The Future of Wound Care in the Quality Payment Program

The annual battle with the Centers for Medicare and Medicaid Services (CMS) to keep a suite of quality measures relevant to wound care and hyperbaric medicine is one of those things I do to be at peace with myself—even though, right now, it doesn’t seem very important. I am happy to report that for the 10th year in a row, CMS has approved a suite of wound care-relevant quality measures offered by the US Wound Registry (USWR) Quality Measures Provided by the US Wound & Podiatry Registries - US Wound & Podiatry Registries for use in the Quality Payment Program (QPP).
 
Most quality measure work is done inside medical specialty societies—at least, when a recognized medical specialty exists. That is the best way to do it, because that’s the best way to gain broad support for creating quality standards and implementing them. Since there isn’t a recognized medical specialty for wound care, the US Wound Registry (USWR) created quality measures in collaboration with the Alliance of Wound Care Stakeholders. CMS agreed that the Alliance was the logical surrogate for a specialty society since it’s the umbrella organization under which all wound care related societies speak with one voice to payers and CMS.
 
However, the Alliance must monitor every aspect of regulatory policy that impacts patient access to wound care services, while most medical specialty societies focus on issues that impact physician payment. Because no clinical society is focused primarily on physician payment for wound care and hyperbaric medicine, there is a general lack of awareness on the part of wound care physicians about some big issues. Physicians don’t understand the “why,” the “what,” or the “how” of healthcare reform as it pertains to the practice of wound care.
 
Most doctors don’t realize that the big plans of CMS have remained incredibly consistent across decades and administrations, no matter who is in the White House and no matter what party controls Congress. The physician payment scheme we have in 2024 was formally set in motion in 2007, but the plans for it happened even earlier.
 
Today, physician payment policy is exactly where CMS planned it to be 20 years ago. In fact, I’ve been writing about this in TWC since 2011! If you have been a long-time reader of TWC, none of this will be a surprise. I will take a walk down memory lane about the Quality Payment Program (QPP) to provide some perspective on why we will eventually need quality measures relevant to wound care.

The Game Plan for Physician Payment Within CMS

The game plan for physician payment (and when I say “physician,” I mean all advanced practitioners) is playing out exactly as planned. The reason for redesigning the healthcare system was that the Medicare trust fund has been predicted to go bankrupt around 2026 due to the massive spending increase needed to care for aging Baby Boomers, and the evidence that higher Medicare spending does not result in better care. The reason that CMS decided to redesign healthcare by changing physician payment specifically is that one way or another, physicians determine how most healthcare dollars are spent.
 
Implementation of the new plan started in 2007 when CMS created “registries” to facilitate what was then a voluntary system of quality reporting. That’s when CMS began to get doctors used to the idea of having bonus money (penalties came later) attached to submitting quality data. At first this was done using old fashioned claim forms. It did not work very well, but that didn’t matter to CMS. They were starting the process of training doctors to report information to CMS and understanding that physician payment would be linked to reporting.
 
Then, in 2009, Congress mandated that all practitioners obtain and use electronic health records (EHRs). Although much was said about how EHRs would make care more efficient and safer, the real reason behind the mandate to get an EHR was to facilitate the reporting of data to CMS. The bonus/penalty system was set up as a “zero-sum” game with relatively small penalties paid by many physicians funding potentially large bonuses for a few. The quality measures first reportable through EHRs began with easy things like calculating body mass index (BMI) or recording medications. Gradually measures got more sophisticated and specialty societies began to develop measures relevant to surgery, cardiology, radiology, emergency medicine, etc. Most physician quality measures that were developed on a national scale went through elaborate and expensive endorsement processes. In fact, there was federal funding for most of them. For quality reporting, the first challenge was to create the quality measures, and the next challenge was enabling the actual reporting.
 
In 2009, it was clear we needed to create some quality measures for wound care, and I started approaching the National Quality Forum (NQF) as the representative of the Alliance of Wound Care Stakeholders. We banged on the doors of the NQF for 7 years, but they had no interest in the field of wound care. The NQF also told me that the clinical studies to support measures like diabetic foot ulcer offloading and venous ulcer compression were not large enough to be statistically reliable. Measure endorsement organizations expect the kind of data obtained from huge pharmaceutical trials and National Institutes of Health (NIH)–sponsored initiatives, so it is not surprising that all these years later, there are still no national quality measures directly relevant to wound care.
 
It is not likely that there ever will be national quality measures, since we do not have the backing of organized medicine (eg, the American Medical Association), the clinical data available in specialties like oncology, or the attention of CMS. In 2009, I saw this as a threat to the survival of wound care as a field, because if CMS intended to pay doctors on the basis of quality measures and we did not have any, we would eventually have no basis for payment.
 
