Cath Lab Digest

  It is estimated that 2% of the US population has a chronic wound and a conservative estimation of the cost of caring for these wounds exceeds $50 billion dollars per year. The current reimbursement model of outpatient care has continued to reward both physicians and hospitals for performing high cost, advanced therapeutics without a feedback mechanism for quality. Although the debate regarding how to measure “quality of care” may seem recent, these ideas actually date back to the early 1900s with the work of Dr. Ernest Codman. He developed the Minimum Standard for Hospitals to help eliminate substandard care. The Health Care Financing Administration (HCFA, renamed the Centers for Medicare & Medicaid Services) first attempted to measure and publicly report hospital outcomes in 1986 but it withdrew its “mortality measures” because of widespread criticism. In 1999, The Joint Commission (TJC) began to develop a set of core measures for hospitals. The core measures were formally adopted by an act of Congress in 2003 as the basis for a reimbursement incentive for voluntary performance reporting among hospitals. In the century since Codman’s initial work, debate has continued to rage regarding exactly what represents a measure of “quality” for healthcare providers. It was for this purpose that The National Quality Forum (NQF) was created.

QUALITY MEASURES AND THE NQF

  The NQF is a not-for-profit membership organization, the mission of which is to improve the quality of American healthcare by setting national priorities for performance improvement and endorsing national consensus standards for measuring and publicly reporting on performance. Although the NQF has hundreds of members (physician specialty groups, nursing organizations, insurance companies, hospitals, healthcare agencies, etc.), in 2007, the Association for the Advancement of Wound Care (AAWC) became the first member group specifically focused on the area of wound care. A 23-member Board of Directors representing healthcare consumers, purchasers, providers, health plans, and experts in health services research governs the NQF. The Board includes representatives from two federal agencies, the Center for Medicaid and Medicare Services (CMS) and the Agency for Health Care Research and Quality (AHRQ). There are some current NQF standards, which are relevant to wound care. Most of these standards were created for use by nursing homes. For example, the “Pressure Ulcer Framework Committee” developed a framework for measuring quality for prevention and management of pressure ulcers at both the facility and practitioner levels across the continuum of healthcare. This was funded by AHRQ.

  There is a circular logic, which presents a challenge to the adoption of more wound care related quality measures. The NQF priorities are set, for the most part, by CMS, so the NQF will not initiate a project unless CMS first recognizes that work is needed in this area to establish quality measures. CMS on the other hand, will not adopt measures as part of its “pay for performance program” (see below) unless the measures are endorsed by the NQF. So, it is nearly impossible to get a quality measure adopted by CMS unless the NQF endorses it, and the NQF will not put resources into developing a measure unless CMS instructs them to do it.

PAY FOR PERFORMANCE: PQRI BECOMES PQRS

  In 2006 President Bush signed the Tax Relief and Health Care Act (TRHCA), which authorized CMS to establish and implement a physician quality reporting system. In response to the mandate, CMS created the Physician Quality Reporting Initiative (PQRI), known as “Pay for Performance” (P4P). To develop and implement these initiatives, CMS collaborated with a wide range of other public agencies and private organizations who have a common goal of improving quality and avoiding unnecessary health care costs, including the NQF, TJC, the AHRQ, the National Committee for Quality Assurance (NCQA), and the American Medical Association (AMA).

  Under PQRI, Physician Quality Reporting Initiative has been voluntary. The Medicare Improvements for Patients and Providers Act (MIPAA) of 2008 authorized a 2% bonus for those who successfully reported quality measures, and this was increased to 4% in 2011 (2% for PQRI plus 2% for electronic prescribing). In 2011, there were 173 measures applicable to primary and specialty physicians. Remember that CMS defines “performance” as, “the right care, to the right patient, at the right time.” Most of the measures are designed to evaluate whether the clinician provides the right care, not whether the outcome is good. For example, a measure to assess counseling for smoking cessation measures only whether patients who smoke are counseled to stop smoking, not whether they actually stop. And the incentive money is awarded merely for reporting on applicable measures, regardless of whether or not the measure was met. To be eligible for the bonus, measures must be reported in at least 80% of encounters where a measure applies.

  There are a variety of ways to report. Physicians can report using their “claims” (by filling out a paper charge document to track these interventions such as smoking cessation counseling). This method has not been very successful because it is complex and requires a lot of work to be done by hand. So, in April 2008, CMS expanded the data collection process from the laborious “claims based” reporting process to include reporting data via Qualified Patient Registries. In the interest of full disclosure, I am the Chief Medical Officer of one of the few national “Registries” which reports data to CMS on behalf of physicians.