Monday Musings

The Centers for Medicare and Medicaid Services (CMS) opened the Physician Compare quality measure preview period on October 5th. The 30-day preview period closed on Friday, November 6th. It provided an opportunity for individuals and group practices to review their 2014 quality measures before they are reported on Physician Compare later this year.

US Wound RegistryThe USWR is now reporting the Diabetes measures group. This might be easiest way to make it through PQRS because you only have to report on 30 patients when you report a measure group. I’ll tell you more later. In the meantime, given the post payment review of HBOT that is rolling out, my advice is for everyone to look at the USWR hyperbaric oxygen quality measures created in conjunction with the UHMS.

Caroline Fife, MD

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  1. Hello Dr. Caroline, In searching online I found several of your articles concerning value-based payment in wound care. I have a question and was hoping to get your insight due to your experience with this. In advance, I appreciate your time as I know your schedule is probably extremely busy. My question is–due to new models in pay for performance, can you estimate a dollar value for an average wound clinic for efficient recording and reporting of wound tracking in reimbursement or cost savings?


    1. Was your question directed at the possible value of technologies that can save nursing time by automating measurements or wound assessments? That value should be pretty easy to calculate in terms of staff time in relation to volume of patients seen per day by studying how long nurses spend measuring wounds, how much time an automated system would save them and how that would translate to an increase in volume of patients seen per day.

      If you were asking a bigger question about the importance of measurements under a new paradigm of payment, the problem is that it’s very hard to calculate the incremental effect of specific products or services since the goal is to improve outcome in relation to total resource use across large episodes of care. Currently, there is language in many Medicare Administrative Carrier LCDs that links whether a product or service is covered (e.g. cellular products, HBOT) in relation to specific changes in wound surface area measurement. So, right now there are things you CAN’T get paid for if you don’t have wound measurements. There is a perverse problem with the way the LCDs are written. For example, the Novitas LCD for hyperbaric oxygen states that there should be no measurable signs of healing over a 30 day period, otherwise HBOT is not needed. Perversely, the more accurately you measure a wound, the more likely you are to show a small decrease in wound size over 30 days, thereby making it impossible to provide HBOT to a patient who may, in fact, really need it (since there is absolutely no evidence base for this criteria). LCDs written with Draconian language like this are a powerful argument against highly accurate measuring systems since the less reliable and accurate “length x width” method provides a lot more “wiggle room” to be able to say truthfully, “there’s no measurable improvement.”


      1. Thank you very much for the reply. I believe, as you noted, that the cost savings from staff time are the easier benefit to calculate and in the bigger picture, its a much more complex process. In researching the effects of healthcare reform in general, it appears that we have a need to balance the human aspect of healthcare with the needs of the payer and the business model.

        If there are poorly written LCDs or other rules that squeeze wound care providers, are there benefits in other areas due to bonuses, or in directing care to a cheaper alternative? For example, if a wound is increasing in size incrementally and needs HBOT, then would timely accurate measurement help move a patient to a more effective treatment faster? And would a minutely measurable improvement in the wound keep the patient on a current (possibly cheaper) alternative?


  2. We know we could use US Wound Registry data to understand whether there are better ways to identify patients who can benefit from HBOT rather than using the arbitrary standard of “no measurable signs of healing” over 30 days, but sadly, there is no funding for that work. I believe that the Diabetes Wound Healing Index (paper in press now) might be the way to do it. For the time being, we have to follow the LCD as it is written, so what we think doesn’t matter.

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