What You Should Know About Quality Reporting And Data Registries For 2015

Podiatrists are aware of the efforts underway to transition the United States healthcare fee-for-service payment system away from one based on volume to one that is determined by “value” and links costs to improved patient outcomes. The problem with the current system is that patients who stay in service the longest and have the most procedures and therapeutic interventions generate the greatest revenue regardless of whether outcomes are favorable. Accordingly, let us take a closer look at the various quality programs applicable to podiatrists.

The transition to a different payment method began gradually in 2008 with the Medicare Improvements for Patients and Providers Act, which authorized a 2 percent bonus of Medicare billing for qualified health providers who successfully reported quality measures. Initially known as the Physician Quality Reporting Initiative (PQRI), the reporting program is now called the Physician Quality Reporting System (PQRS). Bonus payments gradually reduced with the end of the bonus phase in 2014.

Starting in 2013, failure to participate in PQRS resulted in a 1.5 percent payment reduction for all Medicare Part B payments made in 2015.¹ Clinicians who did not participate in PQRS in 2014 will see their Medicare Part B physician fee schedule reduced by 2 percent in 2016.

The PQRS penalties are based on reporting quality measures. This year introduces reductions or bonus payments based not only on reporting of quality measures but on performance as well. This performance has evaluation using the value based payment modifier. For example, a claims submission of G9225 (Diabetic foot exam not performed, reason not given) is a successful reporting of the diabetic foot exam measure, but also represents a failure to achieve performance of the measure. Podiatrists will see the effect of the value based payment modifier in their 2017 fee schedule based on their success or failure in PQRS performance in 2015. Failure to participate in PQRS in 2015 will result in a PQRS penalty of 2 percent in 2017 and an additional value based payment modifier penalty of 2 percent more (for podiatrists in groups of nine or less) and 4 percent more for podiatrists in groups of 10 or more. If podiatrists successfully meet PQRS reporting requirements, they will avoid the 2 percent PQRS reduction and also see an upward or neutral Value Based Payment Modifier adjustment to their fee schedule based on the quality of their performance.

A Closer Look At EHR Emergence And Quality Reporting
Data needed to report quality measures originate from multiple sources including electronic health records (EHRs). It is increasingly difficult for clinicians to participate successfully in quality initiatives without a certified EHR. 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 the Centers for Medicare and Medicaid Services (CMS).

In 2009, incentive programs began to foster the adoption and Meaningful Use of EHRs. Podiatrists who did not adopt and attest to Meaningful Use of a certified EHR in 2013 have had their 2015 Medicare Part B fee schedule reduced by 1 percent. That penalty increases 1 percent annually to a maximum of 5 percent in 2020. (The penalty can be capped at 3 percent if 75 percent or more of eligible providers participate in the program.) The table “How Your 2017 Medicare Payments Could Be Affected” at right summarizes the payment penalties to be applied in 2017 based on 2015 participation.

When PQRS launched in 2008, physicians submitted quality data via claim forms. However, claims-based reporting (using paper-based documents) proved difficult, time consuming and severely limited the types of measures that one could report. Most podiatrists have been successful with claims-based PQRS reporting but CMS hopes to end the claims method of reporting in the near future. To simplify reporting, CMS created a mechanism for registry-based reporting in 2008.

The US Wound Registry (USWR), formerly known as the Intellicure Research Consortium, was one of the original 32 registries recognized by CMS for quality reporting. In addition to submitting quality data on behalf of practitioners, the US Wound Registry, as a nonprofit organization focused on quality of care for patients living with chronic wounds, began to shed light on “gaps in practice.” For example, even among patients presenting to hospital-based outpatient wound centers, only 6 percent of diabetic foot ulcers had documented adequate offloading.² This inspired the US Wound Registry to launch a Do the Right Thing™ quality initiative to improve practitioner compliance with evidence-based care. The US Wound Registry also partnered with the Institute for Clinical Outcomes Research to develop the Wound Healing Index to stratify patients by disease severity in order to provide a fairer way to report healing outcomes.³

The field of wound care cannot continue to report artificially inflated healing rates since this prevents us from being able to assess the value of advanced therapeutics or the effectiveness of wound care programs among the highest risk patients.

