Physicians are expected to improve their cost-of-care outcomes to score better in the Quality Payment Program. But how does that translate for wound care doctors? This article offers the concept of frontloading wound care in an attempt to improve outcomes, value scores, and reimbursement.
Pointing to an aging population and the sharp rise in diabetes and obesity, researchers at major wound care centers warned us all in 2009 that chronic wounds are “a major and snowballing threat to public health and the economy” that cost upwards of $28 billion per year to treat.1 Chronic lower extremity wounds are increasingly prevalent and complex to treat, are a significant cause of morbidity, and are a drain on healthcare resources worldwide. In the United States alone, chronic lower extremity ulcers affect an estimated 2.4-4.5 million people.2 Treatment costs for a venous leg ulcer (VLU) have been estimated at approximately $4,000 per month and $16,000 per treatment episode,2 and recent research suggests an annual U.S. payer burden of $14.9 billion.3 Diabetic foot ulcer (DFU) care adds around $9 billion-$13 billion to direct annual U.S. government and private insurer costs associated with diabetes itself.4 Holistic fundamentals of clinical wound care include addressing factors such as systemic diseases, medications, offloading, nutrition, and tissue perfusion/oxygenation.5 Diabetes, renal failure, peripheral vascular disease, and smoking can greatly influence healing and are among the factors associated with increased cost of care.6 These conditions must be addressed to correct causes of tissue damage. A basic understanding of the pathological condition of a chronic wound is important in addressing costs and patient needs. Despite all that we know related to the fundamentals of good clinical wound care, there exists a paradigm shift within the Medicare Access and CHIP Reauthorization Act (MACRA) that the probability of aggressively frontloading wound care treatments may help in decreasing the cost of care and the length of time that patients are required to be enrolled in a wound care treatment plan. This article will discuss the concept of frontloading wound care services in an attempt to produce better outcomes, value ratings, and reimbursement.
THE Macra EFFECT
MACRA is also referred to as the Quality Payment Program (QPP). The long-range goal of MACRA is to place patients and providers into alternative payment models, but, in the short term, most physicians are subject to the Merit-Based Incentive Payment System (MIPS), which, in theory, awards either positive or negative payment adjustments based on physician scores in quality reporting and spending (as well as practice improvement and electronic records use). Generally speaking, those physicians who, in comparison with their peers, have higher quality scores and lower overall spending are more likely to do well economically. That hints at why this system will not work well for wound care practitioners. Since there is no recognized medical or surgical specialty for wound care, it is nearly impossible for us to define our peer group. Additionally, we can’t be fairly judged on the outcome of our patients because there aren’t any outcome measures for wound care at the national level. There’s only one thing that the Centers for Medicare & Medicaid Services (CMS) will be able to do with certainty, and that’s calculate the amount of money spent on treating wound care patients. (And we all know that we spend a lot of money in wound care.)
It would be nice to say that physicians who improve their outcomes will fare better in the end than those who don’t under MIPS and the QPP, but in the absence of outcome measures, we won’t be able to prove that. That is why having a way to risk stratify how “difficult” patients are to heal is needed. If one wound care provider sees all the sick patients who require a lot of advanced therapeutics while a colleague sees all the “healthier” ones, it will appear that one physician is “overspending” because, yes, the therapies we use are expensive. Currently, there are no MIPS measures for wound care and there are no national measures for reporting the outcome of patients treated with cellular and tissue-based products (CTPs), negative pressure wound therapy (NPWT), or hyperbaric oxygen therapy. There are no MIPS measures for DFUs, VLUs, or any other type of wound. However, CMS will certainly add up the cost on these patients in relation to whatever suite of quality measures the practitioner does report, none of which have anything to do with wound care. Until CMS officials determine how they will handle the “patient relationship” issue, they are going to look at the provider who conducts the plurality of the evaluation and management services over the reporting period among patients who are living with conditions they do care about (such as heart failure, diabetes, and renal failure) and assume that the provider who saw the patient most often is the one “managing” that disease. And they’re going to “wonder” why that physician spent a lot of money on outpatient services compared to his or her peers. As things stand, CMS doesn’t know that these patients are living with chronic wounds. So, not only does CMS not know these patients’ outcomes, they don’t even know that the problems they’re facing are related to wounds. All they know is that a lot of money is being spent. As an aside, CMS may allow those physicians who use a qualified clinical data registry (QCDR) to identify themselves as a “group” for purposes of comparison. Also, CMS has approved wound care risk-stratified outcome measures that can be reported for MIPS credit through the U.S. Wound Registry, a QCDR. So, it is at least possible to report DFU and VLU healing, allowing one’s Medicare spending to be seen in relation to the outcome of the patients treated. We can try to predict the direction of things with CMS and determine what we ought to be doing, even if we aren’t doing that yet as an industry. We are headed toward a “bundled payment” system similar to what is being rolled out for orthopedics and certain cardiac procedures, for which the cost of treating a condition is being added together. That said, wound care practitioners must learn to be efficient and be ready for episode-of-care-based measures. Now, there are many ways to “win” with episode measures. However, here’s an example of a way to lose: A patient living with a severe venous stasis ulcer is seen and scheduled for arterial and venous Dopplers in the Doppler lab before being started in compression. It takes two weeks to get the results, during which time the ulcer worsens and the patient is hospitalized for cellulitis. That patient should have arterial screening in the wound clinic during the first visit using any available options (eg, handheld ankle-brachial index, transcutaneous oximetry, skin perfusion pressure). The patient does not need a venous Doppler prior to venous compression being initiated. (That shortens the treatment course by two weeks.) The provider can then frontload referral to the venous expert to discuss ablation and get the VLU under appropriate care immediately.
