Guest Editorial: Working in the 2017 Parallel Payment System

I am truly honored to serve as the guest editor for this special reimbursement issue that begins the official 10th anniversary celebration of Today’s Wound Clinic (TWC). I hope you all have enjoyed learning from the wonderful authors and board members who have contributed to this real-life wound care clinic journal over these past 10 years. We have all enjoyed sharing our knowledge with you! When milestones like this are reached, nostalgia typically sets in. In fact, I recently felt compelled to retrieve the first issue of TWC from my personal library. Reimbursement concerns back then were considerably different than they are today. In 2007, wound care professionals were worried with: 1) opening a new, hospital-based outpatient department (HOPD), with only one month’s notice from administrators; 2) receiving financial reports about the department; 3) billing for clinic visits when procedures were performed; 4) understanding why many claims were denied; 5) adding wound care procedures and products to the Charge Description Master; 6) allowing patients to bring surgical dressings purchased from durable medical equipment suppliers and intended for use at home into the HOPD; 7) billing for surgical debridement when medical debridement was performed; 8) repaying Medicare for incorrectly billing multilayer compression bandages with the Unna’s boot code; 9) justifying medical necessity for various wound care products ordered for patients’ use at home; and 10) billing the same clinic visit level as the physician’s evaluation-and-management level. These 2007 reimbursement concerns helped me understand why payers describe the United States healthcare system as “volume driven.”  

Our first clinical editors, Caroline E. Fife, MD, FAAFP, CWS, FUHM, and Dot Weir, RN, CWON, CWS, wrote the lead feature article in that first issue: “Getting Started: The Tools You Need to Take Your Hospital-based Wound Clinic from Concept to Care.” Therefore, I thought it was proper and fitting to invite both of them to share their viewpoints about reimbursement issues facing wound care professionals in 2017 for this edition of the journal. When you read their articles, you’ll notice the reimbursement concerns are in stark contrast to what they were in 2007. Dot and Lee Ruotsi, MD, FACCWS, UHM, share a physician’s and an HOPD’s perspective about the “need to see our practices and HOPDs as cost centers rather than revenue centers”. Dr. Ruotsi emphasizes the need for wound care professionals to understand the Institute for Healthcare Improvement’s Triple Aim initiative for better population health, improved patient experience, and lower total cost of care. He reminds us that we need to select the right product/procedure for the right patient at the right time in order to meet the Triple Aim’s goals. He concludes by reminding wound care physicians that their future payment bonuses will be based on providing quality work that aligns with quality metrics. In this same article, Dot explains how life is no longer “simple” in HOPDs. Products that used to be paid separately are now packaged and paid as part of the procedure. Payers are limiting the number of wound care procedures they are willing to reimburse. Like Dr. Ruotsi, Dot also emphasizes that payment is starting to be based on “doing the right thing at the right time for the right patient” while verifying the quality of wound care work. She then eloquently describes how HOPDs must partner with physicians and other qualified healthcare professionals (QHPs) to “assure that quality care can be quantified by wound care-specific quality measures.” 

Dr. Fife shares a two-part article “Thoughts From the Eye of the Healthcare Storm.” In Part 1, she shares the role of various wound care professionals and various sites of care in reporting wound care-specific quality measures. She reminds us that the Centers for Medicare & Medicaid Services intends to reward “better” care rather than “more” care. Dr. Fife also reminds wound care practitioners that it’s vital to report the same wound care quality measures in order to compare their performances against the aggregate. She clearly describes how HOPDs, skilled-nursing facilities, nursing homes, home health agencies, physicians, and other QHPs report quality. Dr. Fife makes it abundantly clear that very few existing quality measures pertain to wound care. She does a fabulous job of reminding all wound care professionals that, regardless of which electronic health record being utilized, everyone can report their care to a registry (eg, the U.S. Wound Registry (USWR). Many wound care professionals will be surprised to learn that the USWR sponsors several specialty wound care registries. Through these registries, wound care professionals will be able to prove the quality of their wound care work — even when payers do not have wound care quality measures. In Part 2 of her article, Dr. Fife describes how wound care physicians and other QHPs can (and should) participate in the new Medicare Quality Payment Program (QPP) via one of two tracks: the Merit-Based Incentive Payment System (MIPS) or Advanced Alternative Payment Models. Readers may be surprised to learn that reporting quality through a qualified clinical data registry (eg, the USWR) may provide “bonus points” in all categories of the 2017 MIPS. I highly recommend taking the time to read this awesome explanation of the new QPP. 

In my Business Briefs column, I remind all readers that you are now receiving and will continue to receive payment for your wound care services via two parallel reimbursement systems: one based on volume (but the allowable rates will continue to shrink), and one based on value (the bonus amounts will continue to increase). Therefore, wound care professionals must continue to properly document, code, and bill. They also must develop expertise in coordinating wound care across the continuum. Finally, several wound care manufacturers and management companies graciously share in this edition how their business models are also changing to exist in both a “volume-driven” and “value-driven” reimbursement system. I’m sure you will agree that, when you finish reading all the insightful articles in this special 10th anniversary reimbursement issue, the 2017 reimbursement concerns are vastly different than those in 2007. You can count on me and TWC to continue educating you all about the reimbursement changes in this parallel payment system. 

Kathleen D. Schaum, MS, is president and founder of  Kathleen D. Schaum & Associates Inc., Lake Worth, FL; and director, medical products, reimbursement, at  Smith & Nephew, Fort Worth, TX.