Medicare’s Quality Payment Program vs. Wound Care Practitioners

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Any views and opinions expressed are those of the author(s) and/or participants and do not necessarily reflect the views, policy, or position of Today’s Wound Clinic or HMP Global, their employees, and affiliates.

It is not likely that anyone reading this article remembers the days when Medicare payments to doctors were simply based on their charges.
 
With no brakes on the system, between 1980 and 1990, spending on physician services grew at an annual rate of 13.4%.¹ To stop this rapid inflation, in 1990, Congress reformed the system to link physician payment to the resources necessary to provide the service.
 
In 1997, Congress came up with a new idea to control physician payment called the Sustainable Growth Rate (SGR) formula.² The SGR increased payment when the growth rate of spending on physician services fell short of growth rate of the gross domestic product (GDP) and cut payments when physician spending grew more rapidly than GDP. By 2002, the SGR formula necessitated cutting physician payment by 4.8%.³ The following year, Congress was forced into the first of many “doc fix” legislative actions to avoid the SGR mandated cuts.³ For 13 years, complicated legislative initiatives continued, which postponed drastic cuts but did nothing to resolve the fundamental problems.
 
In 2015, Congress avoided a mandatory 21% physician pay cut by passing the Medicare Access and CHIP (Children’s Health Insurance Program) Reauthorization Act (MACRA), which emphasized what were called “value-based” payments, which came to be called the Quality Payment Program (QPP).⁴ The legislation enacted the Merit-Based Incentive Payment System (MIPS), which would pay Medicare providers based on a complicated method of measuring performance. MACRA received broad bipartisan support for its attempt to bring long-term stability to the Medicare physician fee schedule. Under MACRA, from 2015–2019, physicians would receive an annual payment increase of 0.5% but after 2019, would remain constant until 2025.⁴ Over the same timeframe, potential payment penalties gradually increased so that this year, in 2024, physicians could face a potential 9% decrease in their Medicare payments if they fail to participate in MIPS.⁴
 
The overarching goal of the QPP is laudable—to tie physician payment to the quality of care and the outcome of patients. Otherwise, physicians could get paid more simply by billing for more services, regardless of whether the patients needed the services or benefitted from them. For many years the Centers for Medicare and Medicaid Services (CMS) had noted the strange fact that Medicare spending and healthcare quality were almost inversely related, meaning, the highest rate of Medicare spending was associated with the lowest quality of care. It was also clear that  in general, physicians did a poor job of implementing evidence-based care. The goal of the QPP was to decrease cost and improve quality of care by establishing national “quality measures.”
 
Sadly, there are no data to show that MIPS participation by physicians has improved patient quality of care. In fact, there is a lot of evidence suggesting that MIPS has decreased the quality of patient care. It has certainly increased physician overhead and administrative costs. The one thing that everyone agrees upon is that MIPS is so complicated it makes getting through medical school seem simple by comparison. However, with as much as 9% of Medicare Fee for Service (FFS) payments at stake now, it is worth taking time to understand how MIPS works.

Who Has to Participate in MIPS?

Medicare decides which practitioners are “eligible” (Medicare’s word for “required”) to participate in the QPP based on the number of Medicare FFS patients seen in the calendar year, and/or their annual billed revenue under Medicare FFS. Unless they are participating via an alternative payment model, most practitioners participate in the QPP through the Medicare Incentive Payment System (MIPS). Now that COVID-19 exemptions are over, the eligible practitioners who have ignored MIPS in the past are facing the prospect losing up to 9% of their total Medicare FFS billing if they fail to report.⁴ It should be emphasized that physicians and podiatrists are not the only types of practitioners who may be eligible to participate in MIPS. Other potentially eligible practitioners include nurse practitioners, physician assistants, physical therapists and registered dieticians.
 
The eligibility rules are complex. Depending on their billed revenue from Medicare, physicians who are part of a group may also be eligible as individuals. Some practitioners who do not reach the threshold for mandatory reporting might be eligible to “opt in” to MIPS reporting. This means they can volunteer to submit data in the hopes of getting a bonus payment. However, once a physician decides to opt in, the same rules apply to them as to those for whom reporting is mandatory, which means physicians could end up with a penalty if they perform poorly. Clinicians can find out their eligibility status using their NPI number here: Participation Lookup.

MIPS Math

Under MIPS, physicians receive a score from 0 to 100 based on their performance in 4 weighted categories.⁵ The final MIPS score determines whether and how much of a penalty or bonus practitioners will experience. The numeric thresholds for negative and positive payment adjustments and the potential amount of bonus money change each year. Because this is a “zero-sum” game, the money collected by CMS from the penalized practitioners funds the bonus payments for practitioners with high MIPS scores.
 
