Navigating the Path Toward Value-Based Wound Care

Editor’s Note: This article is a follow up to an article published in the Jan/Feb 2013 issue of Today’s Wound Clinic.

Much of the ink has already dried and many voices have been raised as to the reasons payers are moving from reimbursing healthcare providers for volume-based work and transitioning to a payment model based on value. We already know that wound care/hyperbaric reimbursement in the future will be based on adherence to clinical practice guidelines (CPGs) as well as truthfully reported patient outcomes and patient satisfaction/patient-reported experience of care. It is highly likely the outpatient wound clinic arena will come under some sort of capitated reimbursement system within the next three years. With all the discussion as to why the healthcare industry is moving in this direction, little has been published on how your wound clinic can actually make the value transition by proving the effective work and positive outcomes clinicians are seeing daily. Payers are going to require all providers to prove success — with data. Healing rates, as they are currently calculated by some, will be exposed for the house of cards they typically represent.  This article will demonstrate how one hospital network has integrated CPGs through utilization of electronic health records (EHRs) and demonstrating adherence through quality metrics.

Real Healing Rates
Healing rates, as a raw calculation, should be easily computed by taking the number of patients admitted divided by the number of patients healed. Some companies may boast 16-week healing rates are over 80% and all-time healing rates are north of 85%. However, rates like these can only be achieved by “fudging the numbers.” One thing that will certainly have to change is the way healing rates are reported.  Among progressive wound centers with practitioners who are focused on quality, the true unvetted wound healing rate is closer to 70%. National data from the US Wound Registry comprised of the actual EHRs of more than 100,000 wound center patients show an overall healing rate of about 66%, depending on how certain outcomes are defined (eg, how data are handled for patients who are lost to follow up or death). No longer are wound clinics going to be able to exclude from outcome calculations all the patients who fail to heal simply because their inclusion may negatively impact the healing rate.  

Payers will begin to direct patients to clinics that can heal their patients faster at a lower total cost. (Many are already discussing the creation of a capitated model for wound care.) Gone will be the pre-authorization of advanced therapeutics. Providers will receive a set dollar amount to heal a diabetic foot ulcer (DFU) or venous ulcer and whatever resources are needed — staff, topical treatments, cellular and tissue-based products, hyperbaric oxygen, electrical stimulation, compression therapy — all will have to be covered by that flat rate. This is not dissimilar to the way in which acute care has been reimbursed since the early 1980s. Wound care clinicians should ask themselves, “If I had only a fixed amount of money to spend on each wound clinic patient, which therapies do I know improve outcomes for the least cost?”

Look to the Data
How are you currently collecting outcome data for your patients? Remember that although payers must contain cost, they do not want to sacrifice quality. Payers will want to send their patients to the clinics and the practitioners who are implementing national CPGs. Currently, the only way payers have to measure compliance with national guidelines (and thus know where to send patients) is through clinician performance on quality measures as reported through the Physician Quality Reporting System (PQRS). These data will not be compiled manually by the clinic or the management company. Wound clinic staff will not have the opportunity to arbitrarily remove patients from the denominator in order to make healing rates appear better than they actually are. Patient outcomes will be captured by the EHR and transmitted to payers, most likely via a qualified clinical data registry (QCDR). This means the stakes are high for your EHR. Your wound and hyperbaric EHR should make it easy to document the treatment you provide as well as the extraction of aggregate and individual patient quality data.

How will this new method of outcome reporting avoid “punishing” practitioners who care for the sickest patients? The Centers for Medicare & Medicaid Services (CMS) requires clinicians to risk stratify patients according to illness severity. That means healing rates will be reported in comparison to how sick the patients were at the time of care. In this new system, payers will reward clinicians who have the highest healing rates among the patients with the lowest likelihood of healing. In a system like that, a healing rate as low as 50% might be a great success if achieved among patients whose likelihood of healing was, say, 25% or lower. That means providers must have reliable risk-stratification methods.

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CPGs & EHRs
Those who’ve been working in the wound care industry since the late 1990s remember what it was like to assess clinician compliance with treatment algorithms by laboriously extracting data manually from paper charts. Those days are over. With the click of a button through quality EHRs, we now know which patients are due for progress reviews as well as where “missed opportunities” for quality lie. The mandate that all practitioners and all hospitals adopt health information technology (HIT) was driven by the need for the biggest payer (CMS, through the Medicare system) to receive patient data in a structured fashion. That is the reason PQRS measures have precisely defined technical specifications and EHRs must demonstrate the ability to transmit PQRS data in order to be certified for any stage of Meaningful Use. In fact, the “Meaningful Use” of an EHR involves transmission of quality data.

