Wound Care During The Economic Downturn: How To Stop The Bleeding

  Part 1: The case for developing better strategies for managing uninsured patients

  It is 2:30 in the afternoon, the clinic has been busy and you’ve just seen the 20th patient. One of the assistants comes back to the exam room to let you know that a “Mrs. K” just checked in and is sitting in the waiting room with her foot wrapped in a plastic garbage bag. You’re thinking, ‘This is not going to be good.’ Meanwhile, a community podiatrist calls in asking for help with a patient who has uncontrolled weepy edema; she sits on the couch with her feet in an inflatable kiddy pool to catch the drainage and wraps paper towels around her legs held on with masking tape.

  Lately you’ve heard this story with increasing frequency; a growing sense of frustration and fatigue settles in. You realize that the reason why Mrs. K waited so long is because she doesn’t have adequate insurance and will now probably end up being an admission. You also realize that under most policies, the out of control lymphedema patient’s insurance does not sufficiently reimburse to cover the most effective treatments. Your clinic manager hovers over the scene, reminding you of the need to manage “the bottom line” which limits what you can do to provide comprehensive care to this patient population. As a dedicated healthcare provider you are overwhelmed with the thought of the patients who for lack of resources, don’t come in at all, and are home putting everything from alum to veterinary products on their wounds. In quieter moments, you wonder how to reconcile the inherent ethical dissonance of meeting economic demands imposed by the business side of health care in terms of the larger ‘social contract’ which acknowledges that we all share in a certain moral responsibility for plight of our fellow human beings.

  The burden of caring for the nation’s uninsured and underinsured population represents a growing challenge to managers of wound clinics, patients, their families and the providers treating these patients. Patients who are obese with poor peripheral vascular circulation exacerbated by diabetes, or those with other systemic medical conditions have an impaired potential for healing. Healthy people do not typically develop chronic wounds so when someone presents with a non-healing lesion, we’re likely to be working against a gradient of co-morbidities. It always has been a challenge to figure out how to deliver advanced wound care to an increasingly frail and medically complex population. The economic downturn resulting from job loss, home foreclosures and tightening of credit markets finds an increasing number of people unable to access the healthcare system, or they may do so at such a late stage what might have been resolved as a localized problem, advances to the stage of a systemic crisis.

  Reimbursement for wound care even for the insured patient represents a dilemma in the wound clinic since many of the advanced technologies have not passed the rigor of cost effectiveness studies compared to standard of care necessary to comply with insurance company’s criteria to qualify for coverage and an incremental payment. Even if the patient does have sufficient resources to access a wound care clinic and they finally achieve closure, these patients are not really ‘out of the woods.’ Since our current U. S. reimbursement system is focused on episodic care, it is expected that when a patient’s wound is finally considered closed, he or she will be discharged from care. This occurs despite the fact wound care providers agree many patients have a high “bounce-back” potential manifested by recurrent wounds and repeat infections often accompanied by various other complications.

  Reimbursement coverage policies that follow The Center for Medicare and Medicaid Services (CMS) coverage guidelines create economic pressures which recommend these patients be discharged back to the community without routine ‘well-check’ wound care visits. Secondary and tertiary preventative wound care visits are not yet an integral part of our care delivery system and so are not financially supported to optimize prevention efforts. The ‘system’ typically ‘assumes’ that monitoring will occur at the primary care level if the patient is under the care of a healthcare provider. The inherent difficulty with this assumption is that primary care clinics are not set up to check on wound care oriented preventative issues such as effectiveness of off-loading and compression strategies. Adequate instruction in evidence based prevention and management of chronic wounds has yet to be widely taught by our medical and nursing educational systems. Developing treatment choices for patients who can ill afford additional out of pocket expenses adds to the healthcare providers’ stress in the clinical decision making process. The Department of Internal Medicine, Yale University School of Medicine, conducted a study to determine the effect a patient’s socioeconomic status (SES) had on physician clinical decision making regarding the care choices they recommended to patients. Results of the study indicated that a patient’s SES did influence the physician’s decision regarding clinical management. The physicians commonly undertook changes to their management plan in an effort to enhance patient outcomes, but they experienced numerous strains when trying to balance what they believed was financially feasible for the patient with what they perceived as established standards of care.⁵

  One might posit that this occurs because we have yet to embrace the care delivery model where ‘total cost of care across the patient continuum’ is considered more significant than the cost of a given episode of care as is the case in other systems such as the U.K. While visiting the U.K. K. a few years ago, it was explained to this writer that it was more cost effective to send a van around and pick up elders with a history of Venous Leg Ulcers (VLU) s and bring them to clinic every six months to make sure stockings fit properly and no other problems were developing. To enhance social support, efforts were made to schedule patients for re-checks who had originally started treatment together with opportunities for group education.