So far, even for a perfect score of 100, bonus payments have been less than 2% of the physician’s annual Medicare FFS revenue. However, as more physicians are required to participate and as monetary penalties increase, the bonus money available to high performers will also increase. High performing practitioners may be able to use MIPS bonus money to offset the recent Medicare fee schedule reductions and perhaps even experience an improvement in their overall Medicare FFS payment rate. For many practitioners struggling to survive financially, a MIPS bonus could make all the difference, and a MIPS penalty could be a serious blow.
 
Although there are 4 components that comprise MIPS, this article focuses on the Quality category. For most physicians, quality reporting constitutes only 30% of a practitioner’s total MIPS score in 2024.⁶ However, there are specific circumstances in which clinicians are not required to report data in the Performance Improvement (PI) category. In such instances, the weight of the PI category is shifted to the Quality category, unless the clinician or group chooses to submit PI data. For example, clinicians working primarily in a hospital-based wound center may be exempted from PI. In 2024, PI comprises 25% of the MIPS score, and if those points are moved to the Quality category, quality reporting could account for 55% of the MIPS score among wound care practitioners working a hospital-based outpatient center. With so much revenue at stake and with quality reporting potentially constituting more than half the MIPS score for some practitioners, the topic is worth exploring in detail. More details about MIPS are available here.⁶
 
The requirements for collecting quality data have evolved over time. Beginning with the 2024 performance period, clinicians must report performance data for at least 75% of the eligible cases for each quality measure, regardless of the type of insurance the patient has.⁶ Additionally, performance data must be collected for the entire 12-month performance period (January 1–December 31, 2024). The requirement to report on at least 75% of patients and over the entire year means that it is no longer possible for physicians to report quality data via a manual data entry process. With some exceptions, most quality reporting must now be done through the practitioner’s electronic health record (EHR).

Reporting MIPS Measures

Physicians need to report a minimum of 6 quality measures and can select them from any measures available in that calendar year.⁶ To successfully report a quality measure, practitioners need to collect whatever data are necessary to report a given measure inside their EHR. Additionally, to succeed with a given measure, a practitioner must have data on at least 20 patients. For the 2024 reporting period, CMS has approved 198 quality measures. That may seem like a lot, but only a few are likely to be reportable by most wound care practitioners.
 
Unfortunately, there are no MIPS measures specifically relevant to the management of patients with chronic wounds. Thus, since the advent of the QPP, wound care practitioners participating in the program have reported general, more primary care–oriented quality measures such as screening for tobacco use and counseling smokers to stop smoking.
 
Over time, measures on which physicians across the USA report very high scores are eliminated from the program because CMS assumes that universally high scores indicate the measure is no longer needed to drive quality of care for that activity. In 2024, many MIPS measures on which wound care practitioners have relied are worth a maximum of 7 points rather than the usual 10 points.⁶ This is true for the two podiatry measures, MIPS 126 and MIPS 127 which involve a neurological evaluation of the feet among diabetics and evaluating diabetics for appropriate footwear. Unless CMS decides to retain these measures, they are likely to be phased out in the coming years. Another example is MIPS #128 Body Mass Index (BMI) Screening and Follow-Up Plan. This measure is now only available for practitioners participating in a MIPS Value Pathway (MVP), which means it is not available for wound care practitioners anymore. Most wound care practitioners report measures like blood pressure and hemoglobin A_1c control even though they do not treat hypertension or diabetes. Although practitioners may have enough data on enough patients to report these measures, and even though the measures may be worth the full 10 points for optimal performance, because most patients with chronic wounds have poor control of both diabetes and hypertension, and because wound care practitioners do not actually treat diabetes or hypertension, practitioners often perform poorly on those measures.
 
Table 1 depicts 8 MIPS quality measures that might be useful for wound care practitioners participating in MIPS in 2024. Note that 5 of the 8 are now only worth 7 points, which means they are likely headed for retirement
 

Finding enough measures is only part of the problem. Successfully reporting them is another. Sadly, even though the ability to report standard MIPS measures is mandatory for a certified EHR, many EHRs are not able to report even these standardized, national MIPS measures correctly. EHR vendors often fail to update new measure specifications from year to year, causing physicians to fail measures they might otherwise have passed, or they are unable to transmit quality data in the required format so that measure data can be reported at all. It is up to each physician to ensure that their EHR vendor updates the measure specifications annually.
 