How The Qualified Clinical Data Registry Has Evolved
“Qualified registries” can only report measures that are in the PQRS system and designated for registry reporting. Many specialty societies had the need to report measures specific to their area of practice. The CMS has been reluctant to add new measures to PQRS unless they are endorsed by the National Quality Forum. That endorsement process is lengthy, expensive and has very high evidentiary standards that are difficult for smaller specialties to achieve.

However, on Jan. 2, 2013, Congress passed the American Taxpayer Relief Act, which in Section 601(b) outlined a new process through which physicians would be able to satisfy federal quality reporting requirements under PQRS by participating in a Qualified Clinical Data Registry (QCDR) in 2014. The critical factor of importance to the wound care industry was that a QCDR could develop its own evidence-based quality measures. A QCDR has to possess benchmarking capacity, allowing it to measure the quality of care that clinicians provide in comparison to other clinicians. At least one measure has to be outcome-based and it has to be able to stratify patients by severity or risk, a difficult task already accomplished by the US Wound Registry with the Wound Healing Index. Thanks to the Wound Healing Index, it is possible to predict the statistical likelihood that a wound will heal based on patient and wound factors. One can then report actual wound outcomes in comparison to predicted likelihood.

For example, it is now possible for clinicians to report that in the category of wounds with a 25 percent or less likelihood of healing, the clinician actually healed 50 percent of wounds. This method does not penalize clinicians caring for the sickest patients for “poorer” outcomes. In fact, using risk stratification, it is possible for clinicians who achieve unusually good outcomes in the toughest patients to demonstrate their effectiveness. This is also the way to assess the value of advanced therapeutics in real-world practice.

The CMS agreed to allow the Alliance of Wound Care Stakeholders, as an umbrella organization for many professional societies, to act as a de facto specialty society for the field of wound care. Although CMS prefers “outcome measures” (e.g. healing), they agreed that “process measures” were needed in wound care as a result of US Wound Registry publications demonstrating gaps in wound care practice, such as offloading. “Processes” are healthcare interventions that have resulted in the desired outcome (e.g., offloading is known to improve likelihood of DFU healing). The CMS will allow process measures in situations in which the outcome is difficult to measure and for which there is a clear “gap in practice,” meaning the literature shows that the intervention should be performed but data also show that clinicians don’t do it. The Alliance and its member organizations worked diligently with the US Wound Registry to craft an initial suite of 12 quality measures, all of which CMS accepted in 2014 when CMS recognized the US Wound Registry as a qualified clinical data registry. In 2015, eight additional measures were added.  

The American Podiatric Medical Association (APMA) provided to the US Wound Registry a carefully designed, comprehensive diabetic foot examination measure and partnered with the US Wound Registry to develop a vascular screening measure for patients with lower extremity ulcers. The table “US Wound Registry Qualified Clinical Data Registry Wound Care Specific Measures” at right shows an abbreviated list of the wound care measures in the US Wound Registry, specifications for which are available at: www.uswoundregistry.com/specifications.aspx . It is important to note that these measures are available for free download as “electronic clinical quality measures” or eCQMs. One can insert them into any EHR certified for stage 2 of Meaningful Use, making this an EHR vendor neutral program.

A clinician using any certified EHR can report wound care quality measures to CMS through the US Wound Registry by providing these specifications to an EHR vendor. One can report some measures from the Continuity of Care Document, which all certified EHRs must be able to transmit. In 2014, eligible professionals who satisfactorily reported data on nine wound care quality measures through the US Wound Registry received an incentive equal to 0.5 percent of their total Medicare Part B allowed charges — the last opportunity for bonus money — and avoided the 2 percent payment penalty in 2016.⁴ Podiatrists who successfully reported on only three measures avoided a penalty but were not eligible for the bonus. Failure by an eligible practitioner to have participated in PQRS in 2014 will result in a 2 percent reduction of the Medicare part B fee schedule in 2016.

What About Registry Submission?
With the proposed rule to modify Meaningful Use from 2015 through 2017, clinical data registry reporting now involves both PQRS and Meaningful Use. Under the proposed rule to modify Meaningful Use, eligible providers must choose two Public Health and Clinical Data Registry Reporting options from a list of five. The transmission of data to the US Wound Registry satisfies one of these requirements. Eligible practitioners can claim an exclusion to any of these five options only if they do not diagnose or treat any condition applicable to that option. The availability of the US Wound Registry means that podiatrists now have at least two viable options to achieve registry reporting.

