Thoughts on Sisyphus and Rehospitalization

There is a word that describes most of my Mondays in the wound clinic: Sisyphean. You probably remember the  Greek myth of Sisyphus, who was condemned by the gods to roll a boulder up a hill only to have it roll down again, a laborious task to be repeated forever. My Sisyphean Mondays are spent trying to regain control of lower extremity swelling in patients with leg ulcers due to heart failure. For 3 years I have seen a lovely elderly woman with venous insufficiency, atrial fibrillation, diabetes, and advanced heart failure. If her legs are not wrapped with compression bandages, they begin draining again. I did not understand why the task seemed so never-ending until I reviewed my own 2017 patient data. As part of my participation in the Merit-Based Incentive Payment System (MIPS), the Centers for Medicare & Medicaid Services (CMS) reported 56% of my patients have diabetes, 55% have heart failure, and 24% have atrial fibrillation. I have a clinic full of patients with obesity,chronic heart failure (CHF), and orthopnea who sleep in chairs. While they have venous insufficiency, their leg ulcers are primarily due to their skin splitting apart from severe volume overload. Even the most expertly applied venous compression cannot control their leg edema (which often extends to the abdomen and buttocks) because they need better control of their underlying heart failure.

Although these complex patients are exactly the type of patient for whom the Outpatient Payment System (OPPS) was devised, ironically, they may bring an end to both hospital outpatient services and the field of wound care as we know it. In 2016, I reviewed my Quality and Resource Use Report (QRUR) provided by CMS under the final year of the Physician Quality Reporting System (PQRS). According to my QRUR, by the end of 2016, 17 patients seen in the wound center with various chronic conditions and 8 heart failure patients had been hospitalized. Additionally, 10 wound center patients had been “readmitted” to the hospital during the year. If the number of rehospitalizations had reached 20, I could have experienced a financial penalty under PQRS. I work only half-time as a physician. It’s probably safe to say that had I worked full-time in 2016, more than 20 of “my” patients would have been rehospitalized. 

Why is CMS holding me responsible for the rehospitalization of wound center patients with heart failure and other serious underlying chronic conditions? The reason is I provided what CMS calls “the plurality” of their evaluation and management (E&M) services, and because I’m board certified in family practice, CMS thinks that I am their primary care physician. Medicare has concluded that these patients were hospitalized due to my poor performance as a primary care physician, and there is no mechanism for me to explain that I am “just their wound care doctor.” Hospital readmissions within a certain time frame count against me under MIPS, just like they did under PQRS. Days later, I was still trying to get my head around this seemingly unfair situation when I attended the National Quality Forum meeting in Washington, DC. The chief medical officer of one of the country’s most successful multispecialty organizations gave a presentation about the success of their quality improvement program. Afterwards, a hospital quality officer in the audience asked how the speaker handled the problem of the “wrong” specialist being held responsible by CMS for readmissions. All 300 attendees leaned forward to hear his answer. The speaker replied, “We have a very simple solution! We tell the doctors to get over it.” 

Last week at the quarterly medical staff meeting, my hospital’s chief executive officer introduced the physician assistant operating the new “transition” clinic. Hospitals are also held responsible for readmissions within a certain time frame! My hospital was opening an outpatient clinic that would, at least for a time, follow patients newly discharged with CHF. I asked him if there was any way we could keep heart failure patients from having to be admitted in the first place. He said he was initiating a program that would allow CHF patients to have a brief stay in his clinic to provide monitored intravenous diuretics. In the most important sense of the word “quality,” it can be argued that it is my problem when a patient with heart failure in the wound clinic is not doing well. I see them more than any other practitioner and I probably know them best. Like clockwork the following Monday, there was my Sisyphean patient, slipping into heart failure so severe her arms were swollen, even though she had just been discharged from the hospital! I spent 20 minutes talking on the phone to her cardiologist and her daughter to understand the barriers and try to find a way to fix them. The barriers included her urinary incontinence when she takes her diuretics and her need for help to put on and take off her Velcro “garments.” I helped her create a strategy for handing these, and last week, she healed.

I don’t have an answer to the possibility that wound care practitioners might experience monetary penalties on account of patients with heart failure, but there may be a new way to keep them under better control using “paramedicine.” In this issue, Emily Greenstein, APRN, CNP, FACCWS, CWON, explains how the wound care staff at the Sanford Wound Care Cente in Fargo (ND) are training paramedics to deliver chronic wound care services. Dr. Fedor Lurie summarizes the guidelines for compression therapy after invasive venous treatment, and you can learn about the new Wound Care Learning Network launched by HMP. I have decided if I am going to be held responsible for a problem like hospital readmissions in CHF patients, I might as well roll up my sleeves and see what I can do about it. Today’s Wound Clinic (TWC) makes that a lot easier. 

This issue of TWC is important: we’re in a transition period as Joe Darrah, former Managing Editor, has taken a new professional opportunity. It’s hard to say goodbye to Joe Darrah from whom I learned so much. We wish him the best!