Cost Measures in the Quality Payment Program (QPP)

As I have discussed before, CMS thinks that I practice family medicine. Since nearly half the patients with chronic non-healing wounds have heart failure, CMS thinks that I am their primary care doctor (PCP) because I see those patients more than anyone else and holds me accountable for all their readmissions for heart failure. The “episode-based” cost measures that have been applied to me in the past were primarily looking at the cost of heart failure treatment and “all cause” readmission for patients with chronic diseases. I have posted a detailed explanation before. That’s why I changed my specialty code to Undersea and Hyperbaric Medicine.

But not only am I held accountable for hospital admissions caused by medical conditions that I do not treat, CMS has noted that I spend far more Medicare dollars then the typical FP. My “Medicare Spending per Beneficiary” (MSPB) is crazy high.

Remember, CMS uses primary specialty to create a comparison group for MSPB – and I will always be an outlier if I am compared to other FPs. It’s true that I see far more complicated patients, but if I am evaluated based on cost alone, I am still in trouble.

That means the “episode-based” measure for “non-pressure ulcers” could be really good news for wound care practitioners. CMS has contracted with Acumen, LLC to develop episode-based cost measure for potential use in MIPS that is focused on any type of chronic ulcer that is NOT a pressure ulcer. That means this cost measure includes a diverse group of problems which includes diabetic foot ulcers (DFUs), venous leg ulcers (VLUs), arterial ulcers, and generic “chronic ulcers” that don’t have a specific name (and which out-number the other types). If this cost measure “works” in field testing (and I have no idea how CMS/Acumen decides whether it “worked”) at least the cost part of MIPS would judge me on problems that I actually TREAT.

Here’s my best stab at explaining the cost measure. A group of “clinician experts” in wound care (of which I was one) were shown a lot of data from Medicare claims and asked to identify what type of clinical encounters would likely identify a wound care practitioners’ involvement with a patient. That’s what they call  “trigger” code. Then we were asked to identify what kind of clinical encounter or procedure would “confirm” that a clinician was providing wound care. The start of a clinician or a group’s management of a patient’s “non-pressure ulcer” is identified by the appearance of a pair of services within 180 days of one another: a trigger code followed by a confirming code. A trigger code is any code from a specific set of CPT/HCPCS codes for outpatient services (outpatient evaluation and management codes [E/Ms], accompanied by an ICD-10 diagnosis code indicating one of the relevant ulcer types.

The expert panel also was asked to decide what kinds of patients should be excluded from the measure (e.g., we excluded those with pyoderma gangrenosum, vasculitis and a variety of other conditions). We were also asked what kind of comorbid conditions ought to be used to “risk stratify” patients in order to create groupings of patients/ulcers based on how complicated they are. Time will tell how good of a job we did. It was a daunting project and involved looking at a lot of excel spreadsheets.

The measurement period for these Field Test Reports is January 1 to December 31, 2022. Any podiatrist or wound care practitioner of any specialty, including NPs, who has 20 of these “episodes” will get a field test report. The Non-Pressure Ulcer (NPU) episode-based cost measure will be attributed to any group practice Tax ID number (TIN) when the trigger and confirmatory codes are met. An individual clinician (TIN-NPI) within that group can be attributed an episode if they bill at least 30% of the trigger or confirmatory services during an episode of care.

The goal is for CMS to identify doctors whose spending on wound care patients is far outside the “norm” when compared to other wound care practitioners, even when the comorbid conditions of the patient are taken into account. And if you are thinking that this whole process is relevant to the overuse of CTP/skin subs – you would be right. Using really expensive products repeatedly is likely to make a practitioner look like an outlier. That part is going to be interesting.

What is the Purpose of Field Testing?

Field testing is a process which includes distributing informational reports to clinicians and soliciting comments from the public via an online survey. During this time, anyone can provide feedback on the draft measure specifications and testing results. The clinician expert workgroup will then review and consider refinements to the measures. Anyone can provide feedback on the draft measures specifications through the general 2024 Field Testing Feedback Survey, which will open at the start of field testing on February 1. A document containing specific questions from this survey will be available on the QPP Cost Measure Information page. The survey questions will be optional. If you prefer, you can attach a comment letter (as a PDF or Word document) in addition or as an alternative to the survey questions. All feedback may be submitted anonymously.

The American Podiatric Medical Association (APMA) has posted information here: Field Testing for Episode-Based Cost Measure under Development