medicare and based on total spending for certain types of patients and diagnoses. To get into serious bonus money, a clinician must fall in the top right-hand corner of the grid, providing high-quality care (defined as a high score on standard quality measures that are not relevant to wound care) and have a low value on “resource use.” There are 11 possible measures in the ACI category, but providers only need to report five. One of those measures must be attesting that patient health information has been protected. Those who don’t complete the attestation form will fail the entire category. Other measures include using electronic prescribing, giving patients access to their clinical data (eg, via patient web portal), and reporting data to a specialty registry. Those who report to a registry will gain a bonus point for ACI. The final category is CPIA, and there are 60 possible points in this category (which contributes 15% of the aggregate score). However, most wound care practitioners only need 40 points because they are in solo practice or small groups. The number of projects a provider must conduct in order to achieve the required number of points is determined by the score allocated to each project (some are worth 10 points, others 20 points). Although CMS has provided a list of 90 types of improvement activities from which to choose, they are only conceptual ideas. Each clinician has to build his or her own project. The USWR has created several CPIAs that are relevant to wound care practice (https://uswoundregistry.com). In 2017, clinicians will only need to “attest” that they’ve performed these activities. However, attesting doesn’t mean saying, “I did it,” without actually performing the activities. Many physicians who attested to MU were audited and had to pay back money to CMS when they were unable to show that they had actually done what was required. Do not attest to anything that you do not actually do. There will be auditing! Given that wound care clinicians are competing with the students in the “advanced-placement” class (eg, large physician groups with lots of infrastructure), there’s little chance a wound care practitioner can finish in the big-bonus category. Unless, of course, the practitioner uses the same techniques as the large physician groups. The secret weapon of practitioners who will get big MIPS bonus money is the qualified clinical data registry (QCDR). 

Succeeding at MIPS With QCDR

Participating in MIPS through a QCDR provides “bonus points” in all 2017 MIPS program categories. Providers must report on at least 90% of their eligible patients, so there really is no way to participate in MIPS without a certified electronic health record (EHR). If a practitioner is still using paper charts and is not exempt from MACRA for specific reasons, it’s not possible to succeed with MIPS. In 2017, it’s still possible to report quality data by the claims method, but bonus points are not possible via claims, and that option will soon be retired. In the quality-reporting category, a maximum of 60 points is possible (which in 2017 comprises 60% of the total score). Up to 10% “extra credit” is available for reporting through a QCDR as follows: There’s one bonus point for reporting a measure through the QCDR, and reporting extra “high-priority” measures can provide an additional 5% of the possible total; two bonus points are awarded for additional outcome/patient experience measures, with one bonus point for other “high-priority” measures; and there’s an additional “EHR bonus” of up to 5% of the possible total (one bonus point for each measure reported using an EHR for end-to-end electronic reporting). Table 1 lists the high-value measures available from the USWR that would qualify a practitioner for bonus points in the quality-reporting category. The electronic specifications for these measures are available free of charge on the USWR website and can be downloaded and installed into any certified EHR, so reporting high-value measures that are relevant to wound care is possible for any provider using a certified EHR. In the category of ACI, a maximum of 100 points is possible (which in 2017 comprises 25% of the total score). Reporting data to a specialty registry earns a bonus point. The USWR sponsors many specialty registries (eg, hyperbaric oxygen therapy [HBOT], diabetic foot ulcers [DFUs], podiatry, cellular and/or tissue-based products [CTPs] for skin wounds, negative pressure wound therapy). Providers can submit data to the USWR without having to perform any laborious secondary data entry by transmitting the continuity of care documents (CCDs) from their EHR, an activity that all EHRs must be able to perform as a requirement of certification and that is one of the measures reportable under ACI. An EHR company refusing to do this is guilty of “data blocking,” a problem that exists and is being investigated.³ In the CPIA category, 60 points are available, although most practitioners only need 40 (in 2017, 15% of the total score). There are bonus points for reporting activities through a QCDR, and the QCDR-reported activities have a higher point value, so providers will need fewer activities. Table 2 summarizes the way in which a provider can accrue bonus points by participating in MIPS through a QCDR and the specific ways the USWR facilitates this for a wound care practitioner. Only the USWR has “high-value” measures such as risk-stratified outcome measures and patient-reported measures (all specific to wound care). The USWR can provide specialty registry reporting without any secondary data entry and has already crafted clinical improvement activities relevant to the wound care clinicians.

