A Way to Save Wound Care

Normally we would remove a physician with numbers like that from our provider network.” That’s what the chief medical officer of a clinically integrated network (CIN) said on this week’s monthly physician advisory board conference call. 

We were reviewing 8 practitioners slated to be removed from participation because their cost and quality data were unacceptable. A superb wound care practitioner with whom I practice was on the list and the question was, should she be removed from the group, limiting her ability to see certain Medicare Advantage patients? 

The problem occurred because last year, 28 wound center patients on the rolls of an affiliated Accountable Care Organization (ACO) didn’t get an “annual visit” with their primary care practitioner (PCP). As a result, the patients did not have a designated PCP, so their annual healthcare spending was attributed to the doctor who saw them with the greatest frequency during the year. Which doctor saw these patients the most? You guessed it! My colleague, the wound care practitioner. 

Making matters worse, the annual Medicare Spending Per Beneficiary (MSPB) among chronic wound patients across the U.S. is staggering. Because of the way Medicare handles “attribution,” nearly every time a patient with a chronic wound is hospitalized for congestive heart failure, the medical costs are attributed to the wound care practitioner. 

How Quality of Care Metrics Can Be Deceptive

Why does this matter? All physicians in the United States are positioned on a grid depicting their “cost” and “quality” data, most of which is derived from data submitted under the Merit-Based Incentive Payment System (MIPS). The ideal position is the top right corner of the grid (see Figure 1), which represents low-cost, high-quality care. Inside of many private payer healthcare plans (because this is not just about Medicare), doctors in the top right quadrant are paid more for their services than their peers. In fact, they may get paid a lot more than practitioners in the bottom left quadrant, which is the “zone of shame” representing high cost, low quality care. An alternative payment plan (like an ACO) that contracts with Medicare to deliver high-quality, cost-effective care can be financially devastated if even a few practitioners are out of alignment with their cost and quality benchmarks. 

It’s no surprise that this wound care practitioner demonstrated much higher patient care costs than average for the doctors in the network, but cost wasn’t the only problem. The other problem was that her quality performance was low. She’s a brilliant doctor and an excellent wound care practitioner, so how could she be assessed as providing poor quality care? The problem is that in this case, “Quality of care” is determined by performance on a specific set of quality measures, which include Rheumatoid Arthritis Management, Breast Cancer Screening, and Statin Use in Persons with Diabetes. 

My colleague’s performance on these primary care measures was poor because she practices wound care! In other words, her quality of care is being determined by measures irrelevant to wound care, while she is being held responsible for the cost of treating conditions like heart failure. This conundrum is not unique to her. It threatens the future of every wound practitioner and access to wound management services for our patients.

As far as my friend and colleague is concerned, we can partially fix the misallocated costs by identifying the PCP for all the Medicare Advantage patients she is seeing in the wound center. Unfortunately, there’s nothing we can do to fix a wound care practitioner’s poor performance on irrelevant quality measures like breast cancer screening. As we’ve been discussing for a decade, wound care practitioners need wound care quality measures to report. Without them, they will appear to be doctors who spend a lot of money unnecessarily while providing low quality care. The reason we need wound care-relevant measures is not because there’s a lot of bonus money affiliated with the MIPS—there isn’t. It’s because private payers are using quality performance score to decide which practitioners can even see their Medicare Advantage and commercially insured patients and to set payment rates. Your Quality score matters in the way your credit score matters. It can determine whether you get a good deal or a bad deal in a contract, or whether anyone will contract with you at all. 

Wound Care Compare Is Here

Quality performance score matters for another reason. This year, quality performance data were posted for all practitioners on Medicare’s Physician Compare website. The Centers for Medicare and Medicaid Services (CMS) hopes that patients (and payers) will use the data on Physician Compare to select healthcare providers. And that leads me to my big news. 

In 2018, about 1,300 practitioners participated in quality reporting through the U.S. Wound Registry (USWR), a non-profit organization that facilitates MIPS participation for wound care practitioners and podiatrists. The USWR helped practitioners report data from 23 different electronic health records (EHRs). Since 2014, through the USWR, a subset of wound care practitioners (MDs, DOs, NPs, DPMs) has reported a suite of wound care relevant “specialty” measures, developed by the USWR in conjunction with the Alliance of Wound Care Stakeholders and its member organizations. In 2018, a total of 14 Qualified Clinical Data Registry (QCDR) measures were available through the USWR. These wound care relevant measures included the adequate compression of venous leg ulcers (VLUs) at every visit, the adequate offloading of diabetic foot ulcers (DFUs) at each visit, arterial screening of patients with leg ulcers, the risk stratified healing rate of VLUs and DFUs, appropriate use of cellular- and/or tissue-based products, appropriate use of hyperbaric oxygen therapy in DFUs, and several others. 

Since 2014, physician organizations across the US have developed and reported QCDR measures relevant to their specialty (e.g., gastroenterology, anesthesiology, neurology, surgery, etc.). It takes 3 years of reporting on a measure for CMS to set a “national benchmark rate” for that measure. Once a national benchmark rate has been set by CMS, the performances of practitioners reporting these measures can be compared with each other. There are about 50 different QCDRs representing all the medical specialties and subspecialties that have launched hundreds of QCDR measures. CMS must approve each of those QCDR quality measures before practitioners can report them. In many cases, only the physician specialty organization sees the quality data reported by their members. 

However, a handful of specialty measures were selected by CMS to be depicted nationally on Physician Compare. CMS obtains patient input to determine whether a measure is understandable and which ones might be most helpful to patients in selecting a healthcare provider. In 2017, about 500 wound care practitioners reported USWR QCDR measure data to CMS.

What You Should Know About National Wound Management Benchmarks

Out of the hundreds of QCDR measures reported by medical specialties, CMS chose 11 to be depicted on Physician Compare in 2019. Three of the 11 specialty measures selected by CMS for inclusion on Physician Compare were developed and reported by the USWR. Those measures are appropriate compression of VLUs at each visit, appropriate offloading of DFUs at each visit, and arterial screening of patients with leg ulcers. The organizations with the other 8 QCDR measures include the American Academy of Neurology, the Anesthesia Business Group, the American College of Emergency Physicians, the Anesthesia Quality Institute, the GI Quality Improvement Consortium, the Primary (Care) Practice Research Network, and the Society of Thoracic Surgeons. It is exciting to see the field of wound management in such an auspicious group.

You can check out my data on Physician Compare at https://tinyurl.com/y6r9d3kb.

For a decade, the USWR has been quietly advancing the quality of care for patients with lower extremity ulcerations. Because of the work of the USWR, more VLUs are being put in adequate compression, more DFUs are being provided appropriate offloading, and more patients with lower extremity ulcerations are undergoing arterial vascular assessment. The result is that more DFUs and VLUs are healing. The MDs, DOs, NPs and DPMs who reported those 3 wound care quality measures in 2017 had higher honestly reported healing rates for VLUs and DFUs than practitioners who did not report them. The USWR quality initiative is a vendor-neutral program. We are making great strides, with small steps. n 

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.

1. Centers for Medicare and Medicaid Services. CMS announces changes to Physician Compare. Available at https://www.cms.gov/blog/quality-payment-program-releases-2017-physician-compare-data-and-sees-increases-clinician.