From the Editor

“What experience and history teach is this — that nations and governments have never learned anything from history, or acted upon any lessons they might have drawn from it.” - Georg Wilhelm Friedrich Hegel, Lectures on the Philosophy of History

In 1998, I was one month into a two-year term as the president of the Undersea and Hyperbaric Medical Society (UHMS) when I learned the Health Care Financing Administration (HCFA) had decided to reduce the facility reimbursement rate for hyperbaric oxygen therapy (HBOT) from $375 to $174. This dramatic downward adjustment was the result of a calculation error using the respiratory therapy cost report for hyperbaric services. Such a reduction would have almost certainly meant an end to the field of hyperbaric medicine. It was narrowly averted after a hastily launched national survey demonstrated the calculations were incorrect. Only weeks after that crisis was resolved, HCFA released a new HBOT coverage policy eliminating the HBOT indication we used to call “preparation for skin graft,” which allowed HBOT treatment for hypoxic wounds. HCFA informed me that even though patients had been treated for this indication since 1977, hyperbaric physicians had “misinterpreted” the language of the original coverage policy, retroactively making the treatment of these patients improper. The late Dr. Robert Warriner, III, and I spent two years in discussion with the Coverage Policy Group (of what later became the Centers for Medicare & Medicaid Services [CMS]) and eventually — and narrowly — managed to secure Medicare coverage for Wagner Grade III diabetic foot ulcers (DFUs). However, nondiabetic ischemic foot ulcers could no longer be treated with HBOT. At the time they issued the DFU coverage policy, they told us verbally they were going to be “watching to see how well we abided by the coverage language.”  

At the same time the new coverage policy was released in 1999, HCFA proposed to reduce the reimbursement rate for physician supervision of hyperbaric therapy (99183) to $0.00, using the logic that “no work was performed by physicians supervising hyperbaric treatments, so no payment was needed.” In fact, HCFA actually published in the Federal Register a Current Procedural Terminology code for hyperbaric therapy without a physician in attendance. Only after exhaustive work on the part of the UHMS to define and explain the role of the hyperbaric physician was the payment rate for code 99183 reinstated.

At exactly the same time, the Office of Inspector General (OIG) launched an investigation into the pattern of use of HBOT. At our initial meeting with the OIG, it seemed very clear the problem officials had uncovered was the use of topical oxygen therapy being fraudulently billed as HBOT. Once we pointed out the confusion, we thought the matter had been effectively resolved. However, because HCFA had decided “preparation for skin graft” was a misinterpretation of the coverage policy and thus physicians were using HBOT improperly, the OIG expanded its investigation from topical oxygen to the use of HBOT for wounds. From that point on, OIG representatives were silently present in the room each time Dr. Warriner and I met with CMS coverage policy officials. The OIG reviewed hundreds of charts from patients undergoing HBOT and, in October 2000, published its report Hyperbaric Oxygen Therapy, Its Use and Appropriateness (https://oig.hhs.gov/oei/reports/oei-06-99-00090.pdf). The OIG concluded $14.2 million (of the $49.9 million allowed charges for outpatient hospitals and physicians) was paid in error for hyperbaric treatments. Officials further determined 37% of patients received “questionable quality care” due to either lack of appropriate testing prior to initiation of HBOT or insufficient progress documented to justify continuation of therapy. OIG medical reviewers determined more than 25% of beneficiaries had no documented physician oversight of their treatments and 44% did not have a physician in attendance at their treatments. Thus, exactly 15 years ago this past October, the OIG recommended CMS: 1) initiate its national coverage decision process for HBOT, 2) improve policy guidance for physicians (eg, practice guidelines and physician attendance policy), and 3) improve Medicare contractor oversight (requiring contractors to initiate edits and consistent medical review procedures).

I had a psychiatry professor in medical school who used to say, “You aren’t paranoid if they really are after you.” In the two years that I served as president of UHMS, the HCFA: 1) tried to reduce hospital payment for hyperbaric services by 75%, 2) tried to end physician payment for hyperbaric treatment supervision entirely, 3) successfully eliminated coverage policy for the most commonly used HBOT indication at the time, and 4) initiated an OIG investigation of billed hyperbaric services. In 2000, the OIG effectively promised there would be a new national coverage policy for HBOT, standards for physician attendance, and enhanced oversight by Medicare Administrative Contractors. At the conclusion of what had been the two worst years of my life, I wrote an editorial in Pressure, the UHMS newsletter, warning membership we had only gotten a temporary reprieve and it was only a matter of time before we had to fight these battles again. There was a 15-year period during which the hyperbaric medical community could have saved itself. We could have ensured the issues the OIG cited in its year 2000 report were never again observed. We could have developed careful standards for patient management prior to initiating HBOT. We could have used registries to demonstrate the effectiveness of HBOT in the real world among patients for whom no other good alternative therapies existed. But, that’s not what happened.

CMS has only blunt tools with which to rein in the improper use and the overuse of technology. Draconian methods have now been put into place to stop the use of HBOT. It isn’t possible to stop only the improper use. The methods they have put in place are going to hurt the patients who need and could benefit from HBOT, and there is no way to walk these measures back. For me, it’s Groundhog Day. This time, the first effort was to cut physician reimbursement by decreasing the work component of the relative value unit for chamber supervision (99183). Does that sound familiar? Thanks to a Herculean effort by Helen Gelly, MD, FACCWS, UHM/ABPM, FUHM, and data from the US Wound Registry, a dramatic cut in physician reimbursement for 99183 was avoided this year, but the rest of the year 2000 playbook has been put into action and is the topic of articles in this issue of Today’s Wound Clinic as well as recent editions. A prior authorization pilot program for HBOT appears to be failing to authorize 80% of HBOT services and has a post-payment review process that is Kafkaesque in its methods and nearly perfect in its ability to deny payment for hyperbaric treatment already provided (not to mention prepayment reviews; see page 12). Also on the horizon is the complete restructuring of outpatient payments, bundled or capitated payments, or even a site-of-service adjustment that could end the outpatient wound clinic as we know it. What experience and history teach us is that physicians and medical organizations have never learned anything from history or acted upon any lessons they might have drawn from it. It’s too late now. I told you so.