A few measures can be reported directly from the practitioner’s EHR without going through the laborious process of submitting data to CMS. For the rest of the standard MIPS measures, technologically savvy individuals can submit the quality data extracted from the EHR to CMS. The mechanism of reporting quality data to CMS is beyond the scope of this article and beyond the technological ability of most individuals. That is why most practitioners contract with a qualified registry to facilitate the reporting of quality measure data. Some qualified registries have achieved a unique recognition from CMS as Qualified Clinical Data Registries (QCDRs). QCDRs can submit standard MIPS measure data to CMS but can also develop measures that are relevant to a particular specialty or disease process. Those measures are known as QCDR measures.⁷

QCDR Specialty Measures

QCDR measures are usually developed by medical specialty societies to capture quality in a clinical area for which national MIPS measures were not created.
 
In 2024, there are 7 CMS approved QCDR measures relevant to wound care available through the US Wound Registry (USWR) Quality Measures Provided by the US Wound & Podiatry Registries - US Wound & Podiatry Registries (uswoundregistry.com).⁸ The USWR measures were developed in conjunction with the Alliance of Wound Care Stakeholders, which acted as a surrogate for a specialty society since no specialty exists for wound care. Unfortunately, the technological barriers to reporting QCDR measures are even bigger than those experienced with standard MIPS measures. In fact, many medical societies have given up on their QCDR specialty measures because EHR vendors have almost universally refused to incorporate the programmatic specifications that would enable reporting.
 
Although the specifications for the USWR wound care quality measures were offered free of charge to all certified EHR vendors, they are currently reportable through only one EHR because the other vendors either refused to make them available, or their incorporation was unaffordable to physicians. These barriers to reporting can spell death to QCDR measures.
 
In order to keep CMS from retiring a QCDR measure, there must be at least 20 physicians reporting it, each of whom must have at least 20 applicable patients for each measure. The performance rates of all reporting practitioners are used by CMS to establish national “benchmark” rates. Where a given practitioner’s performance rate falls in relation to the national benchmark determines how many points a given measure is worth. Theoretically, QCDR measures could be worth more than 10 points because there are bonuses for reporting quality data through a QCDR. However, QCDR measures might be worth 0 points if there is no national benchmark rate.
 
When a benchmark rate is available for a QCDR measure, a physician has a better chance of a high score using a QCDR measure than when using a “topped out” national MIPS measure. For example, MIPS measure 130, Documentation of Current Medications in the Medical Record, has an average performance rate of over 90%.⁹ If a practitioner fails to document medications consistently, their performance rate will quickly drop below the national average, and they can end up achieving only 3 or 4 points for the measure. In contrast, QCDR measure performance is often distributed more normally. Thus, a physician who is consistent at providing and documenting venous ulcer compression could easily achieve the maximum number of available points for that measure, assuming it has achieved a benchmark rate.
 
Something should be said about reporting wound healing rates to CMS under MIPS. CMS requires that outcomes are reported on all patients for whom a measure is applicable. Clinicians are not allowed to make their own decisions about which patients will be excluded from reporting. While the measure can specify that certain types of patients or wounds are excluded (eg, patients in hospice), under CMS rules, the common practice of reporting artificially inflated healing rates by excluding complex patients with poor outcomes is not possible. However, does CMS requires that all outcome measures are “risk stratified” so that clinicians caring for the sickest patients do not appear to have worse outcomes than their peers. In order for the USWR to report healing rates for diabetic foot ulcers, venous leg ulcers and pressure ulcers in a way that is fair, wounds are risk stratified using the Wound Healing Index (WHI), which makes it possible to evaluate outcome in relation to the likelihood that a given wound was ever going to heal. This approach means that practitioners must become accustomed to reporting “average” healing rates that are lower than are usually reported on social media. However, doing so enables practitioners to demonstrate to CMS the complexity of patients with wounds and to justify why advanced therapeutics are often needed. It also becomes possible to identify which practitioners have the best outcomes in the most difficult cases.
 
The USWR measures are available as a “SMART app” for the Epic and Cerner EHRs. SMART app technology could overcome the technological barriers to reporting QCDR measures, but EHR vendors do charge for hosting SMART apps. Whether SMART apps will actually overcome the technological barriers associated with reporting QCDR measures is still uncertain.
 
It is fair to say that most wound care practitioners are dependent on a dwindling number of standard MIPS measures. Only a few wound care practitioners have access to the USWR QCDR measures that could be needed  to ensure success with MIPS in the years to come.

Why Does MIPS Seem Irrelevant to Most Wound Care Practitioners?

Wound care practitioners often speak about being “paid for quality” or being “paid for wound outcomes” as if that were true or even possible. Right now, wound care practitioners are not “paid for quality.” Despite the irrelevance of the QPP to the field of wound care, wound care practitioners may still be required to participate in MIPS due to the volume of their Medicare charges.
 
