The Evolving Landscape of Healthcare Reform: Impacts on Wound Care

  In this dynamic post-reform healthcare climate, wound care clinicians must understand the implications of the Patient Protection and Affordable Care Act of 2010 (PPACA) and other reform programs on their practice. As an interdisciplinary treatment that is provided within essentially all settings throughout the care continuum, wound care is and will continue to experience far-reaching effects of healthcare reform not only in terms of the provider community but also the patient population.   Many notable provisions of the PPACA have already taken hold and have produced a major impact on the US healthcare system, such as those related to a small-business health insurance tax credit, high-risk pools, and mandated coverage by insurers. Arguably, the cornerstone provisions of the history-making law become effective in 2014 with the creation of health insurance exchanges, the expansion of Medicaid, and individual and employer mandates.   From a provider perspective, the federal healthcare reform agenda can be broken down into three key areas: innovative practice models, quality measurement, and outcomes and healthcare expansion. It is through each of these areas that the Department of Health and Human Services is meeting the goals of the Center for Medicare & Medicaid Services’ (CMS) Triple Aim Initiative, which seeks to improve care and outcomes for individuals and patient populations while lowering growth in expenditures.   This article will discuss the role of wound care providers within similarly emerging collaborative-care models, the evolution of quality measurement under the PPACA, and the effects on wound care providers commensurate with the expansion of coverage provisions such as Medicaid expansion and essential health benefits brought about by reform.

Innovative Practice Models

  The integration of healthcare providers such as wound care clinicians into one entity that provides seamless care and is incentivized to streamline processes, reduce redundancies, and increase efficiencies are the basic tenets behind the three emerging models of care: accountable care organizations (ACOs), bundled payment models, and patient-centered medical homes (PCMHs).   The main vehicles for ACOs are the establishment of Medicare’s Shared Savings Program and the Pioneer ACO model managed by the Center for Medicare & Medicaid (CMS) Innovation (CMMI). ACOs are networks of physicians, hospitals, physical therapists, and other providers that are encouraged and incentivized to work together to provide quality care and achieve savings within Medicare fee-for-service. In order to achieve success, ACO providers must coordinate care for a defined patient population and meet certain quality metrics that include patient/caregiver experience, care coordination/patient safety, preventive health, and at-risk populations and frail/elderly health. (For an exclusive Today’s Wound Clinic Q&A with a physician participating in the Pioneer ACO, see page 19.)   The eligible providers who form ACOs are physicians, hospitals, networks of individual practices, partnerships, joints ventures between physicians and hospitals, critical access hospitals, rural health clinics, and federally qualified health centers. All other providers such as PTs in private practice, home health agencies, skilled-nursing facilities (SNFs), outpatient rehabilitation facilities, and comprehensive rehabilitation facilities are eligible to participate in an ACO but cannot form ACOs on their own, as the statute explicitly lists only the eligible providers aforementioned as those who can form ACOs as a singular provider. These providers and suppliers must form contractual relationships with ACOs that define the scope and duration of their involvement and their applicable percentage of shared savings to be derived at the end of each ACO performing year over a three-year contractual obligation.   According to CMS, 343 ACOs are currently operating through the Shared Savings Program in 47 states plus the District of Columbia and Puerto Rico. More than half are physician-led and serve fewer than 10,000 beneficiaries while 20% include a community health center, rural health clinic, or critical access hospital.   While ACOs are responsible for the comprehensive care of a defined patient population, PCMHs are keenly focused on improving primary care. The American Academy of Family Practitioners defines a PCMH as a patient-centered comprehensive system that provides an ongoing, active partnership with a personal primary care physician who leads a team of professionals dedicated to providing proactive, preventive, and chronic care management through all stages of life. Many of the resources in the PCMH have been focused on the state level, as state entities have been provided grants through PPACA to create medical homes based on unique state constituency needs. PCMHs have shown great promise to achieve outcomes among pediatric and Medicaid populations.   To specifically address cost containment, PPACA mandated the pilot testing of bundled payments, which represent single payments made for a defined group of services that may cover services furnished by a single entity or items and services furnished by several providers among multiple care-delivery settings. Bundled payments may be conducted for a single negotiated episode payment of a predetermined amount for all services paid prospectively or retrospectively.   In order to carry out the bundled payment mandate, CMMI launched its Bundled Payments for Care Improvement Initiative in January 2013 for organizations to volunteer to enter into payment arrangements that include financial and performance accountability for episodes of care in four different models.   Under model No. 1, the episode of care is defined as the inpatient stay in the acute care hospital. Medicare will pay the hospital a discounted amount based on the payment rates established under the Inpatient Prospective Payment System used in the original Medicare program. Medicare will continue to pay physicians separately for their services under the Medicare Physician Fee Schedule.   In model No. 2, the episode of care will include the inpatient stay in the acute care hospital and all related services during the episode. The episode will end 30, 60, or 90 days after hospital discharge.   For model No. 3, the episode of care will be triggered by an acute care hospital stay and will begin at initiation of post-acute care services with a participating SNF, inpatient rehabilitation facility, long-term care (LTC) hospital, or home health agency. The post-acute care services included in the episode must begin within 30 days of discharge from the inpatient stay and will end either a minimum of 30, 60, or 90 days after the initiation of the episode.   With model No. 4, CMS will make a single, prospectively determined bundled payment to the hospital encompassing all services furnished during the inpatient stay by the hospital, physicians, and other practitioners. Physicians and other practitioners will submit “no-pay” claims to Medicare and will be paid by the hospital out of the bundled payment. Related readmissions for 30 days after hospital discharge will be included in the bundled payment amount.   Each model allows participants to select up to 48 different clinical condition episodes. If the pilot project is deemed successful, such payment bundling practices can be extended and made permanent.

