From the Editor: The Future of Outpatient Wound Care

  The number of hospital-based outpatient wound care centers continues to increase across the US and is driven by increasing patient demand as the population ages and the incidence of diabetes increases. For most hospitals, they have been productive cost centers as well as generating “spin-off” revenue for other hospital departments. We would call that the “good news.” The bad news is that the impending bankruptcy of the Medicare Trust Fund has created an urgent need to deliver more cost effective care, particularly to patients with chronic illnesses such as diabetic foot ulcers and other refractory wounds. Diagnosis related groups (DRGs) effectively “capped” the cost of in-patient care by limiting hospital reimbursement based on the number and severity of diagnoses. In contrast, the “fee-for-service” model of outpatient care has continued to reward both physicians and hospitals based on the volume of services without a feedback mechanism for quality. It seems clear that the model of outpatient reimbursement is going to change in the next few years. The question is, “How will a mechanism be created to better link quality to outcome in wound care”?

  How to measure outcomes in wound care is a challenging question. We instinctively think of healing as the ultimate good outcome, but some patients do not have open wounds in the first place, presenting to us, for example, with a mummified toe. Other patients cannot ever be healed, such as those with progressive or genetic diseases (eg, epidermolysis bullosa). So for many of our patients, limb salvage or preservation of function (eg, ambulation) are better measures of “good” outcomes. And the best measures of quality of care might be whether venous ulcers are put into proper compression, leg ulcer patients get vascular screening, and diabetic foot ulcer patients are properly off-loaded. Ironically, in many cases, coverage policy reimburses poorly (or not at all) for basic, evidence-based care, incentivizing clinicians to provide more costly interventions that may be less likely to succeed in the absence of “the basics.”1 In his article, Dr. Tom Serena discusses the need for us as “wound care experts” to agree on a set of quality measures as we move forward into the brave new world of medical care. Under the Affordable Care Act, the new Center for Medicare and Medicaid Innovation will direct a number of experimental programs in healthcare payment and delivery, but it is still not yet clear just what these programs will look like. The goal would be for hospitals, clinicians and other healthcare entities to collectively take responsibility for patient care, agreeing to provide high quality, patient-centered, evidenced-based care in the hope of reducing the costs incurred by those patients.

  So we asked our readers how they were planning for the future, and in “The Changing Focus of Wound Care,” you can read the results of the poll of clinic leaders. They responded to questions about how their clinics are doing financially, where they are headed, and how they plan to get there. Some plan to add innovative services, but most expect to continue to operate under their current model, although they intend to hire more staff so that they can see more patients. Some of those leaders mentioned the effect of the new debridement codes on their practice. In her “In Business” column, Kathleen Schaum answers questions about implementing the new debridement codes. Few recent coding changes have been as challenging to implement as the changes in debridement coding, and I am sure you will find the answers to some of your own questions in her column. Many of those who answered our poll mentioned specific technologies they hoped to add to their clinics. This month, the subject of “The Clinician’s Report” covers new technology in the clinic. Vendors review the contribution their products make to clinic efficiency and patient care so that you can make a decision regarding whether that technology is right for you, based on the plans you are making for the future.

  As one of our major features tries to “see into the wound care crystal ball,” we asked Susie Seaman to tell us about her wound care practice. For several years, Susie has been living in an outpatient DRG model of wound care. Susie created a wound center for the Sharp Rees-Stealy Medical Group, a multispecialty practice founded in San Diego in 1923. It offers comprehensive patient care “under one roof,” compensated under a capitated model. She discusses the way in which wound care costs can be contained without rationing by delivering quality care using evidence-based guidelines. I think her insights may be the closest we can come to a view of the future of outpatient wound care, even though I am not sure exactly how or when it will arrive for the rest of us. For a different perspective, I asked Jordan Lovy, the Chief Medical Officer for Amerigroup in Texas, to give us insight into the “payers view” of wound care. Amerigroup is a Medicare Health Maintenance Organization (HMO). Some months ago, Dr. Lovy told me that Amerigroup was keenly aware of the high cost of wound care for its members, and felt that the fragmentation of wound care into “silos” (eg, inpatient, outpatient, long term care, home care) made it harder for them to monitor patients and ensure quality. Their challenge as a payer is to find a way to create a “disease management” model for wound care across the continuum, a project that is still ongoing and may be the first of its kind by a major HMO.

  In this issue we have tried to help you prepare for the future of outpatient wound care, but in the end, I can only quote the great Yogi Berra, “It is hard to make predictions, especially about the future.”

  Finally, are you ready for the change to ICD-10? TWC editorial board members Donna Cartwright and Kathleen Schaum will be hosting a one-day ICD-10-CM Coding workshop specifically designed for wound care professionals. The workshop will be held the day before the SAWC Fall. For more information, visit https://www.icd10codingworkshop.com.

Reference

1. Fife CE, Carter MJ, Walker D. Why is it so hard to do the right thing in wound care? Wound Rep Reg. 2010;18(2):154–158.

Caroline Fife, Co-editor of Today’s Wound Clinic, cfife@intellicure.com