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Special to OWM: Innovative Reimbursement: the Disruption and Challenges for Wound Care

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Special to OWM: Innovative Reimbursement: the Disruption and Challenges for Wound Care

Index: Ostomy Wound Manage. 2016;62(7):14,16.

The innovative, transformative Medicare Access and CHIP Reauthorization Act (MACRA), signed into law April 2015, changes how physicians and other clinicians are reimbursed. It replaces the Sustainable Growth Rate formula with a new framework for Medicare incentive payments, attempting to reward clinicians for better care and consolidating quality reporting. This law is intended to move reimbursement away from the traditional “fee for service” model and into a new risk-sharing, quality measure-based coordinated care model. However, the new system poses unique challenges to providers of wound care as it evolves and is implemented through the Centers for Medicare and Medicaid Services (CMS) Quality Payment Program (QPP).

Innovation: the framework. Currently, Medicare measures the value and quality of care provided by doctors and other clinicians through a patchwork of programs. Some clinicians are part of Alternative Payment Models (eg, Accountable Care Organizations, the Comprehensive Primary Care Initiative, and the Medicare Shared Savings Program). Many clinicians participate in quality reporting programs (eg, Physician Quality Reporting System, the Value Modifier Program, and the Medicare Electronic Health Record [EHR] Incentive Program). Through MACRA, Congress streamlined these various programs into a single framework to help clinicians transition from payments based on volume to payments based on value. With the new QPP,  clinicians and practice groups choose between 2 reporting and reimbursement paths: Alternative Payment Models (APM) and the Merit-Based Incentive Payment System (MIPS).  

APMs. Under an APM, clinicians accept both risk and reward for providing coordinated, high-quality care. To qualify under the QPP, an APM must meet many requirements; many current accountable care organizations (ACOs), Medicare Shared Savings Programs, or other payment models established under the CMS’s innovation do not yet meet the APM requirements. These shared-risk systems currently are few and far between, and many are still in development. As a result, it is anticipated that most clinicians initially will choose the MIPS pathway.

MIPS. All eligible clinicians not participating in APMs will be reimbursed under the MIPS system, which combines parts of the previously established Physician Quality Reporting System (PQRS), the Value Modifier (VM or Value-Based Payment Model), and EHR into 1 program. Under MIPS, eligible professionals (ie, physicians, physicians assistants, nurse practitioners, clinical nurse specialists, and certified nurse anesthetists) will be measured in 4 categories: quality, resource use, clinical practice improvement, and use of certified EHR technology. Using the composite performance score, eligible practitioners would receive an upward payment adjustment, a downward payment adjustment, or no payment adjustment. 

Why Care About MIPS and APMs? 

This “alphabet soup” of acronyms will quickly have a significant impact on Medicare payments, because the CMS has a rapid implementation timetable. The QPP presented will be implemented in January 2017, at which time the CMS will begin to collect the performance measure data. Payment rates to individual eligible clinicians reporting through MIPS or APMs will be adjusted in 2019 based on the data collected and composite score generated in 2017. This means many health systems, practice groups, and billing teams may be making broad changes to documentation practices and EHR systems to keep pace with the evolving reporting requirements for Medicare reimbursement. Changes are coming, and the constant is going be documentation, which is key to the best possible composite score and the highest level of reimbursement for services provided. 

Specific Challenges and Concerns for Wound Care

According to US Department of Health and Human Services Secretary Sylvia Burwell, the payment reform initiatives are “a milestone in our efforts to advance a health care system that rewards better care, smarter spending, and healthier people.” But what will these changes specifically mean for wound care practitioners? 

The Alliance of Wound Care Stakeholders has been closely monitoring the drafting and implementation of these new federal payment programs, providing formal written comments on key wound-relevant issues and advocating as a voice of the wound care community. We have identified 3 top concerns. 

  1. Performance measures are not specific to wound care. Of primary concern is that the obligatory reporting of quality resource use and clinical performance measures may not truly be indicative of our wound care work or of the resources used to treat patients. The 300+ initial topline quality measures were released by the CMS into 2 categories: 1) those all clinicians can utilize as individual measures and 2) those set across specialty groups. However, wound care is multidisciplinary. Our work is not a designated specialty, and because of that, none of the initial measures included in composite scores and that ultimately will impact Medicare payments are specific to wound care. 
  2. Existing wound care quality measures are not currently included. Current quality measures available to wound care clinicians specific to wound care practice include the 20 wound care quality measures in the US Wound Registry, a qualified clinical data registry (QCDR), that have been accepted under CMS’s PQRS. However, at the current time, these same quality measures are not eligible for MIPS reporting under the current rules. This means that while you can and should continue to use these measures, they will not count for your composite score under MIPS. This is a key area of concern and a key focus of the Alliance over the months and years ahead. The Alliance was a key driver of the wound care quality measures, and we will be proactively engaging with CMS policy makers to advocate that as these payment programs evolve more specific measures be available to wound care clinicians for utilization in the quality portion of the MIPS composite score.  
  3. Not all clinicians across the wound care team qualify for the newly incentivized Medicare payment system. Multidisciplinary wound care providers are a conundrum in the new system. For example, physical therapists aren’t eligible to participate in the new payment paradigm for at least 3 years, creating inconsistencies across a multidisciplinary wound care team. Although patient care will not suffer, the documentation and reporting needs may differ across the MIPS-eligible and noneligible practitioners.  

Providing a Voice for the Wound Care Practitioner Community 

MACRA is game-changing innovation that ushers in a new era of practicing medicine and documenting and reporting outcomes. Wound care practitioners will face unique challenges in terms of the relevance of the quality and documentation measures available. The Alliance has submitted comprehensive comments and data to the CMS, sharing its wound care-specific perspective on the proposed regulations and offering specific recommendations to address these concerns. Follow our work at, keep abreast of the advocacy initiatives of your own physician and clinical organization, and make your voice heard. The process of implementing the new physician payment reform paradigm will unfold for years to come, with multiple opportunities to comment on draft policies and rules. We in wound care must work together to be proactive, responsive, and vocal about our concerns. 

The Alliance of Wound Care Stakeholders is an association of physician and clinical organizations focused on promoting quality care and access to products and services for patients with wounds and the providers who treat them. Through advocacy and educational outreach in the regulatory, legislative, and public arenas, the Alliance unites wound care experts to advocate on public policy issues such as coding, coverage reimbursement, and quality measures that may create barriers to patient access to treatment or care. This article was not subject to the Ostomy Wound Management peer-review process.

For more news from The Alliance of Wound Care Stakeholders, click here.