In today’s HIT climate, providers must assess their current EHRs and ask themselves how easy it is, or is not, to extract quality data and PQRS data, as well as how well providers are succeeding at quality reporting. Well-designed quality measures can convey the practitioner’s success in implementing CPGs. The easier it is for clinicians to document the information required to report these quality measures within the EHR, the better their performance rate will be.

Incorporating CPGs
About four years ago, several partner hospitals within Precision Health Care, Boca Raton, FL, redesigned the practitioner salary incentives and performance-review process by basing them on their performance in implementing CPGs. This was established even before wound-specific quality measures were available for PQRS reporting. All physicians were salaried employees of the healthcare system. When the program launched, three basic CPGs were identified upon which to focus: vascular screening of patients living with lower extremity wounds, compression of venous ulcers, and offloading of DFUs. Practitioners were educated on the importance of these interventions and reminders to perform these actions were added within the EHR. Documentation was done at the bedside using computers in each exam room to discourage the “dictation closet,” so that clinicians would document in real time and would thus be able to act on CPG reminders within the EHR. This concept only works if documentation is performed while the patient is in the room. Reporting features extract data directly from the EHR to assess clinician success with these practice guidelines. Providers then receive weekly, personalized feedback based on these reports, which are patient specific to allow staff members to actually ask the clinician, if necessary, “Why didn't Jane Doe undergo vascular screening or offloading of her DFU last week?” Improvement with CPGs increased each week since performance feedback was almost immediate. Reports were designed with a time filter so they could be run by the day, week, month, quarter, or year. Data was integrated into a pre-existing clinical quality program and shared with partner hospitals. Many sites included the performance of these measures in their provider salary bonus equation.

When implementing these basic CPGs was initially discussed, the clinicians were “certain” they were already doing these three things “all of the time.” However, information published by the US Wound Registry — that, among patients seen in hospital-based wound clinics, only 17% of patients with venous ulcers received adequate compression as a routine and less than 5% of DFU patients were properly offloaded — states otherwise and was shared with the clinicians. In other words, the gap in practice for basic interventions (nationally as well as locally in their own clinics) was acknowledged. Documenting compliance with CPGs was made easier, weekly feedback regarding patient specific “missed opportunities” for quality was provided, and initiatives were aligned with salary incentives.

In a previous article published in the January/February 2013 issue of Today’s Wound Clinic, data were presented on this pilot project.¹ Physician performance with practice guidelines (which in the beginning was lower than the clinicians thought) dramatically improved, as did efficiency of patient care. Meanwhile, “wasted visits” decreased. The next step will be to analyze the data to determine what impact this has had on the total cost of care for these patients. It seems obvious that adherence to CPGs should improve outcomes at a lower total cost, but this will need to be proven.

Interestingly (and importantly), physician performance with CPGs improved before any salary incentives were activated. Thus, while we do not want to have a reimbursement system that provides financial incentives to overuse high-cost interventions, the fact is that when clinicians are provided with data they improve performance with quality measures even without financial motivators.

Follow these steps to help navigate toward developing quality CPGs and implementing them into everyday practice:

1) Keep it simple. Start with the basics, then move to more complex measures.

2) Integrate data collection as a routine charting item within the EHR.

3) Share the progress. Provide clinicians with constant, consistent feedback on performance.

4) Stay the course. The healthcare industry is notorious for implementing a new project, following through for a short time, then retiring the thought. Generally speaking, a behavior takes 21 days to become integrated into one’s routine. Just like an effective exercise program, repetition makes the difference.

Additionally, here’s what not to do:

If you are responsible for integrating CPGs within your practice, you will have to break down and avoid barriers, which may include but will not be limited to:

1) Change. Most humans, and a large majority of our healthcare brethren, resist change.

2) Documentation challenges. Due to resistance to change, ease of documentation is a must. Your EHR should already be programmed to gather other quality data, so add CPG documentation to the same area.

3) Buy in. Change is hard enough. If there is no reward for what will be perceived as “extra work,” you will be swimming upstream.

4) Training. Most initiatives fail for the simplest of reasons — inadequate training of staff. Don’t skimp in this area. People need to know why they are doing a task and understand that the future of the clinic will be based on proving the good work they perform.

5) Champion. Someone needs to be in charge of the implementation and ongoing tracking of practice patterns. If they are not integrated into long-term goals, success will not be guaranteed. n

M. Darlene Carey is director of operations of Precision Health Care, Boca Raton, FL.

Reference

1. Carey MD. Proving your quality of care compliance: a case study. Today’s Wound Clinic. 2013;7(1):13-18.