The Uphill Path to Value-Based Wound Care with Nutritional Assessment

For decades, payment for most outpatient healthcare services has been based on the volume of services delivered. This approach can create perverse incentives for practitioners to provide more numerous or more expensive treatments than necessary, regardless of the benefit achieved, and may discourage activities that are beneficial simply because they are not directly linked to revenue generation. The Centers for Medicare and Medicaid Services (CMS) is rapidly transitioning Medicare away from a system based on volume to one based on value.¹ 

Although this titanic shift in the payment paradigm is unsettling, it may empower practitioners to incorporate evidence-based interventions that improve outcome at no additional cost. For example, most wound care practitioners realize that suboptimal nutrition contributes to poor wound healing and may be the cause of many chronic wounds. A value-based healthcare system may encourage wound care practitioners to focus on impactful interventions like nutritional assessment. How can this be effected under the new Quality Payment Program (QPP)?

The Math of MIPS

Most physicians participating in Medicare are subject to the Merit-based Incentive Payment System (MIPS).² MIPS assigns each practitioner a numeric score from 0 to 100 based on 4 weighted components: performance on “quality measures,” clinical practice improvement activities, “promoting interoperability” to facilitate the exchange of patient data, and cost (calculated by CMS using metrics such as Medicare Spending Per Beneficiary). The practitioners’ Medicare part B payment is adjusted positively or negatively based on the practitioner’s composite MIPS score. 

Although substantial bonus payments are theoretically possible, in 2018, positive payment adjustments were less than 2% of Medicare Part B payments, even for practitioners with perfect MIPS scores. Without bonus money to contend for, most practitioners are focused only on avoiding the penalty. In 2019, to avoid losing 7% of their Medicare part B payments, practitioners must achieve a minimum MIPS score of 30. The points available in the quality category are insufficient to achieve the threshold, which means practitioners must report data from at least one additional MIPS category. Most practitioners will decide to engage in practice improvement activities. 

The Role of Qualified Clinical Data Registries

There is broad agreement that MIPS is far too complicated. Even more disappointing, there is little evidence that MIPS participation improves patient outcome or quality of care. This is in part because the typically selected, primary care-oriented quality measures (e.g., blood pressure control, smoking cessation counseling) do not reflect the care provided by specialists. The failure of MIPS to improve quality may not be due to a flaw in the concept of quality reporting, but to the absence of specialty specific quality measures to report. To address this problem, CMS created entities called Qualified Clinical Data Registries (QCDRs), which could not only facilitate the transmission of practitioner data to CMS for MIPS participation, but could develop specialty specific quality measures termed “QCDR measures.” QCDRs can also develop specialty relevant Practice Improvement Activities (IAs) using the broad categories provided by CMS.

QCDR quality measures are generally developed by specialty societies. The QCDR through which they are reported is usually affiliated with the specialty society or clinical association. In 2013, the Medicare Physician’s Fee Schedule Final Rule allowed prospective QCDRs to develop up to 20 specialty specific quality measures. Registries could self-nominate to become a CMS recognized QCDR if they had already been in existence for a year and had at least 50 clinical data registry participants. The U.S. Wound Registry (USWR), a 501(c)(3) non-profit organization, had been a CMS-recognized quality registry since 2008 and hundreds of wound care practitioners were already participating.³

However, since wound care was not a recognized specialty, the Alliance of Wound Care Stakeholders and the USWR met with CMS senior staff to discuss the need for wound care quality measures and address the fact there was no wound care medical society. CMS agreed that the Alliance, as an association of clinical associations involved in wound care, could act as a de facto medical specialty for the field. The Alliance convened its member organization through a series of conference calls and developed a suite of wound care relevant quality measures. Nestlé provided an educational grant to support the development of a QCDR measure specifically targeting the nutritional assessment of patients with chronic wounds. 

In January 2014, the USWR became a CMS recognized Qualified Clinical Data Registry and CMS approved the suite of 12 wound care relevant quality measures developed in collaboration with Alliance member organizations. Since 2014, the USWR has performed quality reporting for thousands of podiatrists, wound care physicians, and nurse practitioners, enabling them to participate in MIPS using quality measures relevant to their practice. Even more exciting is the fact that registered dieticians, the champions of nutrition, are now able to participate in MIPS.

The Uphill Battle of QCDR Measures

The nutritional assessment quality measure allowed practitioners to use any validated assessment tool to ascertain the nutritional status of patients with chronic wounds and ulcers, and then create a plan of care based on the nutritional risk assessment. Reporting a QCDR measure requires the electronic clinical quality measure (eCQM) specifications to be incorporated into the practitioner’s electronic health record (EHR). Although the USWR posted the nutritional assessment eCQM specifications free of charge on the USWR website, only one EHR incorporated it. It is hoped that “smart apps,” which can be hosted by the practitioner’s EHR (for a fee charged by the hosting EHR), will facilitate QCDR measure reporting and overcome the barriers erected by EHR vendors. Additional barriers include the fact that it takes 3 years for CMS to calculate a national “benchmark rate” for a new QCDR measure, during which time the measure is worth only 3 out of the usual 10 points. This discourages practitioners from reporting new QCDR measures since MIPS monetarily incentivizes them to report their highest scoring measures. 

