A year after COVID-19 caused lockdowns and health care disruptions in the United States, this author looks at the results of a survey of wound care clinics on the pandemic’s impact. She analyzes trends in wound care visits, telehealth, reimbursement, amputations and more.
Many sectors of the U.S. economy have taken a financial hit due to the 2020 coronavirus pandemic. Even physician practices around the country have reported a steep decline in revenues.1 When the severity of the pandemic became apparent, the effects it would have on health care spending were uncertain.
As the information spread on the severity of the coronavirus across the U.S., there seems to have been an unforeseen consequence—people became scared to go to doctors’ offices and hospitals. Many patients would rather suffer with serious illness at home than become exposed to COVID-19. According to the Quarterly Services Survey (QSS), ambulatory care settings such as physicians’ offices and outpatient care centers have seen some of the largest drops in revenue year to date.2 Overall, hospital system revenues were down compared to 2019, most likely due to the cancellations of elective surgical procedures in 2020.2
Health care providers are aware that we have been navigating unprecedented times in medicine. COVID-19 has disrupted many aspects of our clinical practices. As wound care clinicians, we are essential caregivers for a very at-risk patient population. Wound care services continue to play an important role during this outbreak by ensuring that the continuity of care of our chronic wound patients is maintained while limiting their exposure to COVID-19. Many health care practices had to pivot quickly, adopting virtual visits and telemedicine platforms, to continue to provide patient care while helping to limit the spread of COVID-19. A change in clinical practice such as this would typically occur over a decade, but due to this unparalleled health care crisis it occurred within a span of a few weeks. Although many insurance plans eased restrictions and enabled coverage of telemedicine services, the use of virtual platforms may not be enough to offset the decrease in face to face patient care. Once states and local jurisdictions eased stay-at-home orders, and the Centers for Medicare and Medicaid Services (CMS) lifted restrictions on non-emergent, non-COVID care, patient visits to physician practices did pick back up, but many reports indicate that patient load remains well below pre-pandemic levels due to social distancing requirements.
As an attempt to better understand how the COVID-19 pandemic has affected wound care practices, a brief 10-question survey was distributed via email to the readers of Today’s Wound Clinic. The focus of this article is to break down the data collected followed by a brief discussion of the factors that may have influenced the responses. Clinicians were asked about both in-person and telehealth visits throughout the past year, percentage of changes in practice revenues and spending on personal protective equipment (PPE).
Wound Clinic Closures
Most wound care centers are hospital-based outpatient departments. Year-to-date, the Quarterly Services Survey showed that health service spending was down by 2.4% as of the third quarter 2020 when compared to 2019.2 Ambulatory care sites, such as outpatient centers, have seen as much as a 60% decrease in patient visits.3
More than 40% of respondents to our survey related that their wound care practice was closed for at least some portion of 2020 (Figure 1). Most of these closures were a direct effect of stay-at-home orders and other COVID-19 precautions as a result of rising coronavirus cases in the spring of 2020. The practice of wound care is multidisciplinary. Many clinicians were called on to practice in other areas of the hospital to provide care to the critically ill, therefore leaving their wound care practices without coverage. Although wound care is an essential service, many hospitals closed outpatient departments in an attempt to conserve resources and PPE.
Wound Care Visits
The same precautions that were adopted to help limit patients and providers from being exposed to the coronavirus seem to be factors in an overall reduction in current patient loads. The overwhelming majority of survey respondents reported a decrease in current patient visits as compared to pre-pandemic numbers (Figure 2). Only 20% reported no change in patient volume, whereas a mere 7.5% report their patient numbers increased.
Clinicians indicated several reasons why they believe the number of patient visits continues to be lower even today. Patients continue to be leery of contracting the coronavirus. Becoming infected or exposed to coronavirus and then having to quarantine is among the most common reported reason. Clinicians report a continuation of limited hours of operation. Mandatory COVID testing for clinicians and patients has been reported by some respondents as a significant hurdle. It was also reported that patient scheduling remains a challenge. Many practices have been forced to take the wait out of the waiting room in order to comply with social distancing requirements, thus restricting the number of patients able to be seen at a given time. Some even feel that decreased personal interaction is to blame due to masking and other PPE mandates.
Telehealth and Wound Care
Although many insurance plans cover telemedicine services, our survey showed that 30% of respondents are not currently utilizing virtual visits to treat their patients (Figure 3). This number is lower than pre-pandemic, during which time more than 57% of clinicians surveyed did not practice telemedicine (Figure 4). This data seems to correlate to reported national trends showing that the use of telemedicine increased during the pandemic. While medical centers in general may be leveraging telehealth services to offset cancellations and decreasing patient volumes, it would appear that virtual visit volumes have not been enough to offset the decline in face-to-face wound care visits.