In Conclusion
Although the shift from the current outpatient payment model will be painful, data from well-designed quality measures that one transmits to the US Wound Registry represent a golden opportunity for the wound care industry. Providers can publicly demonstrate their clinical excellence using the US Wound Registry’s qualified clinical data registry measures. Podiatrists wishing to successfully participate in PQRS in 2015 will need to successfully report on nine measures in three “domains” of care, including one cross-cutting measure or report one entire measure group for at least 20 patients, the majority of whom are Medicare Part B patients.

This may be difficult for most wound care clinicians using only the measures available in PQRS. However, there are currently 20 wound care and hyperbaric oxygen therapy (HBOT) specific quality measures within the US Wound Registry’s qualified clinical data registry. Podiatrists can satisfy the requirements of PQRS by selecting measures to report from among those available within the QCDR in addition to any measures within regular PQRS for which they might have data (e.g., medication reconciliation or hemoglobin A1C). The QCDR process allows wound care organizations to develop their own measures and allows clinicians to receive PQRS credit for submitting data on those measures while providing data that can be used for measure validation.

More wound care measures are needed in order to reflect the broad scope of podiatric medicine. Many medical societies have partnered with industry to defray the cost of measure development. Thankfully, this is beginning to happen in wound care. For example, in 2015, Nestle sponsored a new US Wound Registry qualified clinical data registry measure focused on nutritional screening of all patients living with wounds and ulcers. The Undersea and Hyperbaric Medical Society partnered with the US Wound Registry to develop seven new measures focused on hyperbaric medicine quality reporting, making a total of eight hyperbaric measures available. Podiatrists supervising HBOT should be aware of the availability of these measures, several of which target the diabetic foot.

Stakeholders in the wound care industry need a collaborative approach to the development and testing of a suite of quality measures so wound care will not be left behind in the transition to a value-based healthcare system.

Dr. Lehrman is on the APMA Coding Committee, is an expert panelist on Codingline.com, and is a Fellow of the American Academy of Podiatric Practice Management

Dr. Fife is the Executive Director of the US Wound Registry.

References

1. Centers for Medicare & Medicaid Services. 2013 Physician Quality Reporting System, 2013. Available at www.cms.gov/Medicare/Quality-Initiatives-Patient-Assessment-Instruments/PQRS/MeasuresCodes.html .
2. Eckert KA. Diabetic foot ulcer offloading: The gap between evidence and practice. Data from the US Wound Registry. Adv Skin Wound Care. 2014; 27(7): 310-316.
3. Horn SD, Fife CE, Smout RJ, Barrett RS, Thomson B. Development of a wound healing index for patients with chronic wounds. Wound Rep Regen. 2013; 21(6):823–32.
4. Federal Register. Medicare Program; Revisions to Payment Policies Under the Physician Fee Schedule, Clinical Laboratory Fee Schedule & Other Revisions to Part B for CY 2014; A Rule by the Centers for Medicare & Medicaid Services on 12/10/2013. Available at www.federalregister.gov/articles/2013/12/10/2013-28696/medicare-program-revisions-to-payment-policies-under-the-physician-fee-schedule-clinical-laboratory .
5. US Department of Health & Human Services. The Affordable Care Act. 2010. Available at www.healthcare.gov/law/full/index.html .
6. Centers for Medicare and Medicaid Services. Qualified Registries for the 2012 Physician Quality Reporting System and Electronic Prescribing Incentive Programs, 2012. Available at www.cms.gov/Medicare/Quality-Initiatives-Patient-Assessment-Instruments/PQRS/downloads/2012_Qualified_Registries_Posting_Phase1.pdf .
7. American Society of Plastic Surgeons, Physician Consortium for Performance Improvement, and National Committee for Quality Assurance, 2008. Chronic Wound Care Physician Performance Measurement Set. American Medical Association and National Committee for Quality Assurance. Available at www.ama-assn.org/resources/doc/pcpi/wound-care-worksheets.pdf .
8. Fife C, Walker D, Thompson B. Electronic health records, registries, and quality measures: What? Why? How? Adv Wound Care. 2013;2(10):598-604.
9. Fife CE, Carter MJ, Walker D. Why is it so hard to do the right thing in wound care? Wound Rep Reg. 2010; 18(2):154–8.
10. Fife CE, Carter MJ, Walker D, Thomson B, National Quality Forum. Measure Evaluation Criteria, 2012. Available at www.qualityforum.org/docs/measure_evaluation_criteria.aspx .