Most wound care practitioners have ignored MIPS because either it has not impacted them financially or because they have no control over the reporting process. For example, Hospital-based wound care practitioners are generally reimbursed by Medicare at a lower payment rate than their colleagues in private practice because the hospital is responsible for most of their overhead expenses. Thus, many hospital-based practitioners fall below the annual revenue threshold for MIPS eligibility. Even in the office setting, the increasing percentage of patients enrolled in Medicare Advantage (MA) plans has reduced Medicare FFS revenue below the reporting threshold. Additionally, many wound care practitioners work only part time, and thus are below the annual patient volume threshold.
 
Academic institutions and large hospital systems handle MIPS reporting for the physicians they employ, which generally means those physicians pay little attention to the quality reporting that is done on their behalf. Practitioners who are part of group practices must report the same suite of quality measures for all members of the group, so a wound care practitioner inside a multispecialty group could not report QCDR measures even if they wished to do so. Wound care practitioners, like most physicians across the USA, are more and more likely to be employees and thus likely to leave the details of MIPS reporting to their employer.
 
Unless there is a direct link between positive or negative payment adjustments and an individual practitioner’s salary, employed clinicians are likely to pay little attention to MIPS. Given these realities, it’s no surprise that an online questionnaire posted on the website for Today’s Wound Clinic about MIPS participation garnered fewer than 6 responses.
 
Nevertheless, there are good reasons for practitioners to pay attention to MIPS. The fastest growing aspect of the field is the mobile wound care practice, most of which see a high volume of patients. Those practices have a lot of at-risk revenue linked to their MIPS performance. It should also be emphasized that the individual or corporate owner of a physician practice can experience large financial penalties for the poor MIPS performance of their employed physicians. Furthermore, newly hired practitioners can carry with them monetary penalties or bonuses since these payment adjustments lag two years behind the performance year. Nationally, there is a clear shift to office-based and “mobile” wound care. Busy office-based and mobile physicians can suffer large penalties for poor MIPS performance. And the risk is not limited to Medicare patients. Private payers may use quality measure performance as a method to adjust their physician payment rates, and this could make quality measure performance far more important than it appears to be under the Medicare FFS program alone. For these reasons and others, MIPS is likely to matter more in future years, just as success with quality reporting gets harder.

In Conclusion

The quality reporting program is evolving. By 2026, Medicare hopes to transition every practitioner to the reporting of a suite of quality measures relevant to their medical specialty. These are called MIPS Value Pathways. The transition to MVPs could be a threat to wound care practitioners because at least right now, there is no MVP in which they might participate. If required to participate in an MVP through their primary specialty (eg, Emergency Medicine or Family Practice), wound care practitioners could be at a significant performance disadvantage, with serious financial results.
 
Thus, despite its complexity, wound care practitioners cannot afford to ignore the QPP. The recent efforts by CMS to calculate the cost of “non-pressure ulcers,” which includes every wound type except pressure ulcers, may suggest that CMS is finally paying some attention to the costs associated with wound care. However, it will not be possible for CMS to link cost to quality in the absence of any wound care relevant quality measures. Although 16% of Medicare beneficiaries have a chronic wound¹⁰, using standard MIPS measures, there is currently no mechanism by which Medicare can assess either the quality of care provided to patients with wounds, or the outcome of their wounds. It is fair to say that despite the goals of the QPP, wound care practitioners are not “paid for quality.”
 
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.

References
 
1. Health System Tracker. How has U.S. spending on healthcare changed over time? Published Dec. 15, 2023.
2. 105th Congress. Balanced Budget Act of 1997. Public Law 105-33.
3. Congressional Research Service. The Sustainable Growth Rate (SGR) and Medicare Physician Payments: Frequently Asked Questions. Updated March 16, 2015.
4. 114th Congress. Medicare Access and CHIP Reauthorization Act of 2015 (MACRA). Public Law 114-10.
5. Centers for Medicare and Medicaid Services. Quality Payment Program: Traditional MIPS Overview.
6. Centers for Medicare and Medicaid Services. Quality Payment Program. Quality Measures: Traditional MIPS Requirements.
7. Centers for Medicare and Medicaid Services. A Brief Overview of Qualified Clinical Data Registries (QCDRs).
8. US Wound Registry. Measure the right thing: quality measures.
9. Centers for Medicare and Medicaid Services. MIPS measure 130, Documentation of Current Medications in the Medical Record.
10. Carter MJ, DaVanzo J, Haught R, Nusgart M, Cartwright D, Fife CE. Chronic wound prevalence and the associated cost of treatment in Medicare beneficiaries: changes between 2014 and 2019. J Med Econ. 2023;26(1):894-901. doi:10.1080/13696998.2023.2232256