The Wound Care Clinician's Quality Reporting Survival Guide

  On Jan. 27, the US Department of Health & Human Services (HHS) announced the Obama administration’s ambitious targets for overhauling the physician payment system. By the end of 2016, HHS plans to tie 30% of traditional Medicare payments to quality or value through “alternative payment models.” By 2018, 50-90% of Medicare physician fees will be tied to the quality of the care delivered rather than the quantity. A new “Health Care Payment Learning and Action Network” has been created through HHS to facilitate a similar transition among private insurers. Fee-for-service (FFS) medicine as we have known it will end within five years. The speed of this transition is breathtaking, particularly when the exact structure of whatever will replace FFS appears to be still under development. We are being waved onto the “off ramp” of the road we have always known onto an unfinished highway overpass.

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RELATED CONTENT
Update on Quality Reporting & Data Registries for 2015
Measuring Quality in Wound Care
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  Even if part of the payment structure is still under construction, several quality programs are currently operational, which may profoundly affect clinician revenue. In 2015, many quality programs will transition from the financial incentive to the “penalty phase.” Practitioners who bill under the Medicare Physician Fee Schedule (MPFS) and have not yet begun to participate in these programs will face increasingly stringent financial penalties. This article will explain the details of the programs that are currently in effect and how providers can (and must) become compliant with them.

PQRS & Quality Measures

  The Physician Quality Reporting System (PQRS), which launched in 2008 as a voluntary bonus program known as the Physician Quality Reported Initiative (PQRI), was actually the first phase of US healthcare payment reform efforts focused on shifting reimbursement away from volume-based payment to value-based payment.

  Eligible practitioners (EPs) who do not satisfactorily report data on quality measures (QMs) for services furnished to Medicare Part B beneficiaries to the Centers for Medicare and Medicaid Services (CMS) will be subject to a negative payment adjustment under PQRS as the penalty phase commences in 2015. A “negative payment adjustment” is Medicare’s term for withholding a percentage of billed revenue as a penalty. EPs under PQRS include many different types of professionals whose services are based on the MPFS. If you bill under the MPFS then you are probably an EP.

  QMs are tools that are intended to quantify healthcare processes, outcomes, and patient perceptions. Although PQRS is a Medicare quality program, the same QMs are now being used by many organizations, and in many different ways. As physicians increasingly become employees of hospital systems or other novel healthcare delivery entities, these organizations are using quality data as part of physician compensation packages as well as to negotiate payment rates with insurers. CMS requires that physician quality data be publicly reported (eg, available on the Internet at sites such as the CMS Physician Compare) so that patients can use the information to select healthcare providers.

  So, in addition to their potential use in determining physician compensation, this publicly available physician quality data could have medicolegal, social, and professional implications.It is, therefore, imperative that measures be designed around interventions that are within the control of the provider to implement, are representative of best clinical practices, and actually reflect the services the provider offers. A wound care provider cannot be content with having “something to report” merely to avoid penalties when the downstream effects of quality measure data could be significant. When reviewing the specific quality measures below, consider the potential significance of having the public results of one’s performance on these measures to be used as a way to assess one’s wound care expertise, or to calculate a substantial portion of one’s salary.

Why is Certified EHR Necessary?

  The data needed to report QMs are obtained from electronic health records (EHRs). Although a few QMs can still be reported using claims (and thus do not require a certified EHR), this method is being quickly phased out. It will soon be impossible for EPs to successfully participate in quality initiatives without a certified EHR. Beginning in 2009, incentive programs were created to foster the adoption and Meaningful Use (MU) of EHRs. The legislation mandating EHR standardization and utilization was specifically designed to facilitate the acquisition and transmission of quality data to the various governmental entities responsible for healthcare coverage and payment decisions, particularly CMS.

  The transmission of healthcare data requires that all EHRs utilize a standardized language for information exchange. Unfortunately, in the early years of measure development there was no standard for measure creation and measures were developed by many diverse organizations (an organization that creates a measure is known as a measure steward). Under Stage II of MU, standards have been put in place defining the way data are put in (a standard called the Healthcare Quality Measure Format), as well as the way quality data comes out in transmission (a standard called the Quality Data Reporting Architecture). For EHR vendors to become MU Stage II certified for clinical quality measurement, they had to validate that they could capture, calculate, and transmit electronic clinical quality measurement (eCQM) files. These files are comprised of thousands of lines of computer code that to a non-expert may resemble something out of The Matrix movie. Embedded within them are the instructions required to capture detailed information necessary to report the measure (eg, whether the patient has Medicare, relevant diagnosis codes, procedure codes, laboratory values, dates of service).

