Caroline E. Fife, MD, FAAFP, CWS, FUHM
I am re-reading the book David and Goliath: Underdogs, Misfits, and the Art of Battling Giants by Malcolm Gladwell because, as an underdog, the field of wound care must develop a strategy to survive healthcare reform. We do not have the advantages successfully used by the “goliath” medial fields, which include gadgets (medical devices), expensive drugs, and a powerful medical society. A major impetus for the Quality Payment Program that we all became subject to on Jan. 1 of this year was to force clinicians to reduce waste and improve value through quality reporting and practice improvement. Medicare intends to achieve this through the use of health information technology, namely by partnering with clinicians to transmit quality data to patient registries directly from electronic health records (EHRs). Most practitioners in the United States are now subject to the reporting requirements of the Merit-Based Incentive Payment System (MIPS) that are facilitated by participation in a qualified clinical data registry (QCDR). A clinician friend of mine once told me that, although they are trying to divest themselves from these relationships, cardiology folks have received $48 million in industry funding for their registry. Manufacturers in wound care support registries associated with devices such as venous ablation technology, but not registries focused, for example, on venous ulcer care (which I testified about last year during the Medicare Evidence Development and Coverage Advisory Committee meeting on lower extremity chronic venous disease1).
While we can’t get support for our data registry from industry, wound care has attracted the scrutiny of the Office of Inspector General (OIG), which published reports on both hyperbaric medicine2 and surgical debridement services,3 concluding that improper billing practices occurred in both areas. Medicare’s current prior authorization program for hyperbaric oxygen therapy (HBOT)4 can be traced directly to the OIG report on HBOT. The OIG 2017 Work Plan5 has provider-based departments like wound clinics and HBOT services as a major focus due to poor compliance with various federal requirements, as Kathleen D. Schaum, MS, and I detail in our Business Briefs article on page 5 of this edition of Today’s Wound Clinic (TWC). Registries can help practitioners handle regulatory scrutiny of various types. The American Academy of Ophthalmology has done a masterful job engaging ophthalmologists in its quality registry,6 which is able to provide safety data for drugs and devices, as well as benchmarking for various business metrics. This registry is possible because millions of dollars were available from specialty society coffers.
Wound care is not a recognized medical specialty or subspecialty, although also featured in this issue of TWC are updates from two organizations seeking to change that (see pages 10 and 11). However, the fact remains that without an organization, there’s no monetary support for needed registry services. In 2013, when the Centers for Medicare & Medicaid Services (CMS) created the QCDR mechanism for developing quality measures, the Alliance of Wound Care Stakeholders stepped in to ensure that wound care practitioners would not be completely left behind in the quality revolution. The Alliance met with CMS officials to ask that they be allowed to serve as the “de facto” specialty society for wound care, and CMS agreed. The Alliance collaborated with the U.S. Wound Registry (USWR), a 501(c)(3) nonprofit organization whose mission is to provide registry reporting services for wound care and hyperbaric medicine practitioners. In 2014, the USWR was among the first QCDRs approved by CMS, developing 14 wound care-specific quality measures in collaboration with the Alliance and its member organizations. Last month, the USWR was among the first MIPS registries recognized by CMS, gaining CMS recognition of more than 12 wound care quality measures reportable under MIPS. Hundreds of advanced practitioners report wound care and hyperbaric quality measure data to CMS through the USWR and have helped set “benchmark” rates for diabetic foot ulcer offloading, venous ulcer compression, and arterial screening, among others. Thousands more wound care practitioners participate by transmitting Continuity of Care Documents as part of “advancing care information” under MIPS. Participation in the USWR’s QCDR is a way for providers to earn a positive payment adjustment of Medicare Part B payments for reporting certain high-value quality measures (eg, risk-stratified outcome measures) and participating in “clinical practice improvement activities” that involve national benchmarking. Many practitioners and organizations may soon be required to create corporate integrity agreements through the OIG to demonstrate compliance with Medicare coverage policy. In case you don’t know the story of David and Goliath, Goliath was bigger, stronger, and had better equipment, but he was defeated by David. A small and agile entity can prevail in an asymmetrical fight with a well-thought-out strategy and by making optimal use of the tools under its control. Without funding to develop the next generation of measures, and without the influence and organization of a specialty society, it remains to be seen if wound care practitioners will pool their limited resources and harness the power of their EHRs to battle the giant of healthcare reform. n
Caroline E. Fife, MD, FAAFP, CWS, FUHM, is chief medical officer at Intellicure Inc.; executive director of the U.S. Wound Registry; medical director of St. Luke’s Wound Clinic, The Woodlands, TX; and co-chair of the Alliance of Wound Care Stakeholders.
1. MEDCAC Meeting 7/20/2016 - Lower Extremity Chronic Venous Disease. CMS. 2016. Accessed online: www.cms.gov/medicare-coverage-database/details/medcac-meeting-details.as...
2. Brown JG. Hyperbaric Oxygen Therapy: Its Use and Appropriateness. OIG. 2000. Accessed online: https://oig.hhs.gov/oei/reports/oei-06-99-00090.pdf
3. Levinson DR. Medicare Payments for Surgical Debridement Services in 2004. OIG. 2007: Accessed online: https://oig.hhs.gov/oei/reports/oei-02-05-00390.pdf
4. Prior Authorization of Non-Emergent Hyperbaric Oxygen. CMS. 2016. Accessed online: www.cms.gov/research-statistics-data-and-systems/monitoring-programs/med...
5. OIG Work Plan 2017. OIG. 2017. Accessed online: https://oig.hhs.gov/reports-and-publications/archives/workplan/2017/hhs%...
6. Transforming the Impact of Eye Care Through Data. AAO. Accessed online: www.aao.org/about/2015-year-in-review/iris-registry-2015-yir