The repeated message of delivering a better than 90% healing rate has convinced payers that advanced therapeutics are overutilized, or at least not worth the price tag. The fine print is that we heal everyone, “except for the outliers.” The problem is, nearly all of our patients are outliers. Last week, I diagnosed a severe case of polyarteritis nodosa with inflammatory leg ulcers, a woman living with antiphospholipid antibody syndrome, a limb-threatening case of peripheral arterial disease, and two cases of severe leg edema caused by previously overlooked right heart failure. I can also prove that I am not at all “special” as a wound care doctor and that other wound care practitioners are caring for the same patients.
I looked at the data that the Centers for Medicare & Medicaid Services (CMS) reported as part of my participation in the Merit-Based Incentive Payment System (MIPS). In my 2017 MIPS data, CMS reported that the average age of my patients was 75 years and that 19.6% of my patients were older than 84 years. The prevalence rates of just a few of the major comorbid conditions among my patients are chronic kidney disease (60%), diabetes (56%), heart failure (55%), ischemic heart disease (54%), rheumatoid arthritis and osteoarthritis (50%), asthma (26%), atrial fibrillation (24%), Alzheimer’s (23%), COPD (22%), depression (18%), and active cancer (16%). When I compare these numbers to those of the practitioners participating in the U.S. Wound Registry (USWR), not only is the list of conditions nearly identical, so too are the prevalence rates. Furthermore, the majority of my patients have at least three of those conditions, which means that CMS expects to spend at least $60,000 per year on them. Although “cost” wasn’t included in calculating the 2017 MIPS score, CMS still calculated it and put it in my report. According to CMS, among my patients the average amount of money spent per episode of care was $58,000. If that cost “quality measure” had been counted by CMS in 2017, I would have failed it. Why? Because CMS compares your data with those of the physicians in your specialty. Since there is no “wound care” subspecialty, CMS knows only that I am board certified in family practice. Patients seen by most family practice providers in this country don’t cost as much, because they are not as sick.
CMS has a ranking system for level of “sickness.” Physicians receive a score based on the average “sickness level” of all their patients. All the doctors in a specialty contribute to the average “sickness level” for the entire specialty. Medicare patients vary greatly in terms of their health status, which affects their utilization and cost of care. Individuals living with multiple chronic conditions have higher medical costs than their healthier counterparts. Medicare has to have a way to measure the relative sickness of a patient to determine how much spending is likely to occur. The system that has been created for this is called the CMS Hierarchical Condition Categories (CMS-HCC) model. It is used to adjust Medicare capitation payments for the Medicare Advantage healthcare plans, and it’s used to evaluate whether a given practitioner’s Medicare spending per beneficiary is out of line with other practitioners in the same specialty. The models use data from more than 1 million beneficiaries to estimate the average predicted costs for each condition. “Hierarchies” are imposed among related conditions, so that a person is coded for only the most severe manifestation of related diseases. If the diseases are unrelated, the HCCs accumulate. Each year, CMS publishes an updated list of the model with the individual diagnoses and the “weight” of each (how much it contributes to the final score). Each patient has an HCC score and each doctor has an average of all the patients Medicare “attributes” to that practitioner. As it now stands, the physician who provides the “plurality” of services is considered the patient’s primary care physician (PCP). Which doctor do you think a wound care patient sees the most during a given year: A) their actual PCP or B) the wound care practitioner? If you guessed “the wound care practitioner,” you would be right. Without a subspecialty designation in wound care, CMS assumes that you practice the specialty for which you hold board certification. My HCC score is 3.29. That may not mean anything, unless I tell you that the average HCC score for a family practice doctor is 1.24. Here are some other specialty HCC average scores: infectious disease (2.93), critical care (2.52), and nephrology (4.20). The average HCC for physicians reporting to the USWR is 2.9, which is about the same as infectious disease. My personal HCC is just below that of nephrology, even though I work at a relatively small suburban hospital. So, when people claim that their wound center patients “are very sick,” they are absolutely telling the truth. However, this is not unique to academic centers or big urban hospitals. Why? Because nonhealing wounds are a symptom of disease (and sometimes of several diseases). If the majority of your patients are not “outliers,” then you aren’t seeing the right patients. If we don’t find a way to tell CMS how sick our patients are, we won’t be able to justify the money being spent on them. More practitioners and payers are moving into advanced payment models, but wound care hasn’t been part of the calculation for episode-based payment because we failed to report the “wounds with no name” and misrepresented our healing rates. There is no HCC adjustment for the proposed “episode of care” for cellular and/or tissue-based products. However, the doctors who apply them can potentially be penalized for spending too much money in comparison to peers in their specialty. MD Anderson Cancer Center would not exist if its message was “the overall cancer survival rate is 95%.” MD Anderson exists because it communicates what the likelihood of death is from cancer. If all wounds heal, then it’s not just our technology that is not necessary – we are not necessary. The USWR developed a way to honestly report wound outcomes by reporting healing in relation to predicted likelihood of healing, thus providing a reasonable alternative to “we heal everyone.” Most importantly, thousands of practitioners are now transmitting continuity of care documents (CCDs) to the USWR so that we can collect more data on HCC scores in the absence of a specialty designation. This is an electronic health record (EHR)-neutral program: It makes no difference which EHR product the practitioners use. Although some vendors have been very unhelpful with regard to CCD transmission, it is against the law for an EHR vendor to refuse to transmit CCDs to a specialty registry under the 21st Century Cures Act. CCDs can be transmitted automatically (without any secondary data entry beyond what the doctors did for their clinical documentation) from any certified EHR. It is the physicians who are being held accountable by Medicare for costs, and those costs are linked to the severity of medical illness. We can either be paid more for providing care to complex patients or we can pay a monetary penalty for it. We can either keep advanced therapeutics available, or they can go away. Which will it be? 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. Pope GC, Kautter J, Ingber MJ, Freeman S, Sekar R, Newhart C. Evaluation of the CMS-HCC risk adjustment model. CMS. 2011.
Accessed online: www.cms.gov/medicare/healthplans/medicareadvtgspecratestats/downloads/evaluation_risk_adj_model_2011.pdf