Monday Musings

Every Monday in April I have been talking about the annual National Quality Forum meeting, healthcare reform and what I think it means to wound care professionals. Why is CMS driving so hard in the direction of quality measurement? The measures CMS really wants to develop are total cost of care measures. CMS’ ultimate goal is to understand what practitioners and therapeutic interventions actually decrease the total cost of care. They want to understand the return on their investment. If you want to have some fun with this concept, check out the website for HealthPartners, the largest consumer-governed, non-profit health care organization in the USA which provides insurance coverage for patients in Minnesota. HealthPartners developed the most complex quality measure ever endorsed by the NQF and it’s worth just taking a quick look at it using this link: https://www.healthpartners.com/ucm/groups/public/@hp/@public/documents/documents/dev_057428.pdf.  The data obtainable from this measure are mind boggling. It is possible to “drill into” the various patient co-morbid conditions and to understand the costs contributed by various sites of service.

In case what I just said seemed to full of jargon, I will try to say it another way. A huge percentage of physicians and hospitals in Minnesota, Wisconsin, and Ohio are participating in the public reporting of quality measures data, some of which are composite measures aimed at disease control (which I discussed last week) and which also include how satisfied patients are with their care. In some cases, these measures also include the total COST of care delivered to patients. The public data on how hospitals and doctors perform on these measures are being used by payers to determine physician reimbursement rates. In some cases, payers are willing to pay MORE for better outcomes. If you are curious about what the public can see, check it out at MN Healthsores.org (http://www.mnhealthscores.org/measuring-quality#sthash.5gCr38wW.dpuf).

Now, imagine a quality measure that captures all the data from all sites of care pertaining to a patient with a diabetic foot ulcer. That measure would include hospitalization charges, medications, physician charges, home nursing charges, and outpatient wound center charges (including hyperbaric oxygen therapy and cellular products). The results would be posted on the internet for everyone to see. It will then be possible for CMS as well as individual patients to determine where they could go to get the most efficient care (the best return on investment). Meaning, the patients and the payers could determine which providers and which wound centers (in conjunction with the associated hospital and healthcare system) provide the best care. You realize how imperative it is to ensure that patients are properly risk stratified so that no facility or physician is at a disadvantage for seeing sicker patients. In fact, with proper risk stratification, it is possible for the best programs to demonstrate how much better they really are because they will be able to prove they have better outcomes in higher risk patients. This means no more reporting that “98% of our patients heal.” We will report outcomes like every other specialty does – the % of patients in each risk category who had a good outcome.

In preparation for this transition, the US Wound Registry has been collecting wound care data in structured language since its inception in 2005. We started beating the drum about the need for quality measures in wound care in 2007 and were finally able to start developing quality measures in 2014 through the Qualified Clinical Data (QCDR) process. Public reporting of quality measures will begin next year. Assuming that CMS accepts the 7 new measures we submitted this year (6 in hyperbaric medicine and one in nutrition), we will have a suite of 20 wound care and hyperbaric medicine measures available for wound care and hyperbaric medicine providers to report. Measures like this will not only be how Medicare will reimburse providers in the transition away from fee for service (FFS), but these quality measures will be the way that private payers negotiate their contracted rates.

The USWR has a head start on risk adjustment with the Wound Healing Index but is already working on more advanced risk adjustment models.  This is where data analytics are taking us. We’ve had predictive models which could help us determine who could benefit from HBOT since 2007 but there was no impetus to use them back then. Now there is. The structured data entering the USWR from providers submitting data to satisfy PQRS can get us there. Here is the reality check that is important for everyone to understand: 1) All these data will eventually be public, whether we like it or not, 2) thanks to the QCDR, we can carefully develop the measures ourselves to ensure that they represent our patient data properly, 3) the more clinicians and clinics that participate in the USWR, the faster we will be able to accomplish the necessary analysis, 4) CMS intends to perform these analyses. Poorly built wound care and hyperbaric quality measures (designed just to give doctors “something to report”) will not benefit either clinicians or patients. We have to design measures that demonstrate a return on investment in wound care technology and the skill level of the practitioners who use them.