Outpatient Wound Care in a Capitated Environment: Quality Care for the Patient and an Ideal Practice for the Wound Specialist

  Back in 2006, after practicing in a hospital-based outpatient wound clinic that I had founded eight years before, I was ready for a new challenge and a new setting. I was frustrated by working in a system with a tightening budget, where I perceived that there was pressure on quantity and not quality, and this led me to look for other practice options. I knew I wanted to still work in wound care, in an outpatient setting. But where could I go? Work in another hospital? Maybe get a job in a physician practice, like plastic or vascular surgery? As I looked around, my partner, Patti Cheney, NP, told me that a surgeon from a large local medical group, Sharp Rees-Stealy Medical Group (SRSMG), had mentioned to her that he wished they had some kind of coordinated wound program. He said that their patients with wounds were treated in many different settings: surgical, podiatric, and primary care offices, as well as physical therapy. Some patients were actually referred to our hospital-based wound clinic, and everyone treated the wounds differently. He wondered if Patti was interested in setting up a program at SRSMG. She said she wasn’t, but she knew someone that probably was: me!

  The idea of setting up a wound clinic for SRSMG intrigued me. I had actually set up a small wound clinic 10 years before for Sharp Mission Park Medical Group (now Scripps Coastal) in north San Diego County. I had run this small clinic 1-2 days a week for this 70-physician primary care group for a few years, then left to start the hospital-based clinic, and now was back with them 2 days a week (as I was decreasing my hours at the hospital). I absolutely loved the camaraderie and collaboration of working in this practice, set in a medical office building, on a floor with internal medicine and family practice (although they sometimes complained about the odors from the wound clinic!). But it was a 40-mile commute, and I did not like to drive, so the thought of setting up a similar program for a local group sounded great. I collected more information about SRSMG (see box), liked what I saw, and started making phone calls and sending emails to people at SRSMG.

  It took several months, but I was finally invited to a meeting at SRSMG to discuss wound care there. It was apparent that the group saw chronic wounds as a problem, with high morbidity and cost for them and their patients, and there was concern that without standardization, there was a potential for fragmented care by multiple providers. I learned that SRSMG was all about creating a Patient Centered Medical Home, in which each patient had a primary care physician and was provided integrated, coordinated care that focused on the whole patient. They preferred all care, if possible, to be rendered within SRSMG, so they were not enthusiastic about referring to outside wound clinics or to other services if it could be provided in-house. They were very interested in the idea of their own wound clinic. Over the next six months, we worked together to get the entire team of physicians on board with the idea, developed a staffing plan, found some space for the clinic, ordered equipment, and wrote wound-specific nurse practitioner (NP) protocols. Along the way, I was impressed at SRSMG’s “can-do” attitude and found that as long as I justified why I needed something (like those $8000 exam chairs), I got what I wanted for the clinic. In addition, my expertise was trusted, and while most providers at SRSMG had one nurse/medical assistant and two exam rooms, when I explained why I needed two licensed nurses and at least three exam rooms in a wound clinic, I was given what I needed. This was very different than my hospital experience, in which the red tape could be quite overwhelming, and the words “can’t do it” were more likely to be heard. Another positive: SRSMG understood and respected what a specialized NP could contribute to the group, which was very unlike my hospital experience. After much planning and hard work, we were ready to take in referrals.

  My medical director, a foot and ankle orthopedic surgeon, sent out an introductory email to the group regarding the new wound clinic with information on how to send patients to us (“us” initially consisted of me, one nurse and a part-time physical therapist). The wound clinic staff now consists of two nurse practitioners, one registered nurse, one licensed vocational nurse, a patient services representative, and a physical therapist that is available for contact casting. We are located on the same floor as general and vascular surgery, which we work very closely with, our vascular lab, internal medicine, and family practice. I thoroughly enjoy the team environment and appreciate the give and take as I review a case with the vascular surgeon, or he asks me to come look at a patient with a challenging wound. The internal medicine doctors are wonderful at supporting me when I have questions regarding medication management in patients with multiple comorbidities.

  We are capitated for the majority of our patients. What does that mean? It means that for workers who have HMOs and for seniors who have signed up for Medicare HMOs, we are paid a fee per member, per month by the many health plans that we contract with. For the HMO seniors, the monthly payment is based on the patient’s diagnoses; for instance, we will be paid a higher monthly fee for a patient with diabetes and peripheral arterial disease than we will be paid for a healthy senior. This makes sense, as the care for the senior with multiple comorbidities is more expensive. This monthly payment does depend on our documentation of our assessment of the patient, and subsequent ICD-9 coding of these extra diagnoses. But the bottom line is that, once we are paid, the money is the group’s to manage.

  As a wound care clinician, I have found that this model has freed me to give the best care that each individual patient needs. For example, there is no pressure to perform billable procedures as there might be in a fee-for-service environment. On the other hand, just because a new technology has a reimbursable CPT code, we will not use that technology unless there is reliable data that its use is efficacious and will benefit our patients. So, do we use expensive living skin equivalents? Absolutely, but only for the approved indications, in which randomized controlled studies have shown efficacy. Do we use some of the expensive porcine-based products? Not yet, not until there is good data to support their use in chronic wound care. I will not go to Utilization Management (UM) with a new product to use unless I have the scientific data to support that use. For me, this takes any ambiguity out of what to use in patient care. Again, it does not matter if hospital-based wound clinics are billing for a certain product (and maybe generating revenue)—that is not what is important in my environment. It is the data that drives the decisions regarding patient care.

