In the last two years, the Quality Payment Program (QPP) has changed the way wound clinicians practice. This author assesses the status of the QPP, specifically how the program can help improve the quality of patient care and patient outcomes by reporting quality measures.
In 2014 I invited Guy Clifton, MD—Robert Wood Johnson Fellow, neurosurgeon, congressional aide and author of the book Flatlined: Resuscitating American Medicine—to speak at the Symposium on Advanced Wound Care (SAWC) Fall. Few experts of his caliber have spoken at the SAWC but attendance in his session was sparse. Wound care practitioners had not noticed the health care payment reform freight train that was bearing down on them.
Only two years later, the Centers for Medicare and Medicaid Services (CMS) launched the Quality Payment Program (QPP), which will change forever the way we practice. Dr. Clifton outlined a strategy by which wound care practitioners could thrive under such a system. Now, in 2019, also called Year Three of the QPP, I thought I would revisit his presentation. The audience for his message might have gotten a little larger as practitioners begin to feel the impact of payment reform.
It’s About the Prices, Stupid
Before 1970, the structure of healthcare payment was almost entirely fee for service (FFS). The hospital economic model was not much different than that of an expensive hotel since it was based on the number of days a patient was hospitalized and the number of services provided. Families could literally drop grandma off at the hospital for a few days so they could go on vacation. This model was good for hospitals but bad for taxpayers since the FFS system was expected to bankrupt the government by 2000.
That is why, in 1982, Congress established the hospital “prospective payment” system, which set a predetermined payment rate based on Diagnosis Related Groups (DRGs). In 2001, an outpatient prospective payment system set reimbursement rates based on groups of significant services called the Ambulatory Payment Classifications (APCs). Although APCs control how much can be billed on any given day, they set few limits on the total number of days over which these services can be provided. Left unchanged, U.S. health care spending is now expected to bankrupt the Medicare trust fund by 2024.
In 2000 the Organization for Economic Cooperation and Development (OECD) reported that the United States spent considerably more on healthcare per capita than any other developed country.1 However, the utilization of healthcare services (e.g., physician visits and hospital days per capita) was well below the OECD median. Healthcare spending is the product of the volume of services and their price. If utilization were lower in the U.S. than in other countries but spending was much higher, the reason had to be that U.S. prices were much higher. Policy makers got the message, “It’s the prices, stupid.”1
Higher prices might have been explainable if the quality of healthcare were demonstrably better in the U.S. compared to other OECD nations, but many studies indicated that this was not the case. In 2005, data suggested that patients had only about a 55% chance of getting evidence-based care from their primary care physician and there was no link between payment and outcome.2 CMS and private payers have committed to decreasing the cost of care while increasing the quality of care. To a limited extent, cost reductions have been achieved by reducing the volume of services using tools like prior authorization. However, most efforts at cost control are focused on reducing prices. In other words, payment rates are going down.
It’s About the Physicians, Stupid
Physicians control about 85% of healthcare spending (prescribing medications, ordering tests, performing procedures, etc.). However, doctors are the main losers in the endless cycle of volume and price. In a fee for service world without quality standards, volume becomes excessive and payers respond by reducing the reimbursement rate. When payment is reduced, doctors respond initially by increasing volume even more, hoping to offset the impact of price reductions, but eventually the payment rate gets so low that it’s unsustainable. At that point, physicians stop offering the service. In the 15 years between 1990 and 2005, the mean income of cardiologists, gastroenterologists and cardiac surgeons actually decreased by 5% while their case volume increased a staggering 55%.3
It’s no wonder that physicians feel they are working harder for less money. They are.
It’s About the Variability, Stupid
Extreme variability in practice standards is endemic even though data suggest that patient complexity is not that different from one region to another. Yet, among hospitals, there is a 250–350% variation in the risk of death and complications; Medicare spending for certain chronic diseases varies 250% by region; the rate at which common major procedures are performed varies over 1,000% and in the same market, the pricing of those procedures varies by 600%.4 The bad news is that this variability is in part because quality of care is highly variable. The good news is that pricing variability provides a lot of leeway for practitioners to negotiate payment rates.
It’s About the Quality, Stupid
The new Quality Payment Program transitions practitioners away from FFS to a system that attempts to link quality (as CMS defines it) and outcome (largely defined by per patient spending). Despite the pride wound care professionals have for multidisciplinary care, the survival of “wound management” as a field will be determined by whether the physicians develop and report wound care relevant quality measures and then negotiate reimbursement rates based on their performance. Every medical specialty has figured this out but we have not.
