Overcoming Health Inequities In Wound Care

Q: What resources do you use and/or recommend for physicians to educate themselves on health inequities, especially in the field of wound care?

A:

Babajide Ogunlana, DPM, FACFAS, encourages physician to learn first-hand by engaging in community outreach-type programs that seek to improve access to care. 

“The field of wound care has a lot of cost implications that tend to tilt the services offered and/or available to the patient in the direction of who can afford it or whose insurance company would cover the recommended therapy,” he says.

He continues by sharing examples of when the use of advanced biologics and advanced moisture control wound dressings tend to depend on whether insurance will or will not cover the product. As such, he points out that substitutions for the intended therapies may not be as efficacious.

“So, in essence, patients who can afford to pay for such products out of pocket or who have private health care plans tend to receive the therapies, while patients on some managed care plans tend to have a harder time getting the products covered,” he explains. “It appears that economic inequities and insurance coverage play a pivotal role.”

Dr. Ogunlana shares that he follows WoundSource (woundsource.com) and several wound care blogs on social media. He adds that, as the President of International Limb Salvage Foundation USA (intlimbsf.com), he is involved in education and training of health care workers in underserved communities in Africa with the goal of amputation reduction via wound care training modules and monthly webinars. 

James E. Fullwood, Jr., DPM, FACFAS, FACPM adds that although there are many resources to choose from to gather data on this topic, very few researchers dedicate significant time to analyze this for the purpose of changing the scope of how podiatric medicine and wound care is delivered.

“It becomes more informational than curative,” he says.

Dr. Fullwood notes that there are a few publications that are epidemiological in nature, but even fewer publish with the intent to change how we practice or to change legislation for patient impact. Similarly, he adds that there are many wound care journals occasionally touch on these issues but it remains solely informational.

In general, Dr. Fullwood cites the National Medical Association (nmanet.org), the oldest association for people of color in the United States, as having a periodical very specific to health disparities in African Americans. He also lists that data is available from the Centers for Disease Control and Prevention, the National Institutes of Health, insurance companies and various health systems.

“The Johns Hopkins Bloomberg School of Public Health (publichealth.jhu.edu) has extensive research in health care justice and equity in the African American community, Native American and Hispanic populations,” he adds. “These schools of public health also have data and research in the international community that might be of interest.”

Kazu Suzuki, DPM, CWS feels a good starting place to learn more about these issues is with the American Association for the Advancement of Wound Care (aawconline.org), where there are multidisciplinary educational opportunities available to interested clinicians.

Q: In what way do you feel health inequities, such as those experienced due to race, ethnicity, gender, income, health literacy, language barriers, or other factors, play a role in or pose challenges to the wound healing process?

A:

In Dr. Suzuki’s experience, he has found that socio-economic status and language barriers do play a role in health care delivery, not only in wound care, but across the board in internal medicine, cardiology and other fields.

“In the area where I practice (Los Angeles Metro and West Hollywood areas), we have a large Russian immigrant community,” he explains. “Language and cultural barriers are evident, posing challenges in communication that make it difficult to provide the community standard of care. 

As a health care advisor to a 10-hospital system in the rural state of Maine, Dr. Fullwood shares he faces these challenges, along with his provider and administrative teams. Accordingly, he relates his system developed an equity, inclusion, and diversity council to begin to research and address these problems.

“Medicine and health care are very different,” he points out. “We study medicine, but we do not study health care, quality, health equity, or health justice in many medical schools. This is essentially on-the-job training, so I find many providers push back initially, because health care challenges how we deliver the medicine and surgery, and how we as providers do this seems to be the great debate.”

He notes that many health systems and practices are adopting national protocols or hospital-based system protocols that are not specific to their geographical location, patient population or considering the socio-economic status of the patients in that geographical location.

“The patient with a wound who lives in the city with available taxis, Uber, trains and a city bus has different challenges than people who live in more rural environments with no ride to see their health professional,” he elaborates. “Food insecurity and medical drug insecurity play an enormous role in healing and health. You can do an amazing job reconstructing a patient’s foot and leg, but if they don’t have proper nutrition, transportation, or access to lights, food, and water, you, my friend, as the surgeon, are a part of the problem. Medicine and surgery are not health care, part of the process of keeping people healthy is to help them care for themselves.”

He adds that physicians must recognize their own inherent biases, whether implicit or explicit.

“When we do this we are able to become more objective in our approach to the patient’s overall condition rather than treating disease based on data that many times that is biased. An example is heart failure; many of the drugs studied for heart failure had no African American patients involved in the studies, yet prescriptions continued and many were not working. Recently, the American College of Cardiology has published and began to address these inequities (https://www.acc.org/latest-in-cardiology/articles/2020/10/01/11/39/latest-evidence-on-racial-inequities-and-biases-in-advanced-hf). We need to do the same in wound care.” 

Dr. Ogunlana says that health inequities tend to be based on economic indices, affordability and coverage by the insurance company that  the patient is enrolled with. He explains that there is divergence of access to care especially notable in low-income areas. Patients with traditional Medicare or Medicaid, in his experience, may have an easier time obtaining coverage for advanced wound treatments, and even hyperbaric oxygen therapy. However, he goes on to say that he finds other patients in the community with HMOs or Medicare Advantage plans face more difficulties in coverage, with potential delays before completion of prior authorization requests, which are often denied.

Q: What processes or programs does your practice or institution have in place to assist patients who may be underserved or have limited resources?

A:

Dr. Fullwood shares that Northern Light Health actively partners with food banks, local homeless shelters, battered women’s and men’s shelters and other community organizations to help address and advocate for patients. We have developed the equity, inclusion, and diversity council that meets monthly.