  As a result of the difficulty in achieving this reporting capability, far fewer EHRs have been certified for Stage II MU than were certified for MU Stage I. In fact, while an EHR vendor may have a product that is Stage II certified, that may not be the version currently being used by a provider. Due to the unique challenges that wound care EPs face with PQRS reporting, they will not be successful with PQRS unless they are using an EHR certified for Stage II MU. (To assess whether your EHR meets this requirement, see the resources listed at the end of this article.)

Why Participate In PQRS?

  EPs who did not participate in PQRS in 2014 will lose 2% of Medicare revenue in 2016. Those who did not participate last year cannot avoid a financial penalty next year. However, for those who do not successfully report QMs in 2015, the penalty under PQRS is 2%. Advanced practitioners who have not adopted a certified EHR face a potential reduction of 1% of Medicare payments in 2015. That penalty increases 1% annually to a maximum of 3% in 2017 and beyond. Electronic prescribing (eRx) is a requirement for advanced practitioners to achieve MU of their EHRs and practitioners face an additional reduction of 2% of their 2015 Medicare payments if they are not using eRx.

  A new penalty/bonus system is being rolled out under the Affordable Care Act, under which CMS has begun applying a “value modifier” (VM) for practitioners paid under the MPFS. Both cost and quality data are to be included in calculating the VM, meaning performance in PQRS will be used to adjust the rest of Medicare payments. In 2016, CMS intends to apply the VM to practices with one or more physicians or non-physician practitioners and to double the maximum potential payment adjustment from 2% (which will apply to 2016 payments) to 4%. The 2016 adjustments will apply to 2017 payments based on how CMS classifies the practice.

  In 2015, solo practitioners who do not successfully report PQRS QMs and who do not meet MU requirements of a certified EHR (and are not using eRx) risk losing up to 6% of Medicare payments. When the impact of the VM is added to this, as well as the recent HHS mandate to shift 50% or more of payment to a quality basis by 2018, it should be clear that financial survival will be tied to participation in quality programs, starting with PQRS. The rest of this article will focus on how EPs whose practice is primarily focused on wound care can succeed in PQRS.

Measures to Report in 2015

  A total of 255 measures are available in the 2015 PQRS, including 63 outcome-based measures and 19 cross-cutting measures. There are no measures in the 2015 PQRS relevant to wound care. However, there are three measures relevant to the examination of the diabetic foot. In 2015, EPs must report nine measures covering at least three National Quality Strategy (NQS) domains. One of the nine measures must come from the new cross-cutting measure list.

  By way of example, Table 1 on page 22 lists 11 QMs taken from the 2015 PQRS that a wound care practitioner might be able to successfully report, depending on practice setting. The measures have been grouped by the NQS domain to which they belong. Four domains are represented: effective clinical care, patient safety, community and population health, and communication and care coordination.

  Remember that an EP must report one cross-cutting measure, so the final column identifies which of these are cross-cutting measures. Review the entire 2015 PQRS measures list to determine whether different measures are a better fit for one’s practice (see resources that follow this article). In addition, providers should refer to the detailed descriptions of each measure to understand what it takes to meet requirements. It is always advisable to select more than nine measures so that in the event you are unable to pass one, you have another measure or two as a “buffer.”

  Key Question: When reviewing Table 1, does your EHR contain sufficient data to successfully report on at least nine of the 11 measures listed?

How Measures Are Reported

  There are several options for submitting quality data, but a few of these options are not relevant to wound care practitioners or to this discussion. If you would like more information on reporting via claims, the “EHR direct” method, or group reporting, see the “Step by Step PQRS for Wound Care Professionals” at the end of this article.