In 2014, Guy Clifton said the first step forward was to enshrine wound care best practices into quality metrics. The next step was to compare performance among practitioners. However, the only way physicians in any specialty get pricing leverage is to negotiate payment rates based on quality performance. Five years ago, Dr. Clifton explained that wound care practitioners could get paid better if they collectively agreed on, reported, and negotiated payment rates based on wound relevant Quality Indicators. We could then follow the example of surgeons and cardiologists in developing a method of risk adjustment for patients with chronic wounds. This would allow us to calculate a risk-adjusted reimbursement rate for an episode of care and build in an adequate profit margin for wound care practitioners. Alternatively, we could negotiate supplemental fee-for-service payments for those doctors whose commitment to best practices was evidenced by their quality measure performance. In other words, we could negotiate higher payment rates for “preferred providers.”
Following this roadmap for success, in 2014, the Alliance of Wound Care Stakeholders and the U.S. Wound Registry (USWR) developed 14 wound care quality measures that were subsequently approved by CMS.5 Whether you were aware of it or not, a few physicians began reporting wound care quality metrics to CMS in 2014. In 2019, three of those measures were included on Physician Compare: arterial screening of all patients with lower extremity leg ulcers (on the first visit); adequate compression of all venous leg ulcers (VLUs) and adequate offloading of all diabetic foot ulcers (DFUs). Practitioners who reported these measures had on average a 10% better healing rate for DFUs and VLUs than non-reporting practitioners. Healing rates were reported to CMS using the USWR’s risk adjustment tool, the Wound Healing Index (WHI). Risk adjustment with the WHI ensures that practitioners caring for the sickest patients will not appear to have worse healing rates.
Think about what this means. We are actually able to improve the quality of patient care and patient outcomes using quality measure reporting, and to fairly compare practitioner performance using risk stratification.
Don’t Be Stupid
The recent Hospital Outpatient Payment proposed rule proffered an “episode”-based payment rate for the use of cellular and/or tissue based products. The proposed rule on Medicare Physician Payment suggested that CMS might combine episode-based payment with physician quality reporting to ensure that patient quality of care does not suffer under the episode-based payment that is about to impact wound care.
It’s happening just as Dr. Clifton said it would. Physician payment will be linked to quality measure performance, not really because of the Merit-Based Incentive Payment System (MIPS) but because private payers will create differential reimbursement rates based on quality performance. Quality data are now publicly reported by practitioner name. Private payer use these scores to negotiate payment rates with physicians and to develop capitated payment rates. The last thing we want is for the wound care practitioner payment rate to be determined by practitioners’ performance on standard MIPS measures like blood pressure control when we don’t treat hypertension. If everything about how we get paid for wound care hinges on quality performance, we need quality measures that differentiate clinical excellence in wound care, not primary care.
Few people seem to understand that if physician payment for wound care services is not secure, the entire industry will collapse. Just like the instructions on an airplane, physicians need to get their oxygen masks on first or they won’t be able to help anyone else.
The saddest part of this story is that we are missing an opportunity to improve patient care, decrease healthcare spending and improve the payment rate for wound management services. Unlike every other medical field, the burden of developing and reporting wound care relevant quality measures has not been supported by either the industry or the practitioners themselves.
However, that is not nearly as sad as the lack of support by wound care clinical associations. Wound care clinical associations have not been able to separate the importance of collaborative patient care from the need to support quality reporting requirements that are specific to advanced practitioners. If the linchpin for wound management reimbursement is physician quality reporting, clinical associations and manufacturers ignore that reality at their peril.
Five years after Dr. Clifton explained how we could thrive under a new system, the healthcare payment reform train has left the station. Given the years of advanced warning we had, it is unfortunate that so few physicians practicing hyperbaric medicine or wound management are on board.
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. Anderson GF, Reinhardt UE, Hussey PS, Petrosyan V. It’s the prices, stupid: Why the United States is so different from other countries. Health Aff. 2003; 22(3):89-105.
2. McGlynn EA, Asch SM, et al. The quality of health care delivered to adults in the United States. N Engl J Med. 2003; 348(26):2635-45.
3. Data from the Medical Group Management Association. Available at https://www.mgma.com/ .
4. The Dartmouth Atlas Project. Understanding the geographic variations in health care. Available at https://www.dartmouthatlas.org/ .
5. U.S. Wound Registry. USWR wound care relevant quality measures. Available at https://uswoundregistry.com/quality-measures/.