“We have even begun to look at physical make-up of our hospitals to make sure people with any physical challenges are safe and can use our health care facilities,” he says.

He continues to say that his organization has made a significant investment in his local community with respect to the opioid epidemic on education, training of staff, and addiction support.   

Dr. Ogunlana relates that his office usually tries to work out payment plans with patients who have limited resources.

“We try to put the patient first in what we do and we try to research companies that may have compassionate resources to help with donations and wound care supplies,” he says. “We use a lot of advanced wound care products on patients that could benefit as such if we have samples available in our office from local company representatives, who are often readily available to assist in these cases.”

He also stresses that his practice also educates patients on the importance of regular, close follow-ups in all specialties to prevent complications. He cites available low-cost primary care clinics or charity medical clinics manned by volunteers, some run by resident doctors, which help such underserved patients get the care they need.

“Our hospital has such programs in place for uninsured patients get their medications refilled and help reduce the frequency of ER visits,” says Dr. Ogunlana.  

Dr. Suzuki shares that his facility has a clinic devoted to the underserved population in the community, and that hospital staff are mandated to supervise these specialty clinics two weeks each year. He relates that remote interpretation video terminals that cover most languages that they encounter helps to overcome challenges in communication.

Q: What process or programs would you like to see in the future to assist these patients?

A: 

Dr. Suzuki says he would like to see the wound care industry provide more pro-bono services and products to underprivileged patients, while universal health coverage is among what Dr. Ogunlana would like to see, to complement private health care insurance.

“The need is great, and a lot of underserved communities have poor health indices due to access to care and resources,” he explains. “Health care should be a human rights issue, in that access to quality, affordable health care should be every citizen's individual right.” 

Dr. Fullwood stresses that podiatrists can be a part of the solution, due to a need for more podiatrists in public health. He also feels there needs to be more podiatrists in leadership positions outside of APMA and ACFAS.

“Our patients living with wounds need representation by all bodies in the house of medicine,” he says. “We need more research that is specific to our practice locations. We need data that is simple and actionable at the local and state levels to fight for changes in our health care delivery systems, health policy and dollars allocated to our patients needs living with chronic diseases that suffer from wounds.”

Q: If you would like, please share an instance of when addressing a health inequity made an impact in your community or for a patient. 

A: 

Dr. Ogunlana shares encountering numerous cases where a limb-threatening, severely infected, gangrenous diabetic foot ulcer would normally have received a recommendation for below-knee amputation, but finding ways to offer advanced treatments to these patients despite lack of coverage made a difference. He relates one patient without insurance that battled a severely infected DFU that progressed to gas gangrene and osteomyelitis. The case required multiple surgeries, advanced biohealing wound care products and moisture control dressings while in the hospital. He says she received six weeks of IV antibiotics, had a two-week hospital stay and weekly office visits and dressing changes for nearly four months.

To contribute to making this possible, Dr. Ogunlana says his practice made a payment plan with the patient based on what she could afford.  He used donations of advanced wound dressings and enrolled her in a study so she could obtain supplies while monitoring clinical progression.

“We published her successful case as an abstract for SAWC Spring and Fall 2021 as a poster presentation with this case highlighting the importance of advanced wound dressings and monitored control in advancing a complex, hard-to-heal wound,” he shares. “So it was a win-win for both. Also, we've also been able to enroll such patients in DFU research studies which sometimes provide the dressings or advanced biologics to help the wounds heal.” 

Dr. Suzuki relates that, as he is in private practice, he uses his discretion in providing free medical services and products to some under-insured patients in his community. He also says he makes referrals to a community free clinic (sabancommunityclinic.org) as needed, as they provide quality medical care, free of charge, all over Los Angeles.

“Unfortunately, we live in a country where health care is a privilege, not a human right,” he says. “Although it is a touchy subject politically, I would like to see universal coverage of health care in the United States as we are the wealthiest and the most powerful nation in the world. Proposed Medicaid expansion and the lowering of the Medicare eligibility age to 60 years old in current legislation is a solid step towards that mission to provide good health care coverage to all Americans.”    

“When I came to the state of Maine, podiatrists could not perform preoperative history and physicals,” shares Dr. Fullwood. “This was a 25-year fight. Patients had to travel to see multiple physicians for clearance, which cost patients money and time away from work. Gary Degen, DPM, President of the Maine Podiatric Medical Association and I, as Vice President, began a grassroots campaign to get this put into a bill and then passed into law. We engaged the APMA, state policy makers, hospital presidents, the Maine Hospital Association and the Maine Medical Association. We showed that this was a public health concern and an issue for which all bodies of medicine and our community had an interest. We got this put into a bill that passed into law for podiatrists and our patients.”   

Dr. Fullwood is President of International Limb Salvage Foundation USA and the Maine Podiatric Medical Association. He practices in Pittsfield, Maine.

Dr. Ogunlana is the Chief of Podiatry at Memorial Hermann Southwest Hospital in Houston, Texas and a Past President of the Harris County Podiatric Medical Association.

Dr. Suzuki is the Medical Director of the Apex Wound Care Clinic in Los Angeles. He is also a member of the attending staff of Cedars-Sinai Medical Center in Los Angeles. He can be reached at Kazu.Suzuki@cshs.org.

Disclaimer: The views and opinions expressed are those of the author(s) and do not necessarily reflect the official policy or position of Podiatry Today or HMP Global, their employees and affiliates. Any content provided by our bloggers or authors are of their opinion and are not intended to malign any religion, ethnic group, club, association, organization, company, individual, anyone or anything.