  Reporting PQRS via a Qualified Registry: When PQRI/PQRS began, only the claims-reporting method was available. Participation was low and the failure rate was high, leading CMS to create “qualified registries” in 2008. The job of a qualified registry is to aggregate an EP’s clinical data, calculate the performance of the quality measures the EP wishes to report, and transmit the results to CMS on behalf of the EP. (In other words, qualified registries calculate an EPs “report card” and transmit the final grade to CMS.) Qualified registries undergo an intense vetting process by CMS in order to obtain and maintain status. Each year, each registry must notify CMS of the specific PQRS measures it intends to report. Most registries focus on a particular area of interest (eg, cancer or heart disease) and many are run by medical specialty societies to serve the reporting needs of their physician members (eg, the American College of Cardiology’s Pinnacle registry, which reports cardiac measures on behalf of members).

  Key point: Qualified registries can report only measures available within PQRS, and no qualified registry reports all PQRS measures.

  Once an EP identifies at least nine PQRS measures that will likely be reported successfully, the task then becomes identifying one registry to report to CMS on one’s behalf for all measures chosen. Some EHR vendors have their own PQRS registries, as do some medical schools, healthcare systems, specialty societies, accountable care organizations, etc.

  The 2015 qualified registry list is posted on the CMS website (also refer to the resources that follow this article). The list includes registry names, contact information, cost of reporting, and which measures each registry can report. If you have identified nine PQRS measures with which you feel you can be successful, the next task is to review the list of qualified registries for 2015 and select one registry accepting new clients that can report all of the measures you have selected. You would then use the contact information provided to begin the process of working with that registry.

Why Aren't There Any Wound Care Measures in PQRS 2015?

  For more than a decade, medical specialty societies, the American Medical Association (AMA) Physician Consortium for Performance Improvement (PCPI), the National Quality Forum (NQF), and many other organizations have been developing quality measures. However, since wound care is not a recognized medical specialty, measure development in this field has lagged. In 2007, as part of an AMA-PCPI initiative, the American Society of Plastic Surgeons (ASPS) led a working group to develop wound care-related quality measures. CMS selected two of the ASPS measures — both “overuse” measures — for inclusion in PQRS: not performing saline wet-to-dry dressings and not performing swab culture of any wound. Both measures were retired from PQRS in 2014. That means that there are no wound care-related PQRS quality measures in 2015.

  The US Wound Registry (USWR) alone, and later in partnership with the Alliance of Wound Care Stakeholders (AWCS), submitted four PQRS wound care measures to CMS during open calls for measures in 2009 and 2011: a per-visit measure of diabetic foot ulcer (DFU)-effective offloading, a per-visit measure of effective venous ulcer compression, a measure for vascular screening patients living with leg ulcers, and a measure for pressure ulcer support surface.

  However, CMS summarily rejected these measures on both occasions, apparently due to their lack of endorsement by the NQF, an organization that evaluates and endorses quality measures (among other activities), although the CMS decision process was not transparent. The NQF measure review and endorsement process is lengthy and the evidentiary requirements are high. It is worth noting that the three wound care measures previously included in PQRS and subsequently retired did not have NQF endorsement and probably could not have obtained it. When the NQF was approached by the AWCS and the USWR regarding the submission of wound care measures, officials indicated that proposed wound care measures were not likely to achieve NQF endorsement because the evidence base for processes such as DFU offloading would not likely meet their standards. As a result, despite seven years of concerted effort by the USWR and AWCS, it did not appear that wound care EPs would have access to relevant quality measures before the looming deadlines of healthcare reform. However, on Jan. 1, 2014, CMS allowed registries meeting certain criteria to apply for consideration as qualified clinical data registries (QCDRs). Measures developed by a QCDR, while not considered to be officially part of PQRS, could still be reported by EPs to satisfy PQRS requirements. The USWR, having been a qualified registry for PQRS reporting since 2008 when PQRS began, was among the most experienced quality registries. It was accepted by CMS as a QCDR along with 12 new wound care-related quality measures in 2014. The Wound Care Quality Improvement Collaborative (WCQIC) by CECity,® a healthcare software provider whose products are geared toward quality reporting, performance improvement, and lifelong learning, is also a QCDR.

