Caroline E. Fife, MD. Professor of Geriatrics Baylor College of Medicine Houston, TX. Medical Director CHI St. Luke s Wound Clinic The Woodlands, TX

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1 The Big Squeeze: MIPS and Its Implications to the Wound Care Practitioner Caroline E. Fife, MD Professor of Geriatrics Baylor College of Medicine Houston, TX Medical Director CHI St. Luke s Wound Clinic The Woodlands, TX Chief Medical Officer Intellicure, Inc. The Woodlands, TX Executive Director US Wound Registry

2 Clinics transmit EHR data electronically to the Registry: All ICD-9 and CPT codes were queried What did we do differently than others have done? Electronic data transfer of 100% of all patients and 100% of all wounds List of all Diagnosis codes treated in HOPDs in the USA, run against the 5% Medicare dataset Clinics Using Wound Care Specific EHR What problems do wound centers actually TREAT?

3 Do these conditions look familiar? (1,814 ICD9 codes) Surgical dehiscence Venous ulcers Pressure ulcers Diabetic foot ulcers Chronic ulcers Traumatic wounds Related to... Malnutrition Atrial Fibrillation Edema Gout Obesity Anemia Congestive Heart failure Depression Sickle Cell anemia PAD Atherosclerosis COPD Lupus Renal failure Steroid dependency Result in Healing rates of <50%

4 Wounds with no name are a third of the data Surgical dehiscence has always been the biggest single category: 20.9% Nameless wounds: Traumatic wounds that never heal: 19.2% Chronic ulcers (nameless): 12.1% = 31.3% of all wounds Wounds with no name are almost never reported. Value in Health: Medicare spending for all wound types estimated between $28.1 to $96.8 BILLION Why do wounds cost so much if 90+% of them heal? Is there a down side to failing to discuss the patients we DON T heal? Excuse me while I sweep 30% 50% of all wounds under the rug USWR data

5 The Zero Sum Game of MIPS 2018 is Year Two (> 4,000 pages of regulations) Money for bonus payments to a few comes from penalties levied on many Practitioners are scored and receive a bonus or a penalty based on performance Meant to drive providers into Alternative Payment Models (APM) MIPS gradually increases the importance of COST in determining physician payment Cost now contributes 10%; comprised of 2 measures Medicare Spending per Beneficiary (MSPB) Total per Capita Cost (TPCC). CMS is evaluating episode-based quality measures 50% 50% 60% 40%

6 You can lose 5% of Medicare part B payments, or gain 15% 70 Exceptional Performance 15% + $ Performance (5 x 3 =15% bonus) Performance threshold now at 15 points. Payment adjustment for the 2020 payment year now ranges from - 5% to + (5% x scaling factor not to exceed 3) + 5% bonus (15 points 70 points) 15-5% negative adjustment below a score of 15

7 The Merit-Based Incentive Payment System (MIPS) 2018 Your MIPS performance score is based on 4 weighted categories and the contribution from each category changes from year to year: The composite score goes from points Cost points 50% 25% 10% 15% Nurse Practitioners and physicians working in the HOPD are exempt 7 from ACI so Quality = 75%

8 8 PRACTITIONERS NEED AN ALMOST PERFECT SCORE TO HIT THE TOP DECILE OF MOST NATIONAL QMS 10 th D

9 USWR QCDR Measures Relevant to Wound Care/HBOT Non Invasive Arterial Assessment of lower * extremity wounds or ulcers for determination of healing potential * Adequate Off-loading of DFUs at each visit Adequate Compression of VLUs at each visit DFU Healing or Closure VLU Healing or Closure Vital Signs and Blood Glucose Check Prior to HBOT Plan of Care for VLUs and DFUs not Achieving 30% Closure at 4 Weeks Appropriate use of CTPs in DFUs and VLUs Appropriate use of Hyperbaric oxygen therapy in DFUs Patient Reported Wound Outcome Nutritional Screening in Patients with Chronic Wounds Patient Reported Nutritional screening in patients with Chronic Wounds Major Amputation in Wagner 3, 4, or 5 Diabetic Foot Ulcers (DFUs) Treated with HBOT * 2 Measures mentioned in the OPPS proposed rule as a possible requirement to report under a CTP episode of care

10 MIPS Cost Category and the Complex Patient If we want to continue to take care of patients, we have to report the outcomes of the sickest ones Cost points Medicare spending per beneficiary is factored by the Hierarchical Condition Codes of those patients. We actually want to be measured on the sickness of wound care patients.

11 As practitioners we spend a lot because the patients are sick- but CMS sees us in relation to peers by specialty

12 Quality Measure data are now on Physician Compare and soon to be on Yelp! In 2018 the Quality Measure Decile rankings are going to be translated into the Yelp star rating- so the stars will be determined by your performance on... BMI measurement and counseling?

13 Physicians reporting through the USWR have relevant quality measures on the USWR site accessed from Physician Compare In 2018 the primary reason to participate in MIPS is to ensure that your Physician Compare data is relevant, and the primary reason to participate in MIPS through a QCDR is to be able to determine what is reported.

14 MACRA - economics Minimum MIPS participation options for the HOPD MD, NP 2 medium weight IAs OR 6 QMs Most physicians don t believe that the standard MIPS measures help them improve quality of care Government Accountability Office report (October 2016) The USWR offers relevant QCDR measures that have been shown to improve healing rates It s worth participating in MIPS to have some control over the messaging of your data on Physician compare In the absence of a specialty society, the USWR is creating a data repository on the co-morbid conditions of wound care patients and the HCC scores of practitioners. Without a specialty designation, wound care practitioners spending per beneficiary will be compared to others in their primary specialty. Reporting to the same registry enables fair group comparisons.

15 The Big Squeeze: MIPS and Its Implications to the Wound Care Practitioner Caroline E. Fife, MD Professor of Geriatrics Baylor College of Medicine Houston, TX Medical Director CHI St. Luke s Wound Clinic The Woodlands, TX Chief Medical Officer Intellicure, Inc. The Woodlands, TX Executive Director US Wound Registry