MOVING FORWARD WITH FRONTLOADING
How do we frontload wound care to get better outcomes despite these challenges? Here are two more scenarios that can work in this regard:
- Private office settings that would fall under MACRA guidelines and regulations can do the following:
a. Increase frequency of visits to twice weekly for the first four weeks of care, focusing on the management and control of the chronicity of the inflammatory cycle of the wound.
b. Effective protocoling of debridement, antibiosis, vascular assessment, and interventional treatments that are evidence-based and medically necessary to achieve early reduction of the chronic wound inflammation and systematic reduction of matrix metalloproteinases.
2. Considerations for hospital-based physician wound care:
a. While increasing the number of visits to twice weekly will increase a facility’s relative value units, this may pose problematic due to the scheduling conflicts of the outpatient wound center.
b. Same principle of evidence-based wound care to achieve early reduction of the chronic wound inflammatory environment.
c. Judicious use of home health agency wound care nurses to intervene twice weekly will support continuity of care and can reduce inflammation to the point that patients may be discharged once the wound is “under control,” or to the point that patients may be seen on a once-weekly basis.
However, we run into the problem of the use of CTPs. While many wound care practitioners (this author included) use these advanced products, we are all bound by the local coverage determinations (LCDs) of our Medicare Administrative Contractors (MACs) and private insurer medical policies regarding these products. Being able to frontload and use these products also means that we need to be very mindful of these policies, otherwise we will not be reimbursed for their use. What follows is an example of a coverage policy (adapted from First Coast Service Options Inc., Jacksonville, FL):
Presence of a chronic, non-infected venous stasis ulcer with failure to respond to documented conservative wound care measures (outline follows) for more than 4-6 weeks with documented compliance.
- For purposes of this LCD, conservative wound care measures include (but are not limited to) comprehensive patient assessment (history, exam, ankle-brachial index [ABI], and diagnostic test as indicated) and implemented treatment plan.
- For patients living with DFU(s): assessment of type 1 versus type 2 diabetes mellitus and management history with attention to certain comorbidities (vascular disease, neuropathy, osteomyelitis); review of current blood sugars/HgbA1c, diet, nutritional status, activity level, physical exam (that includes assessment of skin and wound, ABI, and offloading prosthetics or shoes for signs of abnormal wear).
- For patients living with VLU(s): assessment of history (including prior ulcers and thrombosis risks), physical exam (including edema and skin changes), ABI, and duplex scan to confirm CEAP (clinical etiologic anatomic pathophysiologic) classification. CEAP classification categorizes chronic venous disorders to facilitate communication between physicians, to serve as a basis for standardized reporting during scientific analysis of management alternatives, and to identify segments of venous incompetence amenable to vein ablation therapies.
- Implement treatment plan as indicated:
b) pressure relief (eg, repositioning schedule for DFUs/VLUs; prior and ongoing compression therapy)
c) infection control
d) management of exudate; maintenance of a moist environment (eg, moist saline gauze, other classic dressings, bioactive dressing). For indications of NPWT, consult the durable medical equipment MAC LCD for NPWT (L5008).
e) patient counseling on the effects of smoking on surgical outcomes and treatment for smoking cessation.
Ultimately, problems will arise when one physician utilizes many CTPs versus another physician who does not. With the way MACRA works, because it is a combination of valuing costs and outcomes, we still do not know the formula about how CMS is going to calculate among various providers that perform wound care services and how they are going to weight things for those who practice in private office environments versus those who practice in outpatient hospital-based clinics. Either way, the base decision is the same: Do what is believed to be best for the patient, but also be judicious when choosing products to perform advanced care. n
Eric J. Lullove, a staff physician at West Boca Center for Wound Healing, Boca Raton, FL, co-chairs the healthcare policy committee of the AAWC and is the AAWC liaison to the Alliance for Wound Care Stakeholders. He also serves as a consultant for Hollister Wound Care,® Integra® LifeSciences, and Skye® Biologics.
1. Sen CK, Gordillo GM, Roy S et al. Human skin wounds: a major and snowballing threat to public health and the economy. Wound Repair Regen. 2009;17(6):763-71.
2. Frykberg RG, Banks J. Challenges in the treatment of chronic wounds. Adv Wound Care (New Rochelle). 2015;4(9):560–82.
3. Rice JB, Desai U, Cummings AKG, Birnbaum HG, Skornicki M, Parsons N. Burden of venous leg ulcers in the United States. J Med Econ. 2014;17(5):347-56.
4. McCall B. Huge Burden of Foot Ulcers Doubles Diabetes Costs in US. Medscape. 2014. Accessed online: www.medscape.com/viewarticle/821908
5. Lullove EJ. Use of ovine-based collagen extracellular matrix and gentian violet/methylene blue antibacterial foam dressings to help improve clinical outcomes in lower extremity wounds: a retrospective cohort study. Wounds. 2017;29(4):107-14.
6. Fife CE, Carter MJ, Walker D, Thomson B. Wound care outcomes and associated cost among patients treated in US outpatient wound centers: data from the US wound registry. Wounds. 2012;24(1):10–7.