Reporting Quality Data Via QCDR

  Data submitted to CMS via a QCDR covers quality measures across multiple payers and is not limited to Medicare beneficiaries. The major difference between a QCDR and a traditional qualified registry is that QCDRs are not limited to reporting measures within PQRS. A QCDR may develop its own measures and submit them to CMS for approval. QCDRs were first established in 2014, and that year each QCDR could submit up to 20 homegrown, non-PQRS measures. In 2015, QCDRs will be allowed to develop up to 30 non-PQRS measures.

  To achieve quality reporting using a QCDR, an EP must report at least nine measures covering three NQS domains for at least 50% of the EP’s applicable patients seen during the 2015 participation period. (Note: All patients are eligible, not just Medicare beneficiaries.) An EP must report at least two outcome measures. However, if the QCDR does not possess two outcome measures (patient outcomes must be risk stratified), it must possess at least one outcome measure and one of the following other types of measures: resource use, patient experience of care, efficiency/appropriate use, or patient safety.

  The 2015 list of CMS-approved QCDRs was not available at the time of publication of this article. Using the 2014 list, there were two QCDRs with homegrown wound care measures. The Chronic Disease Registry (doing business as the USWR), a nonprofit 501 (c)(3) organization, has developed 20 homegrown wound care and hyperbaric oxygen therapy (HBOT) measures and reports 32 PQRS measures representing a total of four NQS domains.

  There are several outcome measures (including an outcome measure for DFUs treated with HBOT). USWR outcome measures are stratified by a validated, published risk-stratification method (Wound Healing Index). The USWR reports a patient experience-of-care measure (wound-related quality of life) as well as two appropriate-use measures (HBOT in DFUs and cellular and tissue-based products [CTPs, formerly skin substitutes] in venous ulcers and DFUs). There are several patient safety measures, including those pertaining to HBOT.

   (Watch for updates in April at https://uswoundregistry.com/qcdr.aspx.) As of the publication of this article, the WCQIC lists six homegrown wound care measures and three PQRS measures. (Look for updates in April at https://info.cecity.com.)

  Table 2 on page 24 provides an example of PQRS- and QCDR-developed measures from the USWR that might be relevant to an EP practicing wound care and HBOT. Note that five NQS domains are represented as well as four outcome measures, so all QCDR reporting requirements are met. Review the entire list of measures offered by the QCDR before deciding which measures to report.

  Note: The USWR can report 20 homegrown wound and HBOT measures as well as 32 PQRS measures. Refer to the USWR (https://uswoundregistry.com/QCDR.aspx) to see if other measures are a better fit for your practice.

How Does EHR Data Transmit to QCDR?

  In 2015, all homegrown QCDR measures must be developed as eCQMs. The detailed specifications of each eCQM must be posted to CMS by April 30. (See the resources following this article for better understanding of eCQMs.) Once the QCDR is selected, be sure to inform respective QCDR representatives of your intention to work with them for PQRS reporting. They can begin to help you immediately. On April 30, EPs can download eCQMs for the measures they have decided to report and provide them to their EHR vendors. As long as the EHR is certified for Stage II MU, it should be possible for the vendor to install the eCQMs into the EHR, thus enabling EPs to report the selected wound care quality measures.

  EPs will be required to enter into and maintain an appropriate legal agreement with the QCDR selected. This agreement allows the QCDR to receive patient-specific data and allows the registry to release quality measure data to CMS. It is important to provide the correct tax identification number/national provider identifier (TIN/NPI) combination to one’s registry for incentive-payment purposes.

  The TIN/NPI is important because the QCDR has a limited timeframe during the submission window to correct invalid TIN/NPI submissions. If CMS does not receive correct TIN/NPI information, the EP could be subject to a negative payment adjustment even if measures have been satisfactorily reported. In other words, an incorrect TIN/NPI could result in paying despite any efforts to participate in PQRS. Perhaps the most common mistake EPs make is getting their TIN/NPI wrong – data cannot be correctly reported when this occurs.

Future of Reimbursement

  The FFS reimbursement system we have always known in US healthcare is changing quicker than we ever expected and is being replaced by a system we still do not fully understand, but will be based in large part on quality performance. It is unlikely that wound care clinicians will be successful with PQRS unless they utilize some homegrown measures developed by a QCDR. Although these changes to outpatient payment are unsettling, they can provide an opportunity for wound care clinicians to revolutionize the way in which patient care is provided and outcome data are reported. Additional wound care quality measures still need to be developed. Until then, practitioners should embrace this inevitable change and support the development and reporting of national quality data.

