I have been thinking about technology in wound care and the meaning of value. I remember the space race of the 1960s even though I was a child, because my Dad was at the School of Aerospace Medicine where human physiology research was being conducted at a breakneck pace.
Recently, I was reflecting on the fact that to handle the problem that ink pens didn’t work without gravity, NASA spent a lot of money to develop a pen that would write upside down in space, while the Soviets just used pencils. The U.S. did get to the moon first, but we are currently dependent on the Russian Soyuz for transportation back and forth to the International Space Station. It’s ironic.
Some ideas are valuable because they are practical; some ideas are practical because they create value. Our field needs both types of solutions. Wound care is involved in a technology race, albeit an undeclared one. We are racing to find solutions before the money to pay for them runs out, and before the payers simply take matters into their own hands and decide what to pay for without input from us.
I have been increasingly worried about the fact that so many leg ulcer patients return to the wound center for wounds caused by volume overload as their skin simply splits open from edema. We call them venous ulcers, but they really aren’t. We are forced to call them venous ulcers because otherwise insurance doesn’t cover the compression bandaging that they need to heal over the short term, or the garments that they need to stay healed in the long term.
Although I am only their wound care doctor, I provide the plurality of services for these congestive heart failure patients, so Medicare holds me accountable for their re-hospitalizations. I decided if the Centers for Medicare and Medicaid Services (CMS) were going to blame me when patients got re-hospitalized, I’d try to keep these patients out of the hospital. I discovered that my hospital had opened a clinic to manage patients discharged from the hospital until they could get back into their primary care doctor’s office (which sometimes took so long they got re-hospitalized before the next follow-up appointment).
Recently I spent the day with the nurse practitioner who runs my hospital’s transitional care program. I learned some valuable things from him. Thanks to the transitional care NP, I discovered that my county has a program to reduce heart failure readmissions run through our emergency medical services (EMS). I didn’t know about “paramedicine” until last year’s article about it in Today’s Wound Clinic.1 It turns out to be incredibly important in my own community.
I didn’t know how much my own hospital was struggling with the cost of wound care among the uninsured until I spent the day with the transitional care NP. The hospital’s transitional care clinic is where patients with little or no insurance go for follow-up after hospital discharge. Many of them have open wounds. There are low cost methods to offload diabetic foot ulcers and heel pressure ulcers, and there are cost efficient wound treatments. To prevent hospital readmissions, my hospital (working in concert with other hospitals in the county) wants to find those innovative solutions and is willing to pay for them if they reduce the likelihood of readmission.
Patients don’t have access to surgical dressings without insurance, so on the Monday we spent together, the transitional care NP and I spent a lot of time discussing low cost but effective wound treatments. It’s possible to make Dakin’s solution and acetic acid in the kitchen, CVS wound gel is a reasonable antimicrobial (it contains benzalkonium chloride), baby diapers are highly absorptive dressings, and if you know for sure that there’s good arterial flow, Pet Wrap can be used for compression if you do it carefully. Some patients need a vascular assessment, but a vascular work-up wasn’t part of the diagnosis related grouping (DRG) for which they were admitted, so it wasn’t done. Many patients just need is $10 of vitamin D and some L-arginine, and thankfully, my hospital nutritional supplement rep has been helpful with the latter.
Before the above comments get me in serious trouble, I will hasten to add that the problem is not that advanced wound dressings aren’t valuable, it’s that how valuable they are is dependent on whether patients have gotten the basic care they need first. Advanced dressings don’t heal ischemic wounds and malnourished patients don’t benefit from advanced technologies. First things should be done first, and we struggle with that.
It is likely that within the next year, CMS will move to an episode-based payment model for cellular products. I predict it will go badly, but not for the reasons you think. I predict it will go badly because it will accidentally impact payment for things they didn’t mean to include, be crafted to run over too short a timeframe (because it will be based on data from clinical trials that are irrelevant to real world patients), and not enforce quality standards for things like arterial screening, compression and offloading. These pitfalls could be avoided but the parties that should care the most (e.g., hospitals and patients) won’t be part of the planning for it and all the payers want is to reduce cost. We won’t know whether it changed outcome (for better or worse) because in the absence of registry participation, outcome won’t be one of the things that gets measured.
It appears to me that the only useful innovation right now is coming out of hospital programs to reduce readmissions. So, for now, I’m trying to be part of that. It seems to me that we don’t need better technology, we need a better way to provide it.
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.
1. Darrah J. Community paramedicine & chronic wound care: collaborative potential or too many complicated questions? Today’s Wound Clinic. 2019; 13(3):9–12.