With the transforming climate of wound care, wound clinics may want to consider developing varied business and wound management strategies to continue providing the best care to patients as well as to succeed in the market. Experienced clinicians share their views on the future of wound clinics, collaborative care, and potential methods to withstand the ongoing modifications impacting wound care practice.
The wound clinic in the coming future may look a little different than it does today, notes Eric J. Lullove, DPM, CWSP. Due to the nature of consolidated insurances, payors, and coverage policies, he predicts wound clinics are going to have to adapt and change the way they perform and the type of business they conduct. He notes clinics may even change their location and place of service in order to remain competitive in the market.
The need for managing chronic wounds will only increase over the foreseeable future, predicts Desmond Bell, DPM, CWS. As he notes, the number of baby boomers in wound clinics continues to grow, as do the numbers of those with diabetes and pre-diabetes. Dr. Bell notes that inherent in the increasing populations of these groups will be an increase in the number of wounds of all etiologies.
“The big problem is that wounds are a symptom of the underlying disease and I spend most of my time finding the reasons the wound hasn’t healed because once you do that, assuming you can mitigate them, they heal,” says Caroline E. Fife, MD, FAAFP, CWS, FUHM.
Dr. Fife notes payment models are in a state of flux. As she notes, if the hospital can’t be compensated for the cost of operating a wound center, then hospitals will close wound centers, while if doctors can’t get paid for providing care, the doctors can’t see patients.
Given that flux, Dr. Fife suggests a “site of service” adjustment is likely, although currently it is delayed in the courts. If that happens, she says it will be hard for hospitals to continue to have wound centers as departments under the Hospital Based Outpatient Payment System. The logical move will be into the office-based setting, notes Dr. Fife. However, if physician payment continues down the Merit-based Incentive Payment System (MIPS) Value Based Pathway, she says it may be that only surgical subspecialists can offer wound management, and that depends on the quality measures they are forced to report for their primary specialty.
Dr. Bell cites “intensive scrutiny” into the present model of delivering wound care services in a hospital-based outpatient center, calling into question hyperbaric oxygen therapy (HBOT), the need for debridement and cellular- and tissue-based products (CTPs), and other aspects of wound care. Dr. Fife cautions that audits “will significantly impact” the use of CTPs and HBOT.
“The traditional model of a fee-for-service wound center may be an anachronism of the past,” asserts Dr. Lullove, noting that bundled payments and Diagnosis-Related Group/Ambulatory Payment Classification (DRG/APC)-based revenue streams will eventually replace the fee-for-service system. He says this will challenge the wound center management and physician staff to focus more on episodic care mechanisms and rely less on relative value unit (RVU) procedural medicine.
“Wound centers under the current model are being asked then to do more with less,” says Dr. Bell. “Reimbursement represents a never-ending challenge with documentation and administrative aspects exasperating to all involved.”
To that end, Dr. Bell says the present mode of delivery of services must evolve, noting the outpatient wound clinics’ models of delivery will need to function as a hub with services extending into communities via home health and skilled nursing facilities. As he notes, many hospital emergency departments have created an extension of their services by building facilities within communities beyond the walls of the hospital.
“Wound centers need not create brick and mortar facilities, but affiliations with home health agencies or creation of home health services in conjunction with the wound center,” says Dr. Bell. He notes that these options “will help meet needs of patients who are unable to be treated in a hospital-based center, while reducing reliance on revenue generated by HBOT, debridement and other procedures.”
Dr. Fife acknowledges the possibility that both the physician and the hospital will end up partnering in some sort of bundled payment approach since episode-based payment is coming. She predicts bundled payment “will go badly, noting increased out of pocket costs for patients and the use of less expensive dressing products. The best survival option for wound management, says Dr. Fife, is likely as part of a multi-specialty group, any entity that has capitated payments, or in conjunction with vascular, dermatology or aesthetic centers. Medicare Advantage will be the primary payer so she says physicians will need to demonstrate adherence to best practices, which she cites as Quality Measure performance.
Harriet Jones, MD, FACP, comments that—assuming there are no significant changes made in the financial structures/methods of payments, reimbursements, or in the regulations that allow third party hospital systems to contract with third party wound management companies—she does not think there will be any significant changes realized in vast majority of clinics. She expects documentation requirements to become more onerous for nursing staff, therapists, and providers.
A Collaborative Approach to Care
For wound clinics to be successful going forward, Heather Hettrick, PT, PhD, CWS, CLT-LANA, CLWT, says they will need to have a more integrated and collaborative approach to care. As she notes, patients with wounds often have quite complex medical histories and require various specialists to truly address the underlying issues affecting and impacting the potential for wound resolution. To that end, a one-stop shop model for medical management may be a cost-efficient and time-efficient way to manage these individuals. Dr. Hettrick says such a model would also reduce delays when special tests or procedures are needed, as those resources would be accessible in real time.
Dr. Lullove says wound clinics will need to make sure they have reliable staff that is properly trained in wound management techniques. It just will not be enough to be on the “staff” of a wound center. As he says, each provider will need to be board-certified in wound management rather than just board-certified in their primary specialty. Each provider will need to understand APC/RVU generated, and will need to become more business-oriented to the cost needs of the treatment plan for each patient, according to Dr. Lullove.
Dr. Lullove adds that the wound center staff also needs to be retrained for the possibility that minor surgical procedures will need to be done in the wound center. As he notes, it may be more advantageous to perform level 4 skin surgery at a visit versus admitting a patient to the hospital as an inpatient. He acknowledges there may be a push to keep more clinics on an “outpatient office” basis versus “hospital-based.”
Dr. Jones predicts there will be further requirements for pre-certifications for the use of advanced therapies and even for standard radiologic diagnostic evaluations. “I really hope I am wrong because the one who is most impacted by the above, and in a negative way, is the patient,” adds Dr. Jones.
As part of that collaborative approach, Dr. Hettrick suggests every wound clinic have a certified lymphedema therapist on staff. She notes the majority of wound patients have edema and emphasizes that all edema is on a lymphedema continuum. Furthermore, the majority of lower extremity lymphedema patients have skin impairment requiring the expertise of knowledgeable practitioners who understand the interplay of the two systems: lymphatic and integumentary.
Dr. Hettrick adds that access to physical therapists to address patients’ functional impairments is also essential, as PTs can manage issues with gait, balance, strength, range of motion, offloading, shoe wear, assistive devices, and other areas. She notes PTs also have knowledge of the integumentary and lymphatic systems.
Better Management of the Wound
“The need to perform better advanced wound care management—not necessarily ‘wound care’—but management of the wound will be of paramount importance,” says Dr. Lullove.
What does management of the wound mean? As Dr. Lullove says, it means to stop looking at the wound and seeing “debridement, compression, offloading, and CTP” as individual concepts of care. He notes management will morph into creating a full treatment plan for each patient, from week 1 to week 4 to week 12.
“This may mean early, aggressive debridement technique and advancing the patient to harvested skin graft; it may mean aggressive co-management to revascularize a patient,” says Dr. Lullove. “It will be more dependent on the need to manage the cost of the wound center and less on the revenue of the wound center.”
“While all of this is going on, change is imminent,” says Dr. Lullove. “We as wound care practitioners have to be ready for the changes that are going to come. It is just a matter of time, which we never have enough.”
“Changes for both the physicians and the hospitals will be big,” says Dr. Fife. “If we don’t react differently than we are doing now, the only wound care in most places will be the ostomy and wound nurse.”