The problem seemed hopeless until 2014 when CMS created entities called “Qualified Clinical Data Registries” (QCDRs). CMS realized that a lot of medical specialties and subspecialties were left out of the measure development process. They empowered QCDRs to develop specialty specific quality measures which are now carry the obvious name of “QCDR measures.” Most QCDRs are run by specialty societies, although the fact is that many societies have stopped supporting them because they are expensive and time consuming. Also, truth be told, it has become clear that CMS doesn’t really like QCDR measures and works hard to get rid of them by making it harder every year for a society to keep a measure. The measures currently CMS-approved for wound care are all QCDR measures—meaning they have to be reported through a qualified clinical data registry. These wound care measures are not reportable by the typical EHR, because EHRs in general do a lousy job of quality reporting and only when forced.
 
Unfortunately, EHRs were (and often continue to be) so badly designed that the quality data they are supposed to collect still has to be calculated through some manual process  by the physicians themselves or by entities like registries, which must extract the data from the physician’s EHR. (The process of having physicians fill out electronic or paper forms for reporting measures has fallen by the wayside now that quality data has to be reported on every patient.) Gradually, CMS has developed ways to get data transmitted directly from the EHRs. Trust me when I say that the day is coming when quality data will be routinely transmitted directly from your EHR to CMS, without going through a registry first. The goal of CMS is to look right into your EHR and assess quality of care that way. For five years after the first suite of wound care QCDR measures were developed, the programmatic specifications for the measures were offered free of charge to every EHR and none of them agreed to do the work of incorporating the wound care quality measures. The wound care relevant QCDR measures are currently available in only one EHR, but it was never meant to be that way. We had hoped that every EHR would report wound care quality data and the USWR tried hard to make that happen. Quality reporting in wound care was intended to be a way to fairly and transparently compare the performance of wound care services, regardless of what EHR was in use. Unfortunately, EHR vendors did not support this concept and most practitioners have little control over the EHR they must use.
 
Under what is now called MIPS—the Merit Based Incentive Payment Program—at least so far, physicians have been allowed to select the quality measures they wanted to report – as long as they stuck to national MIPS measures. Understandably, physicians reported the measures with the highest performance rate, since the entire program is focused on having the best MIPS score. Quality reporting was (and still is) an incredibly silly program since most people understand that calculating BMI and then “counseling” the patient about their weight, or recording whether the patient smokes and then “counseling” them about their weight and smoking, are not valid measures of whether, for example, an orthopedic surgeon offers high quality care when he/she does a hip replacement. In fact, there is no evidence  that the current quality reporting system has improved medical care, and there is a lot of evidence  to suggest that it has hurt patient care.
 
But remember, CMS has a bigger game plan. Right now, the reasons to participate in the QPP and associated quality reporting is mostly to avoid the 9% penalty to Medicare Fee for Service (FFS). The “bonus” payment for a perfect score in this complex game of electronic chess is only about 2% of your Medicare payments, and it may cost a doctor more money than the amount in the bonus just to report.
 
The QPP feels increasingly irrelevant as the percentage of patients insured under Medicare FFS continues to decrease and the percentage of those with Medicare Advantage plans continue to increase. The QPP feels particularly irrelevant to most wound care and hyperbaric medicine doctors working in a hospital-based outpatient department because they are often under the QPP “reporting threshold” (based on billed revenue) and thus do not have to report. Doctors in private practice have been paying more attention to the QPP, however. Last year, their little 2% bonus offset a 3% reduction in physician payment. Since wound care is moving more and more into the private practice setting, more wound care practitioners are paying attention.

It’s What You Don’t See Coming That Gets You

I have skipped the agonizing details of the way that laws and regulations changed over the years that lead to the current “Quality Payment Program.” Let’s just summarize it by saying that the QPP grades every practitioner on a 0 to 100 point scale based on 4 components, and the relative contribution of each component to the final score changes from year to year. Quality is only one of the four components, with the others being Improvement Activities (IA), Promoting Interoperability (PI) and cost. It's gone mostly unnoticed by practitioners that the relative contribution of quality reporting has been decreasing inside the QPP, with CMS putting more and more emphasis each year on cost. The “cost” part of the QPP is entirely calculated by CMS. Most doctors are unaware of these “cost measures” because CMS calculates them in mysterious and largely unexplained ways that are out of the physician’s control.
 
When it comes to cost, CMS has a method to determine whether a patient’s course of care is “attributable” to a given practitioner. CMS then determines the average cost for that patient’s “episode of care” and rates physicians according to where they fall in a bell curve of cost for other doctors in that specialty. In 2016, while looking at my quality report, I realized that to CMS, I looked like a very bad Family Practice doctor because way too many of my patients got hospitalized for heart failure. I was not responsible for treating heart failure, but since nearly half  of my wound center patients had heart failure, and since I saw those patients more than their cardiologist, CMS assumed I was responsible. As soon as undersea and hyperbaric medicine (UHM) got its own specialty code, I changed my specialty to UHM so I would not be mistaken as an FP when it came to cost calculations.
 