This may be tied to the fact that wound care is a hands-on discipline. Those surveyed related that early in the pandemic, telehealth was a good way to keep patients stable and out of harm’s way while freeing up resources for those ill with COVID-19. Clinicians were unable to sustain care via virtual visits for long periods of time because wound care centers are procedurally driven departments. Wound debridement, specialized dressing applications, and the application of advanced products including cellular- and tissue-based products (CTPs) all need to be performed in person. Furthermore, having 3 to 4 telehealth visits a day does not offset seeing 15–20 patients in clinic daily. Respondents also relayed that they were reluctant to commit the necessary resources to adopting telemedicine because it is not clear whether reimbursement will continue after the pandemic ends.
Wound Care Revenues
Corresponding with the reported drop in patients was an overall decrease in annual practice revenues since the beginning of the pandemic with 57.5% of respondents reporting a decrease in practice income of 25% or more (Figure 5). This figure seems to be compounded by the cancellation of elective procedures seen across hospital systems. Several of those surveyed report that they have not been allowed to return to providing care to patients in nursing facilities. As health care utilization declined, so did wound care practice revenues. Before clinicians can begin to allow more in-person visits, many states and regions must report a sustained decline in COVID-19 cases or positive tests for a sustained period of time. Clinicians also relate increased costs of supplies and long wait times to get materials.
As part of the battle to protect patients and staff from COVID-19, wound care clinicians reported an overall increase in PPE spending (Figure 6). Only 15% of clinicians surveyed reported no change in PPE spending (Figure 6). Product shortages early in the pandemic prompted clinicians to stockpile items regardless of cost. Smaller wound care centers or solo practitioners lacking purchasing power or vendor relationships seemed to be particularly hard hit. Survey respondents related that in certain circumstances they considered including a PPE surcharge to the services that were provided. It is uncertain if these currently PPE standards will become our new standard of practice, but these significant expenditures have been reported to have a negative effect on the bottom line.
The survey notes 47.5% participated in some form of federally funded pandemic relief program (Figure 7). While clinicians related that this early relief was helpful and appreciated, the core revenue issues these programs were intended to address remain to the present day.
Wound Severity and Amputations
Data revealed that the severity of wounds currently being treated by surveyed clinicians has increased in the past year. Fifty-seven percent of respondents said that wound severity has either increased or significantly increased since the start of the pandemic (Figure 8). Many clinicians related that patients have been hesitant, unable or unwilling to attend clinic visits. This nonadherence to care recommendations was thought to be one of the biggest factors contributing to delayed wound healing and therefore the increase seen in patient acuity.
A published report in Morbidity and Mortality Weekly showed that 40.9% of patients have delayed or avoided any medical care during the pandemic.3 It was estimated as many as 12% did not seek care for urgent and emergent conditions due to COVID-19 concerns.3 This increased prevalence of medical care delay has translated into an increase in the need for amputations among wound care patients.
Survey respondents were split. Half of responding clinicians related an increase in amputations among their patients, whereas the remaining 50% did not (Figure 9). According to research published in the Journal of the American Podiatric Medical Association, diabetic amputations have increased nearly threefold since the onset of the pandemic.4 Clinicians surveyed echoed this trend with some noting their inpatient hospital load had grown substantially throughout the past year with patients presenting with very severe infections due to avoidance of treatment for wound-related concerns.
The survey's findings illustrate the widespread changes seen in the delivery of wound care across the United States as a result of the COVID-19 pandemic. As the coronavirus rapidly spread, medical attention shifted to treating COVID-affected patients while protecting others from infection. Patients became apprehensive about seeking wound care due to shelter-in-place orders and concerns about contracting the coronavirus.
Wound care clinicians were left to answer the question: how do we best care for our at-risk patients with non–COVID-related disease? For many clinicians these new health restrictions warranted reconsideration of usual standards of care precipitating rapid adoption of telehealth and modifications to other office procedures. The need to protect patients and preserve critical care capacity appeared to negatively affect the bottom line. For many wound care providers, the radical transformations seen in the health care delivery system as a result of the pandemic continue to influence their practices and challenge their ability to maintain high-quality patient care even today.
Windy Cole, DPM, CWSP, is an Adjunct Professor and the Director of Wound Care at Kent State University College of Podiatric Medicine in Independence, Ohio.
1. Loria K. How COVID-19 is Affecting Practices Financially. Medical Economics. May 27, 2020.
2. United States Census.
3. Czeisler ME, Marynak K, Clarke KE, et al. Delay or avoidance of medical care because of COVID-19-related concerns. MMWR Morb Mort Wkly Rep. 2020; 69(36):1250–1257.
4. Casciato DJ, Yancovitz S, Thompson J, Anderson S, Bischoff A, Ayres S, Barron I. Diabetes-related major and minor amputation risk increased during the COVID-19 pandemic. J Am Podiatr Med Assoc. 2020 Nov 3:20–224.