  Another example of a potential difference between a fee-for-service environment and a capitated environment involves every day basic care. Take the use of an Unna boot for a patient with an acute wound on an edematous leg. In a fee-for-service setting, the clinician will only be paid for applying that Unna boot if the wound is diagnosed as a venous ulcer or a chronic ulcer. What if an elderly person presents to you (or your hospital’s urgent care/ER) with a severe avulsion injury on the leg that was sustained the day before and they have chronic edema from being sedentary and having a bit of CHF? You cannot really call this a chronic ulcer; it is an acute wound. But you know that the wound will most likely have delayed healing due to the edema, so the patient’s leg needs to be compressed. But if you apply an Unna boot, you will not be reimbursed by insurance for it. And to make matters worse, the patient lives alone, has no family, and cannot bend over to put on a stocking or ace wrap. And the patient is not home bound, so they do not qualify for home care. You will still offer the Unna boot to the patient, explain why they need it, but in most cases, as soon as you tell the patient that the charge is for the Unna boot and that it is not covered by insurance, they will refuse it. What is really sad in this scenario is that once the wound has not healed within 3-4 weeks, you can then diagnosis it as a chronic ulcer and get reimbursed for the Unna boot. But the patient then has delayed care. In a capitated environment, I can put that patient in an Unna boot right away. It is one of the supplies that I have in my clinic, and I do not worry about the cost of it. If that is what my patient needs, then my goal is to provide the best care possible without worrying about whether or not I will get paid (I am already paid monthly, remember?). So I can start appropriate care immediately, regardless of the acute diagnosis.

  In addition to being able to provide appropriate care in a timely manner, the process of ordering supplies and durable medical equipment is seamless compared to my previous experience in a hospital-based program. In the hospital-based clinic, ordering supplies for Medicare patients is simple, but I found that ordering for the different HMOs that the hospital contracted with to be a hassle. The referral might have to come from the primary care provider (requiring multiple phone calls); different HMOs may use different suppliers, etc. SRSMG contracts with certain providers for beds, mattresses, overlays, diabetic shoes and insoles, and compression stockings, among others. All I have to do is write a prescription and my staff inputs the referral in the computer, where it goes to UM, and we usually get authorization within days, a week at most. UM follows each member’s health plan rules to determine coverage. For most equipment, the coverage is similar to what a hospital-based program would encounter. For example, for Medicare HMO seniors, the HMO follows Medicare guidelines regarding coverage (eg, 30-40 mm Hg compression stockings are covered for venous ulcers, low air loss mattress for Stage 3-4 pressure ulcers). At any time, the wound clinic staff can easily check the computer for the status of the authorization. Once approved, the staff faxes the prescription to the supplier, who has already gotten authorization as well. For dressings, we use our central pharmacy for dressing supplies, which do not require authorization. We fax what the patient needs on a pre-printed form and the patient is shipped the dressings, sometimes by the next day. No need to deal with multiple HMOs for approval; our UM department handles it all.

  Perhaps the only challenge I face in my capitated setting involves copays for the use of more expensive technology, such as living skin equivalents, low air loss beds, or arterial compression pumps. In a fee-for-service environment, if patients have Medicare and a secondary insurance, they will most likely not have any out of pocket expenses for these products. However, patients who enroll in HMOs have copays, and the copay for many technologies/equipment is 15-20%. Many of these patients do not have secondary insurance, so even if they meet criteria for something like a living skin equivalent, in many instances, the patient is unwilling to pay the co-pay on the supply charge.

  Despite the latter challenge with copays, I have found that there are many more advantages of running a wound clinic for a large medical group in which capitation drives reimbursement. As in any business, SRSMG strives to be sustainable and profitable. In today’s healthcare environment, providing excellence in patient care has many financial rewards. SRSMG is involved in California’s Pay for Performance (P4P) Initiative, in which medical groups are awarded quality bonuses by a group of participating health plans for achieving targets in clinical care, patient experience, meaningful use of health information technology, and appropriate resource use. SRSMG has been recognized as a top performer in this program for the past five years, and most recently, scored in the 90th percentile on patients’ overall rating of their care. Achieving our targets has resulted in significant financial awards for the medical group, and our patients are happy and well cared for. Having a wound clinic has also helped SRSMG reach P4P goals. Jerry Penso, MD, MBA, Medical Director, Continuum of Care states,

   “The wound clinic clearly helps SRSMG achieve top performance in Pay for Performance in many ways. First, patients with diabetes are identified and referred to diabetes care managers to assure optimal management of blood sugars, lipids, and blood pressure. In addition, the wound clinic helps manage transitions of care from inpatient to outpatient, which reduce readmissions, emergency room visits, and inpatient length of stay. We also assist in ensuring that home healthcare utilization is reserved for patients who are medically homebound; non-homebound patients with wounds come to the wound clinic instead.”

  Further potential for revenue exists from the federal government. SRSMG is on top of making sure we meet the criteria for any federal money related to meaningful use of health information technology. We have a fully functional EMR, with computers in each exam room, in which we can access all notes, labs, hospitalization records, etc, and on which we can send “tasks” between providers and staff to facilitate rapid collaboration and communication. We also prescribe electronically, which maintains an accurate record of medications that patients are on. As healthcare changes, many more providers may find that they are no longer paid for what they do, but how well they do it. Capitation is just the first step in this process. Although the prospect of “managing your money” may sound daunting to some, I have found it to be empowering in that I can give better care, providing for what patients need, in a highly collaborative team environment. Wound care clinicians may want to consider the large medical group setting as an excellent place to set up a wound clinic.