In other words, the thing that could bring an end to our field has been sneaking up on us for years, and that is the fact that the spending of every wound care practitioner is being compared to that wound care practitioner’s designated medical specialty. If, for example, you are a vascular surgeon, your costs as a wound care practitioner might not look too bad since your vascular surgery peers tend to be associated with high-cost procedures. However, the internists and family practice doctors will be in trouble if their wound care cost data is compared to their peers who still practice that specialty. Wound care practitioners see much sicker patients than the typical internist or FP. But even more worrisome is the fact that the cost measures associated with those specialties assume we are responsible for conditions that we do not treat.
 
Now you can understand why I was actually relieved when CMS began developing a cost measure for “non-pressure ulcers.” Such a measure would include all the costs associated with treating diabetic foot ulcers, venous ulcers, generic chronic ulcers, and arterial ulcers. There is good news and bad news here. The good news is that if CMS creates a wound care–relevant cost measure, we won’t be held accountable for the cost of problems like heart failure. The bad news is that, based on my Field Test report, the cost measure as it is currently designed, holds me accountable for a lot of treatments I had nothing to do with. For example, it appears that I am being held accountable for the use of skin-substitutes (cellular- and tissue-based products) in podiatry offices and even in the home setting, treatments which might not have been necessary or appropriate in the first place, and over which I had no control.

Why Having Relevant Quality Measures Will Matter (Someday)

CMS knows its needs doctors to report quality measures that are relevant to their specialty, rather than selecting generic “easy” measures like tobacco screening. CMS has been working with specialty societies to select the specific quality measures that each specialty  should report. The next step is to tie the cost of care to quality reporting for that specialty. To do that, they are developing “MVPs” (MIPS Value Pathways) based on specialty. Every MVP is comprised of a cost measure and a suite of relevant quality measures. CMS intends to mandate that every doctor report the specialty relevant MPV by 2026. Since it is possible there will be a chronic ulcer cost measure by 2026, we have to ask what quality measures might  be part of the wound care MVP?
 
The number of national MIPS quality measures on which a typical wound care doctor might be get a good score is down to about 6, and that is the minimum number a practitioner needs to report. Every year there are fewer “generic” MIPS measures that wound care practitioners can report—because by design CMS has been retiring the easy, nonspecific ones. In a few more years, there won’t be enough nonspecific measures left. In fact, most wound care practitioners are already having to screen patients for fall risk or depression to get through MIPS (check out Dr. Monica Stout’s article on falls risk screening in TWC).
 
Whether we will be able to survive as wound care practitioners will, at least in part, depend on having quality measures that are relevant to what we actually do. That’s why, every year I do hand-to-hand combat with CMS to save these measures. There are fewer than there used to be because the truth is that CMS hates all QCDR measures. One year CMS rejected the arterial screening measure for patients with lower extremity ulcers because they said it was “just a process,” so I had to explain why missed arterial disease is a major reason for limb loss. The next year they rejected the venous ulcer compression measure because they said it was “just a process”—so then I had to explain about the importance of venous ulcer compression to healing. This year they rejected the nutritional screening measure—until I showed them that even though only about 2% of wound patients get a nutritional screen, 60% of those screened are malnourished or at risk of malnutrition.
 
The quality measure battle with CMS is a lonely one for me and my team because we are on our own every year, and it is expensive. Although the USWR is a nonprofit organization, no one funds wound care measure development or maintenance. But, despite the time commitment, hassle and cost, every year when I finally get the encrypted email from CMS confirming that at least the most important wound care quality measures survived CMS’ attempt to get rid of them, I remind myself that some battles we do not fight for ourselves, but for those who come after. You can check out the 2024 wound care relevant quality measures here.
 
CMS remains unwavering as it implements health care reform. If the “non-pressure ulcer” cost measure can be made to work, it could help wound care practitioners survive the next phase of the QPP. If we can hang on to wound care relevant QCDR measures, and if we can force EHRs to incorporate them so they can be reported by all wound care practitioners, then wound care  practitioners can actually thrive inside a chronic ulcer MVP—despite not having a specialty designation. There is a possible pathway to survival for us, but getting there will require a level of engagement that we haven’t had in the past. Manufacturers will need to support the quality measures that indirectly increase product use (eg, venous ulcer compression), and the development of new relevant measures. Practitioners will have to collectively fight with their EHRs to ensure they can report QCDR measures, and we will need more than 3 doctors to have evaluated their Field test cost report, which is how many have done that, as of the writing of this editorial.
 
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.