USWR & Quality Measures

It’s probably worth a digression to mention how the USWR developed its wound care quality measures. In 2012, the Alliance of Wound Care Stakeholders (Alliance) began to raise the alarm that quality measures relevant to wound care were desperately needed. The trajectory of healthcare reform made it clear that quality reporting would be the key to economic survival for wound care practitioners. Even before MIPS, penalties for failing to succeed with PQRS were due to begin in 2014, and the likelihood that wound care practitioners could succeed without relevant measures was low. In late November 2013, the final rule for Medicare’s Physician Fee Schedule was published and provided details regarding a then-new entity, the QCDR. QCDRs could create up to 20 quality measures that did not have to go through the expensive and time-consuming NQF endorsement process. The Alliance, including members representing the Association for the Advancement of Wound Care (AAWC), met with CMS officials in December 2013. At that meeting, the relevant CMS officials agreed that the Alliance could act as a de facto specialty society for wound care, representing all its member organizations, including the AAWC. The Alliance then partnered with the USWR, which had been providing PQRS reporting for wound care practitioners since 2008, making it one of the oldest PQRS registries in the U.S. and the only one specifically focused on the needs of wound care practitioners and their patients. The Alliance and the USWR then hosted a series of conference calls over the approximately five-week period preceding the deadline for submitting QCDR measures to CMS (Jan. 31, 2014). The purpose of these conference calls was to craft wound care quality measures via a consensus process. Representatives from all Alliance member organizations were invited. There were many people on each call, including members of the AAWC, the American Professional Wound Care Association, and others. In 2014, CMS recognized the USWR as a QCDR and approved all 14 of the wound care quality measures developed via this consensus process. (There are now 21 wound care quality measures.) Thus, the wound care quality measures available through the USWR’s QCDR were created by the wound care practitioners who now need to report them if they are to succeed with MIPS. As a 501(c)(3) nonprofit organization, the USWR receives no monetary support from the Alliance, the AAWC, or any organization, unlike the QCDRs affiliated with major specialty societies. While a few manufacturers provided support for the initial programming of the measures as electronic clinical quality measures, none have contributed to its support since (despite appeals to do so). The largest single grant was awarded by Nestlé in 2015 to fund the nutritional-screening measure. The USWR is the only QCDR focused on helping wound care and hyperbaric medicine practitioners succeed with MIPS, and is funded only from the nominal fees that practitioners pay for reporting their quality data to CMS. Depending on which MIPS services a practitioner needs, the average fee a practitioner pays the USWR for a year of data submission is $350 per year. Despite the fact that the average wound care practitioner lost nearly $8,000 under PQRS in 2016, physicians still insist, “it just didn’t seem worth the fee.” That might be true if a clinician practices “very part time” and/or sees very few Medicare patients, but it’s only temporarily true. While the maximum negative adjustment is a loss of 4% of the Medicare part B payments, the maximum bonus is not 4%. As we discussed, there’s a possible three-fold multiplier with an extra 10% added on for exceptional performance. In other words, it’s theoretically possible for a provider to get a bonus that is 22% above the Medicare allowable in 2017. This bonus will be experienced in 2019. The only way to obtain any bonus money beyond the “modest” amount promised by CMS is through QCDR participation. Also, registry data can be used for comparative-effectiveness research and has already helped the field of hyperbaric medicine avoid a large negative adjustment in the amount paid for hyperbaric chamber supervision.⁴ 

What To Do Now?

Because 85% of MIPS participation is derived from the programs in which a provider should already be participating, the first thing all practitioners should do is understand how they are currently being rated by CMS while reviewing 2014 and first quarter 2015 QRURs. The QRUR will help providers understand how they are currently being rated on both cost and quality.⁵ Providers can also evaluate their quality measure performance scores to get a sense of what can be improved. Remember that the data transmitted to the QCDR is collected inside the EHR, so know where the weaknesses are, even if that weakness is in a process (eg, not performing medication reconciliation and/or not knowing how to record it in the EHR). Ensure that the EHR being utilized is certified.⁶ Providers should know how to report at least five ACI measures through a particular EHR, which probably has a feature that allows access to progress reports with ACI measures. Then, decide which quality measures to report. The biggest challenge for a majority of wound care practitioners will be deciding which quality measures make the most sense, since almost none are directly relevant to wound care (and providers may need data that reside in the EHR chosen by their hospital-based outpatient departments [HOPDs]). Bonus points will be obtained if six quality measures are reported via the USWR’s QCDR. More importantly, those providers who download and install high-value USWR quality measures into their EHR will have access to measures worth bonus points, as well as the ease of having the USWR handle the reporting. Three of them can be performed only by transmitting CCDs to the USWR, a task any certified EHR can and must (by law) perform. Transmitting CCDs will earn a bonus point for ACI. 

Virtual Groups

CMS is still evaluating the rules for “virtual groups,” so the details of this are not clear as of this writing. CMS is trying to find a way for solo practitioners or those in very small groups to band together for the purpose of MIPS participation in a “virtual” practice. It’s possible that being able to form a virtual group through QCDR participation could improve a practitioner’s chances of earning bonus money. The USWR will provide an update when those details are finalized.

The Role of the HOPD in MIPS

Wound care HOPDs can use the USWR quality measures for internal quality programs. Given the way in which the interests of the physician and the HOPD will soon be aligned via alternative payment models, anything the HOPD can do to help the provider succeed in MIPS is a good investment. Wound care practitioners can succeed with the support of the HOPD. Yes, MIPS is complicated. Sadly, in its current state it measures almost nothing that contributes to the provision of quality wound care. However, through the USWR’s QCDR, we can turn something we must do into something we want to do (because it helps us save our billed revenue). Frankly, improving the quality of care we provide to patients living with chronic wounds is something we ought to do. Participating in MIPS via the USWR is the way to success for practitioners, HOPDs, and patients. 

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. 

References

1. Fife CE. Measuring quality in wound care. TWC. 2011;5(9):12-5. 

2. Fife CE. The wound care clinician’s quality reporting survival guide. TWC. 2015;9(2):18-24.

3. Report on Health Information Blocking. Office of the National Coordinator for Health Information Technology. Accessed online: www.healthit.gov/sites/default/files/reports/info_blocking_040915.pdf

4. 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.

5. How to Obtain a QRUR. CMS. Accessed online: www.cms.gov/medicare/medicare-fee-for-service-payment/physicianfeedbackprogram/obtain-2013-qrur.html

6. Certified Health IT Product List. Accessed online: https://chpl.healthit.gov/#/search