Quality Measurement & Outcomes

  The second major theme of the PPACA is linking payment to quality. Over the past several years, CMS (along with the quality community, namely the National Quality Forum) has worked to create consensus-based process, structural, and outcomes measures that assess the impact of specific interventions on patient care across the continuum. These programs are referred to as pay-for-performance in the Medicare outpatient setting while value-based purchasing is the correct nomenclature in the post-acute care arena. In the past, these programs have merely sought to achieve accurate and consistent reporting, but in this era of reform, CMS has moved from quality reporting to basing payment on the data collected.   This is especially true among the new innovative models such as ACOs and bundled payment. Both initiatives are specifically linked to a set of quality indicators that measure the success of these models on patient care. If better outcomes are achieved at a lower cost, providers are incentivized to continue this behavior by being awarded bonus payments from the derived savings.   Of particular interest to wound care clinicians is the standardization of readmissions and pressure ulcer measures in the acute care and inpatient rehabilitation facilities. Wound care complications play key roles in hospital readmissions. Therefore, hospitals are relying heavily on wound care clinicians to ensure that quality care is provided to avoid costly conditions associated with pressure ulcers and other wounds. Medicare payment reductions were estimated to impact 1,400 hospitals in fiscal year (FY) 2013 and more than 2,200 acute care hospitals in FY 2014 by as much as 5% for each Medicare claim.

Healthcare Expansion

  The Medicaid program has transformed from a welfare benefit program to a complex system of care that plays three main roles: providing health insurance to more than 52 million individuals (including 25 million children) who otherwise would be uninsured, covering LTC services to Medicare recipients and lower- and middle-income families, and providing subsidies to safety net providers.   Per the Supreme Court case, National Federation of Independent Business v. Sebelius, state Medicaid programs have the option of expanding coverage to nearly all people younger than age 65 with incomes of $14,856 per year for individuals and $30,657 per year for a family of four based on federal the poverty level for 2012. A few states have obtained waivers from CMS to cover populations whose incomes are well above these levels. The reality, however, is that most states do not offer such coverage, as they are struggling financially to cover the minimum populations mandated by federal law.   In addition, the PPACA required most US citizens and legal residents to have health insurance by 2014. Tax credits and subsidies will be available to help people obtain coverage, but individuals who lack health insurance will be subject to penalties. To purchase health insurance, individuals can go to state-based exchanges or federally facilitated exchanges, depending on their state. Through these exchanges, individuals and small employers can buy insurance through private insurers or multi-state health plans.   The “essential” health benefits that must be included in the plans offered within the exchange and Medicaid expansion must contain ambulatory patient services; emergency services; hospitalization; maternity and newborn care; mental health and substance use disorder services including behavioral health treatment; prescription drugs; rehabilitative and habilitative services and devices; laboratory services; preventive and wellness services and chronic disease management; and pediatric services including oral and vision care. Wound care may be covered under a number of the “essential health benefits” such as ambulatory patient services, rehabilitative care, hospitalization, preventive and wellness, and chronic disease management.   There are several opportunities for the wound care community to play a pivotal role in healthcare reform. The initiatives discussed here are just a sampling of the prime areas in which access to quality wound care can impact outcomes, improve population health, and decrease costs. It is imperative that wound care clinicians actively seek out opportunities to show the value of their services as part of the interdisciplinary team by collecting and disseminating meaningful data through clinical data registries and other quality-measurement initiatives. Roshunda Drummond-Dye is director of regulatory affairs in the public policy, practice and professional affairs unit with the American Physical Therapy Association, Alexandria, VA.