When you consider that practitioners could achieve as many as 10 points for simply documenting body mass index (BMI) and providing brief counseling compared to the 3 points contributed by a new QCDR measure and that the BMI measure is a fraction of the work of nutritional assessment, it is no surprise that wound care practitioners did not report the nutritional assessment measure. In fact, reporting any QCDR measures is such an uphill battle that one might question whether CMS really wants practitioners to utilize them. 

No Compare for Wound Care

This year, CMS began making quality performance data available on the “Physician Compare” website for all practitioners. The intent was to help patients compare physician quality performance and locate a specialist in their area. In addition to practitioner name, the Physician Compare website uses medical specialty to help potential patients identify local practitioners. Without a recognized specialty, patients with wounds are not able to locate a wound care provider. Additionally, absent a wound care specialty designation, the quality scores of wound care practitioners will be compared to practitioners who share their original board certification and not to other wound care practitioners. The only way for wound care practitioners to aggregate quality data is through a QCDR. If a wound care practitioner has reported their quality data through a QCDR, anyone searching for their quality measure performance data will be redirected to the QCDR’s website, which depicts the relevant information. 

QCDR participation may be a big advantage for wound care practitioners for a variety of reasons. CMS now translates quality scores into a star rating system similar to Yelp, but without defining the specific reason, a physician might be awarded only one or two stars. For example, a surgeon reporting the blood pressure control measure is not responsible for adjusting the medications needed to lower blood pressure and raise his/her performance score on blood pressure management. If the surgeon has a one-star rating because of poor blood pressure control, patients do not know that this rating has no bearing on the surgical services he/she provides. 

The Physician Compare website may not yet be in common use by patients, but it is being used by payers. Private payers have begun to use MIPS quality scores to set differential reimbursement rates for their physician fee schedules. Accountable Care Organizations use quality measure data to select or reject physician members, and at least one state Medicaid provider uses quality scores to decide which practitioners will participate in the Medicaid program. In other words, low quality scores on measures that are not even relevant to a practitioner could have far more sweeping financial implications than the MIPS-related penalty because they can impact patient self-referrals, payer reimbursement rates, and participation in certain programs. 

Practice Improvement with Patient Reported Nutritional Assessment

CMS strongly promotes “patient reported” quality measures, and patient reported measures can contribute more total points to the MIPS score. Given that Nestlé had a validated a patient reported nutritional assessment tool, the USWR decided to develop a patient reported nutritional assessment measure. Although CMS approved this new measure, they rejected it the following year, arguing that it was redundant. Instead, the USWR gave up the original physician reported measure and retained the patient reported measure. The practitioner is required to create a plan of care for supplementation based on the score. 

Even when practitioners cannot get over the barriers to reporting the nutritional assessment QCDR measure, they can still get MIPS credit for improving the nutritional status of patients with nonhealing wounds by reporting an IA. In 2018, CMS approved a USWR developed Practice Improvement Activity focused on improving the frequency of nutritional assessment within a practice. Patients can be provided a paper copy of the self-assessment tool in the waiting room and the results reviewed with the practitioner at the point of care so that supplement recommendations can be made. For the practitioners able to report the nutritional assessment measure through their EHR, the USWR can repurpose the QCDR measure data into quarterly benchmarking reports. Practitioners can use these benchmarking reports to determine whether they are improving on a quarterly basis and to evaluate their performance in relation to the aggregated (de-identified) data of other wound care practitioners. 

For practitioners who are not able to report the QCDR measure because their EHR vendor will not incorporate the eCQM, the USWR has crafted a guide to help practitioners use manual methods to document their engagement in the nutritional IA. There is less pressure around practitioner performance within an IA than a quality measure, because the goal of an IA is to demonstrate improvement over time rather than a specific (and perhaps unrealistically high) performance rate. Practitioner commitment to practice improvement can be messaged on the QCDR website, when patients and payers are redirected from Physician Compare.

Improve Outcome, Reduce Cost

If in addition to nutritional assessment, practitioners are reporting the USWR wound healing quality measures for diabetic foot ulcers, venous leg ulcers, and pressure ulcers, it will be possible to determine whether nutritional assessment and supplementation improve wound healing rates. That is an exciting opportunity. What’s more, QCDRs can link to Medicare claims data (for a fee), making it possible to evaluate whether nutritional assessment has a positive impact on care costs. It is worth remembering that numerous audits of wound care services are currently taking place, and a common reason for denial of payment is failure to optimize nutritional status. Participating in the USWR nutritional assessment IA is a way to protect Medicare reimbursement for many advanced therapeutics. 

While protecting revenue may be good motivation to start an IA focused on the nutritional assessment of patients with wounds, the real reason is to improve the quality of their care and the outcome of their wounds. That is, in fact, the goal of the Quality Payment Program. n

Caroline E. Fife is Chief Medical Officer at Intellicure Inc., The Woodlands, TX; executive director of the USWR; and medical director of the CHI St. Luke’s Wound Care Clinic - The Woodlands. 

1. CMS. What are the value-based programs? Available at https://www.cms.gov/medicare/quality-initiatives-patient-assessment-instruments/value-based-programs/value-based-programs.html.

2. CMS. MIPS Overview. Available at https://qpp.cms.gov/mips/overview.

3. USWR. Why Do I Need A Registry? Available at uswoundregistry.com/why-do-i-need-a-registry.