When Today’s Wound Clinic (TWC) first published in April 2007, the editorial board established its goals to educate qualified healthcare professionals (QHPs) and their newly opening outpatient wound clinics on issues related to clinical practice guidelines, reimbursement, and various business matters affecting patients and the overall operation of a wound care facility. At that time, the demographics and issues facing outpatient clinics, although similar, were quite different than they are for today’s facilities and QHPs. Over the past seven years, this journal has maintained its mission to address this ever-changing landscape. With this edition of TWC, we focus on the business practices and clinical protocols necessary for existing wound clinics that continue to navigate this crucial industry within the continuum of healthcare. This article provides commentary from two of our expert editorial board members who took the time to analyze and provide feedback on a recent reader survey conducted that asked QHPs and program directors to assess their wound clinics and shed some light on the state of their businesses and patient care practices in 2014.
Demographics of HOPDs in 2014
We received more than 170 responses to our “Reassessing Your Outpatient Wound Clinic” survey, and the results have provided a fascinating window into the changing landscape of clinics over the past decade. The vast majority of our readers (85%) have entered the industry since 2000, when the Medicare Outpatient Prospective Payment System (OPPS) was created, and 35% of respondents began working in their current clinic within the last four years. As you might expect, 91% of readers work in a hospital-based outpatient department (HOPD), with only 7% providing wound care in a private practice setting. While 65% of those in HOPDs have been in facilities that opened more than 10 years ago, 35% are in clinics that are no more than five years old, giving us some sense of the rate at which new HOPDs are opening. Interestingly, 65% of these newer HOPDs were not established in partnership with a management company.
Of those that were, more than half ended their contracts within five years either due to hospital administration believing it could manage the HOPD independently or it was determined the contract was too costly and/or little value had been gained.
Only 3% of QHPs in HOPDs are employed by a management company among respondents. However, 31% reported the hospital (or a hospital-owned entity) employed HOPD physicians. This is a significant increase from a decade ago.
In 60% of responses, the QHP coverage model is that of a “panel” of more than three providers covering the HOPD in a rotation. Some HOPDs use physician assistants or nurse practitioners. Other wound care clinicians include physical therapists, emergency medical technicians, hyperbaric oxygen therapy (HBOT) technicians, lymphedema therapists, case managers, social workers, registered dietitians and/or nutritionists, orthotists, and prosthetists. These results reinforce the image of wound care as a transdisciplinary endeavor.
Not surprisingly, the top revenue-driving services, procedures, and/or advanced products in HOPDs are: HBOT (44%), debridements (37%), cellular and tissue-based products [CTPs, old term “skin substitutes”] (8%), and “other” [eg, negative pressure wound therapy pumps (NPWT), compression therapy, IV therapy, etc.] (11%). The up-and-coming service of telemedicine is now offered by 10% of readers who responded to the survey.
Breaking Down Silos
It is of particular interest that 72% of HOPDs provided wound care services to some other site of care (eg, 44% to hospital inpatients, 12% to skilled-nursing facilities [SNFs], 8% to long-term care [LTC] facilities, and 8% to home health agencies). In some cases, HOPD nurses provided “other services,” which consisted of any of the following:
• consultations to hospital inpatients living with wounds, pressure ulcers, or ostomies;
• placement of NPWT on hospital inpatients; and/or
• wound care services for patients in SNFs.
Physicians also provided services across many sites of care, including:
• rounding on new admissions to SNFs;
• bedside debridements on hospital inpatients or patients in the SNF; and
• caring for LTC patients living with wounds.
The list above provides a broad overview of the services provided by wound care clinicians, but respondents also took the time to list some specific services offered, such as:
• coordination of patient care from other facilities;
• selection of advanced dressings;
• compression bandaging;
• creating an overall plan of care;
• supervision of home health nurses;
• routine foot care;
• patient and family education in the care of a chronic wound; and
• a fully integrated “wound care service line” from inpatient to outpatient to home.
The individuals who provide this comprehensive list of services represent the entire spectrum of healthcare providers. Eighty percent of respondents stated that at least one of the QHPs in their HOPDs is a certified wound specialist. Nursing credentials also included:
• licensed practical nurses; and
• certified wound ostomy and continence nurses.
Physician wound care specialists included podiatrists, vascular surgeons, plastic surgeons, infectious disease experts, family practice doctors, internists, general surgeons, endocrinologists, orthopedic surgeons, interventional radiologists, and dermatologists.
Insurance Authorization: “Just Say No?”
Many respondents have noticed changes in patients’ insurance coverage, but not because more patients are uninsured. Half of you claim you’ve noticed patients with high deductibles while about one-fourth of readers have noticed insurance companies denying services such as HBOT.
Overall, 73% of respondents have noticed an increase in the number of patients with more restrictive insurance coverage. It is fair to assume that it will be increasingly difficult to get advanced therapeutics approved by insurers and that when these modalities are approved, patients may have deductibles so high they may be unable to afford them.
More than one-third of respondents (38%) indicated their HOPDs are involved in some type of Medicare shared savings demonstration project (eg, accountable care organization [ACO] or bundled payment system). Shared savings programs didn't exist seven years ago. Interestingly, only 22% of respondents indicated they had made any changes to accommodate these new Medicare payment programs. Those respondents who did report making changes mentioned stopping the use of certain expensive CTPs and moving to quality outcomes-based performance.
