Recently someone asked me if it was actually possible to report wound care relevant quality measures to CMS as part of MIPS (the Merit Based Incentive Payment Plan). The answer is yes.

Here are screenshots from my own reporting, so you can see that I reported them and got credit for them. As an aside, my DFU healing rate was only 33.14% but I got 8.39 of 10 possible points for that low score because using the risk stratification, my DFUs are so severe that a healing rate of 33.14% is actually excellent because the majority of my DFUs were expected to fail or be amputated. This is how we ought to measure success! Not by whether we heal “everyone,” but what percentage of patients are we able to heal among those that were expected to FAIL.

My data on arterial screening of patients with lower extremity ulcers at the first clinic visit (which was 75%) was not used by CMS in calculating my MIPS score because I got more points for other measures, however, you can see that I REPORTED it. I also reported the VLU healing rate measure, but CMS didn’t use that one for the same reason (more points in other measures). CMS decides which measures will apply to a given physician’s score – usually by picking the ones for which you will get the most points and/or bonus points. I got bonus points for simply reporting to the US Wound Registry (USWR) QCDR and additional bonus points for reporting the DFU outcome measure because it is risk-stratified.

While CMS has approved a large suite of USWR measures, three of the USWR Wound Care Quality Measures were chosen by CMS to be depicted on Physician Compare. This is a big deal. Very few specialty societies had even one of their QCDR measures selected by CMS for “Compare” while the USWR had 3 chosen – more than any organization. CMS chooses measures to depict on compare in part by showing them to “consumers” and asking whether as a patient they think they matter, and whether the scores would impact their choice of doctors. Patients told CMS they understood the USWR measures and would make a decision about what doctor they saw based on the scores.

Here’s an article from a year ago about the measures chosen for “Compare,” published in Advances in Skin and Wound Care.

In answer to the question I was asked about quality measure reporting to CMS:

  • Yes, there are a dozen wound care relevant measures endorsed by CMS
  • 3 of the USWR wound care measures were chosen by CMS for depiction on Physician Compare
  • Doctors are have been reporting wound relevant quality measures to CMS since 2015
  • I reported last year and got bonus points simply for participating in the USWR QCDR, as well as bonus points for reporting healing rates using risk stratification (severity scoring) – which is how we ought to do it.
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