Taking A Peek Into Your Wound Care Future Through Quality Measures

  The nails are already in the coffin of the fee-for-service reimbursement model we used to know as healthcare providers. It’s not quite buried, but we are presiding over the funeral. Two weeks ago, I went to the “baby shower” for the new healthcare system at the annual National Quality Forum Meeting in Washington, DC, which was themed, “Tackling Costs: The Quality Solution.” Detailed notes will be posted on my blog (view online at www.carolinefifemd.com), but I’d like to summarize here some specific things that the wound care industry needs to do to prepare for the bouncing bundle of joy that is the new value-based healthcare reimbursement system.

  In order to transition to a payment system that is patient centered and quality driven, the Centers for Medicare & Medicaid Services (CMS) is focused on: 1) incentivizing clinicians through quality programs and risk sharing; 2) improving care delivery through better integration of services; and 3) transparency of information on quality and cost. In Minnesota, 84% of primary care clinicians contribute data to a statewide, publicly reported database of patients’ experiences of care measures. Get a glimpse of what this looks like at Minnesota Health Scores (www.mnhealthscores.org). Payers use quality measures data to determine how much health insurance companies will reimburse providers for the care they give to patients. CMS officials have made it clear that patient experience of care measures are among the quality measures they most want. That is why the US Wound Registry (USWR) has licensed the “Wound Related Quality of Life” questionnaire — the first patient-reported quality measure for which wound care clinicians can get Physician Quality Reporting System (PQRS) credit. But we as an industry need more patient-centered experience-of-care measures for wound care.

Establishing Quality Data

  While many clinicians worry that healthcare reform will mean cutbacks to necessary services, CMS estimates that fully half of all Medicare spending is wasted from overuse or misuse. CMS’ move to “package price” cellular and tissue-based products (CTPs) and the preauthorization of nonemergent hyperbaric oxygen therapy (HBOT) are both aimed at what CMS perceives as “over delivery” of those services. Sadly, these modalities probably have been overused and misused. That’s one reason that “appropriate use” measures for both CTPs and HBOT were among the first suite of quality measures developed by the USWR. For wound care clinicians to compete for our share of the healthcare dollar, we will need to publicly report quality measure data like the USWR appropriate use measures by wound care providers. Other clinicians are already doing this! Aligning Forces for Quality is the Robert Wood Johnson Foundation’s signature effort to improve the quality of healthcare in targeted communities (www.forces4quality.org). For example, a “composite measure” has been created for diabetes management, which nearly all physicians in the city of Cincinnati agreed to report. After the data are validated, a community average is generated for each measured condition, a score is given for each physician practice, and then the scores are reported on a patient-focused website (www.yourhealthmatters.org). That is why the USWR has worked so hard to carefully craft wound care and HBOT measures that define optimal care. This is also why it’s such a problem if we don’t all use the same measures. For example, if one group of physicians reports a diabetic foot ulcer (DFU) offloading quality measure as “the percentage of DFUs prescribed any offloading one time in 12 months,” but another group reports the USWR measure of “the percentage of DFUs prescribed evidence-based offloading at every visit,” they are not reporting the same standard of care. (Remember that you still pass a quality measure if you document that the patient refused or there was a medical reason not to implement the measure.) The second quality measure is the better measure of quality, and thus harder to pass. So more physicians may score 100 percent using the “easy and not meaningful” measure. However, which group is most likely to have the best healing rates in the shortest period of time and at the lowest total cost?

  Remember that the measures CMS really wants to develop are total cost-of-care measures. CMS wants to understand the return on investment (ROI) for various interventions. How is that possible using quality measures? HealthPartners is the largest nonprofit healthcare organization in the US and provides insurance coverage for patients in Minnesota. To date it has also developed the most complex quality measure ever endorsed by the National Quality Forum. This measure allows a payer to understand the costs contributed by various sites of service for a given episode of care (eg, a total knee replacement), as well as how various patient comorbid conditions contribute to cost. Imagine a quality measure that captures all the data from all sites of care pertaining to a DFU. That measure would include hospitalization charges, medications, physician charges, home nursing charges, and outpatient wound center charges (including HBOT and cellular products). The results would be posted online. It would then be possible for CMS and individual patients to determine where they could go to get the most efficient care (the best ROI). The patients and the payers could determine which providers and which wound centers (in conjunction with the associated hospital and healthcare system) provide the most efficient care. Of course, it is imperative to ensure patients are properly risk stratified so that no provider is at a disadvantage for seeing sicker patients. In fact, with proper risk stratification, it is possible for the best programs to demonstrate how much better they really are than the standard because they will be able to prove they have better outcomes in higher-risk patients. This means no more reporting “98 percent of our patients heal.” We will report outcomes like every other specialty does – the percentage of patients in each risk category who had good outcomes.

Proving Real Quality

  In preparation for this transition, the USWR has been collecting wound care data in structured language since its inception in 2005. The USWR has a head start on risk adjustment with the Wound Healing Index, but is already working on more advanced risk-adjustment models. This is where big data analytics are taking us. In 2007, we published a model that could help predict which DFUs could benefit from HBOT, but there was no impetus to use predictive models back then. Now we need to refine the models we’ve already created. The structured data entering the USWR from providers submitting data to satisfy PQRS can provide the data we need. Here is the reality check that is important for everyone to understand: 1) All these data will eventually be public, whether we like it or not. 2) Thanks to the Qualified Clinical Data Registry, we can carefully develop quality measures ourselves to ensure they represent our patient data properly. 3) The more clinicians who participate in the USWR, the faster we will be able to accomplish the necessary analysis. 4) CMS intends to perform these analyses one way or another.

  Poorly built wound care and HBOT quality measures (designed just to give doctors “something to report”) will not benefit clinicians or patients. We have to design measures that demonstrate the ROI in wound care technology and the skill level of the practitioners who use them. Other specialists are a decade ahead of us. The smart ones jumped into various quality programs early and helped get the “bugs” worked out with reporting so that by the time insurance rates and salaries were tied to their performance they could blow past their less savvy peers. The survivors of this transition won’t be the clinicians who practice evidence-based medicine, who are efficient with resources, whose patients are satisfied with their care, and who can reduce the total cost of patient care. The winners will be the clinicians who do all those things and have the quality data to prove it.

  For author disclosures, see page 4.