Tracking Outcomes & Patient Satisfaction
The vast majority of HOPDs (86%) track patient satisfaction, which is a huge increase over the last seven years.
More than 80% of respondents said they track patient outcomes while 86% define “healed” as complete closure. However, at least one-third of respondents reported they exclude some patients from outcome tracking. Patients who:
• “don’t heal”;
• are considered “palliative”;
• are lost to follow up;
• are engaged in research;
• have an amputation;
• are considered noncompliant;
• live with cancer;
• have multiple comorbidities; and/or
• live with sickle cell disease.
Quality of Care Vs. Quality Measures
When asked if there were quality measures they were concerned about today that might continue to be a quality problem in the future, only one-third of respondents said “yes.” It’s possible that this question was worded in a confusing way, and that may account for some of the survey responses. Fifty-one people took the initiative to actually list issues they believe affected the quality of care they delivered, such as:
• increasing difficulty finding wound care QHPs on the patient’s insurance or healthcare exchange;
• decreased availability of CTPs;
• long wait times for patients;
• lack of vascular screening;
• lack of diabetes education;
• difficulty obtaining referrals to specialists;
• understaffing in the HOPD;
• poor documentation on the part of QHPs;
• patient noncompliance; and
• general problems with patient access.
While all are valid concerns about quality of patient care, only one of the 51 comments indicated the respondent was familiar with quality measures currently recognized by the Centers for Medicare & Medicaid Services (CMS). That person observed that the currently available hospital quality measures were not relevant to that HOPD. These responses indicate we still have a long way to go to educate QHPs about the existing quality programs within CMS and the quality measures available for reporting to CMS. However, it is clear that QHPs care deeply about providing quality care to patients and they understand the importance of having a functional system in which to do so.
Times Are Changing
When asked about the biggest change they’ve had to make since starting to work at an HOPD, 89% of respondents wrote answers that indicate this question struck a nerve. Here, we attempt to group answers into 10 categories based on frequency of responses. Below is a list of changes respondents are currently struggling to make.
1. Staffing issues: eg, fewer staff members combined with increasingly complex patients; seeing more patients in less time; hospital management not understanding staffing needs; how best to find and train new staff (leased staff, float pool); and how to create efficiencies and do more with less.
2. Dealing with insurance authorization and denial of services: includes more aggressive screening for HBOT candidates/obtaining HBOT authorization. This may threaten whether the HOPD can stay open as revenue decreases.
3. Increasing documentation burden and electronic health record adoption issues: eg, increased time for documentation, increased regulation, documentation of medical necessity.
4. Coding, coverage, and chargemaster issues: eg, cumbersome process to add procedures to chargemaster, arcane rules about how to bill services provided on the same day, coverage policy in local and national coverage determination documents.
5. Dealing with the loss of certain advanced therapeutics or other clinic services due to cost factors: eg, packaged payment.
6. Ensuring evidence-based practice by QHPs: eg, QHP leadership or lack thereof, QHP training, and QHP incentive programs.
7. Obtaining timely referrals/advertising/marketing.
8. Increasing cost of dressings and problems obtaining dressings for some patients.
9. Increasing coinsurance amounts that make frequent visits a financial burden for patients and heightens the need to collect coinsurance at time of service.
10. Tracking outcomes and data management.
The survey also asked respondents to predict changes that would be needed in the next five years. Because many of these comments are similar to those above, we have listed below only those predictions that are different or offer significant refinements. We have tried to place them in roughly the order of frequency with which they were noted. Here are the top 10 changes you predicted would be needed:
1. Changing payment systems: performance-based reimbursement with decreased reimbursement across the board; hospital moving toward ACO; increased community health (eg, more free screenings, preventative care); capitated payment; pay for performance.
2. Increasing HBOT requirements/restrictions: accreditation for HBOT facilities, which will be a significant expense; physician training and credentialing in HBOT; need for full-time HBOT physicians; decreased insurance coverage of indications; increasing insurance denials; increased documentation requirements for coverage.
3. Breaking down silos of care: providing inpatient care, SNF care, rehabilitation hospital care, preventive care, coordinating with primary care QHPs.
4. Providing evidence-based care through treatment algorithms and evaluating products for cost effectiveness: changing what HOPDs do and what they use.
5. Monitoring patient satisfaction: more closely and report it better.
6. Acquiring provider certification and/or credentialing: QHP, nurse, HBOT technician.
7. Preparing for ICD-10-CM: documentation, electronic systems, coverage policies.
8. Providing telemedicine.
9. Increased competition due to more HOPDs: ie, “We have a wound care center on every corner.”
10. Increasing population of morbidly obese and nonadherent patients.
The wound care arena is definitely changing and it’s particularly gratifying to see how well TWC has helped readers identify many of these issues. To those of you who took the time to respond to the survey, thank you!
Caroline Fife is clinical editor of TWC and chief medical officer at Intellicure Inc.
Kathleen D. Schaum is director, medical products, reimbursement, biotherapeutics at Smith & Nephew.