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From the Editor

How Wound Care May Change, for Better and Worse, in 2020

A lot changed for me in 2019. I became a widow, sold the house we lived in for 29 years, moved into a rented townhouse, got my daughter off to college and my son off to graduate school. Thankfully, even the most difficult life changes have at least some positive aspects. I have a lot less living space, but I also have a lot fewer responsibilities. Change is an inevitable part of life so we must focus on the positive aspects and adapt to the rest. 

The field of wound management is in for a lot of big changes in 2020. Some of those changes are going to be painful, but they could have beneficial aspects for both clinicians and patients. I don’t have a crystal ball, but we can look at the events of 2019 and see some of the changes that are coming.

Hyperbaric oxygen therapy (HBOT) services are at a 10-year low and are still declining (at least for Medicare approved indications). The drop in HBOT is being driven in part by the prior authorization requirements of the Medicare Advantage plans that are rapidly replacing traditional Medicare fee for service (FFS). It is also being driven by nationwide Medicare audits of HBOT services. If you think your hospital has been spared an audit of your HBOT charges, it’s probably because the revenue integrity department hasn’t notified you about an ongoing audit. In response, some hospitals have made the decision to stop providing HBOT and some have even decided to close the hospital-based outpatient department (HOPD). 

Even bigger changes are afoot. As of January 1, 2020, all HOPD services are now under general, rather than direct supervision by the advanced practitioner. This means the advanced practitioner does not have to be physically present in the HOPD for services to be provided. In response, it is likely that the American Medical Association (AMA) Relative Value Scale Update Committee (RUC) will decrease the payment rate for physician services in the HOPD, although this probably won’t happen in 2020. However, in 2020, hospitals could see a change in the facility payment rate for services provided in the HOPD. That’s because the legal battle over “site neutrality” is making its way through the courts. It is possible that in 2020, site neutrality will impact the “on-campus” HOPD and there could be a significant decrease in hospital facility fees.

The combined impact of dwindling HBOT revenue and a decrease in hospital facility fees could result in wound management services moving into the doctor’s office. I don’t think 2020 will be the year we literally close the doors of the hospital-based outpatient wound center, but in 2020, a lot of wound care practitioners will evaluate either an employment contract or a lease for office space.

Transitioning HBOT services to the private office may not be as difficult as it seems. The physician reimbursement rate for HBOT supervision is actually the same in the office setting and the hospital. However, the office-based setting will profoundly impact wound management. We will discuss this a lot more in future issues of Today’s Wound Clinic, but as only one example, when compression bandaging is performed in the doctor’s office setting, Medicare reimbursement allows only about $16.00 for the associated supply costs. 

That brings up one of the positive aspects to office based wound management. The hospital supply contracting process is complicated and slow. Physicians, however, can make purchasing decisions quickly and directly. Manufacturers need to get prepared for a dramatic shift to less expensive wound dressings and compression bandage systems in the private office setting. A price differential of $1.00 will be enough to change physician brand loyalty when the cost of the dressing comes out of the physician’s wallet. 

Furthermore, in the private office setting, physicians will be able to make those brand changes practically overnight. The downside to this shift is that there will be a temptation to use substandard products. That’s a major reason the U.S. Wound Registry (USWR) has fought so hard to defend wound relevant quality measures. The only way to ensure the highest quality of care is to compensate physicians for providing it, and the only way to do that is by reporting wound relevant quality measures like adequate compression at each visit for venous leg ulcers and adequate offloading for diabetic foot ulcers. Even a small financial bonus from participating in quality reporting through the USWR could ensure the success of the office based “wound center.” I remain mystified that manufacturers have not supported quality reporting for this reason. 

There’s another potential upside to the private office setting. Many physicians who wanted to report wound relevant quality measures have been prevented from doing so because their hospital’s electronic health record (EHR) vendor has been unsupportive. In their private offices, physicians have more control over decisions like quality reporting. Practitioners will have a compelling reason to report wound relevant quality measures. Their wound care quality performance will be depicted by the Centers for Medicare and Medicaid Services (CMS) on the Physician Compare website. Remember that Yelp will be turning the Physician Compare data into a “star rating” that will be depicted on social media sites, effectively providing “free” advertising of their wound management services. This could be a big plus to doctors in private practice who have a limited advertising budget. 

The private office setting will have both positive and negative effects on the cellular- and/or tissue-based product (CTP) industry. The private office setting will not be subject to the “episode-based payment” that CMS plans to implement in the HOPD. In the private office setting, physicians can be reimbursed for the cost of a CTP based on its average sales price plus 6%. The downside is that physicians in private practice may not be able to afford to purchase high tier CTPs and wait several weeks to be reimbursed by payers. The expense of the upfront purchase of CTPs by physicians will likely drive the use of low tier products. It may not be true that low tier CTPs require more applications for the same outcome than high tier CTPs, but even if they do, the patient copays will be less with low tier CTPs and so will total cost of care. CTP manufacturers should closely monitor any trend toward office based wound care, and group purchasing organizations should begin to consider how they can help private practitioners with their supply contracting. 

There are ways that manufacturers and hospitals could ensure the survival of hospital based wound management. Manufacturers will have to come to terms with the fact that brand loyalty will be based on competitive pricing unless there is transparent data to justify a price differential. Manufacturers could accept that quality reporting on a national level is the least difficult and most fair way to demonstrate effectiveness and value. Without comparative data, hospitals and providers have no reason not to use the lowest priced product in any category. Hospitals could demand that their information technology (IT) departments support rather than impede quality reporting. Hospitals have allowed their EHR vendors to block quality reporting by practitioners, behavior that is not only illegal but unwise. Additionally, hospitals continue to be unable to wield their own data to facilitate product comparisons. If institutions cannot link the cost of products to the outcome of patients, then they better get ready to hear the doors of the HOPD slam shut for the last time. 

All of these changes may be painful, but if the result is better value and improved quality of care for patients, then we had all better learn to focus on the positive, and adapt to the rest. 

Caroline E. Fife is Chief Medical Officer at Intellicure Inc., The Woodlands, TX; executive director of the U.S. Wound Registry; medical director of St. Luke’s Wound Clinic, The Woodlands; and co-chair of the Alliance of Wound Care Stakeholders.

From the Editor
Caroline E. Fife, MD, FAAFP, CWS, FUHM
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