A Step-by-Step Guide for Measure Reporting

  1. Confirm that you are an eligible provider (EP; review the list of EPs at www.cms.gov/medicare/quality-initiatives-patient-assessment-instruments/pqrs/downloads/pqrs_list-of-eligibleprofessionals_022813.pdf).

  2. Ensure the exact version of the electronic health record (EHR) being used is certified for Stage II Meaningful Use. Call your vendor or review the complete list of EHR vendors and certified products at https://oncchpl.force.com/ehrcert?q=chpl.

  3. Review the 2015 Physician Quality Reporting System (PQRS) measures list at www.cms.gov.

  4. If possible, identify more than nine measures in three National Quality Strategy domains (including a cross-cutting measure) that can be reported based on patient data collected in the EHR.
    a. If you are able to identify nine PQRS measures you can pass, use the list of 2015 participating registry vendors on the Centers for Medicare & Medicaid Services’ (CMS) website to find a registry that can report your PQRS measures.
    b. If you do not think you are likely to succeed at nine of the standard PQRS measures, the only remaining option is to use one of the 2015 QCDRs that have created homegrown wound care quality measures.
    c. For the purpose of discussion, follow this link to all CMS-approved 2014 QCDRs: www.cms.gov/medicare/quality-initiatives-patient-assessment-instruments/pqrs/downloads/2014qcdrposting.pdf (an updated list for 2015 will be available April 30).
      i. The chronic disease registry (doing business as US Wound Registry): https://uswoundregistry.com/Specifications.aspx.
      ii. Wound Care Quality Improvement Collaborative (by CECity): https://info.cecity.com/assets/Wound_Care_QCDR_NonPQRS_Measures.pdf.

  5. As of April 30, 2015, review the homegrown and PQRS measures related to wound care that qualified clinical data registries (QCDRs) can report. Select the QCDR you will work with by selecting at least nine measures (more is better) that you believe you can successfully report.
    a. Contact the QCDR to begin the process of data collection and transmission.
    b. Sign the necessary documents (eg, business-associate agreement).
    c. Download the electronic specifications for clinical quality measures (eCQMs) from the QCDR website.
    d. Contact your EHR vendor regarding the process of installing the eCQMs into your EHR.

Resources

1. Cassel C, Jain S. Assessing individual physician performance, does measurement suppress motivation? JAMA. 307:24;2595-2597.

2. 2015 PQRS Implementation Guide. Accessed online: www.cms.gov/medicare/quality-initiatives-patient-assessment-instruments/pqrs/downloads/2015_pqrs_implementationguide.pdf.

3. 2015 Cross-Cutting Measures List. Accessed online: https://cms.gov/medicare/quality-initiatives-patient-assessment-instruments/pqrs/downloads/2015_pqrs_crosscuttingmeasures_12172014.pdf.

4. Quick-Reference Guide for Understanding the 2015 PQRS Negative Payment Adjustment. Accessed online: www.cms.gov/medicare/quality-initiatives-patient-assessment-instruments/pqrs/downloads/quick-reference-guide_2015pqrspaymentadjustment_F101414.pdf.

5. Guide for Reading eCQMs. Accessed online: www.cms.gov/regulations-and-guidance/legislation/ehrincentiveprograms/downloads/emeasures_guidetoreading.pdf.

6. 2014 PQRS Registry Reporting Made Simple. Accessed online: www.cms.gov/medicare/quality-initiatives-patient-assessment-instruments/pqrs/downloads/2014_pqrs_registry_made_simple_f01-08-2014.pdf.

7. 2014 PQRS Qualified Clinical Data Registries Made Simple. Accessed online: www.acr.org/~/media/acr/documents/pdf/qualitysafety/quality%20measurement/2014%20PQRS/2014_qualifiedclinicaldataregistry_madesimple.pdf.

8. CMS Help Desk Support. Accessed online: www.cms.gov/medicare/quality-initiatives-patient-assessment-instruments/pqrs/helpdesksupport.html.