  Change however, is in the air. With 64% of the U.S. population obese and 7.8% having diagnosed or undiagnosed diabetes the uninsured and underinsured patient population presents financial risk to our medical institutions that would best be treated proactively.^1,2

  As a nation we are coming to terms with the reality that something must be done to expand access to appropriate care while controlling costs. Wound care providers are in an ideal position to demonstrate the benefits of a total cost of care model and with it, the economic and clinical benefits of expert wound care provided in the context of a chronic disease model where there is integral long-term follow up. We are also in an excellent position as part of the treatment team, to refer patients for early medical intervention. For example, when edema increases and a wound deteriorates, we often are among the first to recognize that the process may be heralding exacerbation of a systemic issue that with prompt medical management, a costly crisis may be averted.

  To illustrate the significance of these points, consider the incidence of the problem by considering that approximately 1-3% of the nation’s uninsured or underinsured population suffer from VLUs.² These patients often have complex co-morbidities and when they try to treat a VLU on their own, they are likely to present to the emergency department at 2:00 a.m. with recurrent severe infections that may lead to sepsis, progressing to possible organ failure. The recurrent inpatient admissions tend to be very costly, of long duration, with little to no prospect of payment for the physician’s work or the medical supplies, drugs and personnel cost incurred by the treating facility. The economic burden is only one aspect of this crisis. Costs in terms of human suffering and the concomitant ethical dissonance created by the need to deny care or access to care through financial ‘gate-keeping’ is borne by our society as a whole and impacts the clinic environment on a daily basis. Dismal as this scenario may sound, there are strategies being developed to mitigate the short term effects of the current economic environment and create a less dysfunctional system for the future. A proactive approach designed to better assess a facilities risk of managing these patients coupled with a focused community outreach program may aid improved health of the community and promote financially favorable referrals to the wound clinic thus improving access to care. Based upon the observation of the advanced progression of chronic wounds once the patients finally reach the wound clinic, we believe that many more people needing a wound care specialist do not have access to one. To provide some level of support in 2004 CMS set forth regulations causing hospital financial managers to create financing and payment mechanisms aimed at addressing the uninsured and underinsured patients in their service areas. Epidemiologists, hospital financial controllers, and the director of the wound clinic can identify metrics to measure their financial risk and identify protocols to reach out to these patients.⁴

  Today in the U.S. more than 46.5 million Americans are uninsured, and another 16 million are underinsured with health insurance plans that leave patients unable to afford their portion of their co pay for medical care. Among this population young adults account for 13.2 million, the largest group of uninsured, according to the 2007 figures from the Commonwealth Fund, a nonprofit research group in New York.² According to the U.S. Department of Labor Statistics as of March 5, 2009 4.4 million people had lost their jobs, 60% since November of 2008. The job loss has been large and widespread across nearly all major industry sectors. Many of these newly unemployed workers will add to the number of uninsured and underinsured exacerbating the problem facing healthcare executives and care providers responsible for the financial health of wound clinics now facing 66.1 million people without the means to pay for their medically necessary care. We have observed that our wound clinic patients are often still in the workforce while dealing with neuropathic and venous ulcers. Once their wounds get out of control preventing them from working, these individuals as well are added to the unemployment figures and become an additional burden to the healthcare system.

  The prospects for health insurance coverage for the newly unemployed have improved. The American Recovery and Reinvestment Act of 2009 signed into law on February 17, 2009 included a provision whereby employers are to cover 65% of their laid-off workers COBRA healthcare insurance in exchange for a tax credit to be paid back to the employer at a later time. Eligible individuals include those laid off from September 1, 2008 through December 31, 2009.

  Based on US incidence estimates, approximately 0.66 million to 1.98 million uninsured or underinsured people are suffering with VLU and do not have the means to receive lower cost medical care that could be provided from a wound clinic. Given that 7.5% of the uninsured and underinsured patients suffer from diabetes and 64% are obese 5.2 million people with diabetes are not receiving treatment and 42.3 million obese people have little or no means to pay for medical care. The total number of people may be less than the sum, since obesity and diabetes tend to go hand in hand. Having this disease case mix in one’s service area is comparable to having a series of virtual “time bombs” awaiting explosion after coming through the entry foyer.

  When these patients are admitted through the hospital’s emergency department they tend to result in a significant financial loss to the institution and the physicians providing treatment. With the added crisis facing hospital’s seeking access to capital from bond markets, this is a cost that needs to be managed and ethically avoided. Ethical avoidance requires understanding the disease prevalence in a hospital’s service area and joining with the Chief of the Wound Clinic and engaging community resources such as parish nurses, public health and low cost clinics, to create proactive strategies to better manage the chronic diseases of their community based patients who have inadequate means to pay for medical care.

    • Effective community strategies could include community oriented educational offerings at low or no cost screening to detect early venous insufficiency, peripheral vascular disease and neuropathy with appropriate early referral to the wound clinic. Over time, this might mean we see more patients with fewer severe problems thus conserving precious resources and more effectively helping people stay active and out of our emergency rooms.

    • Web based or other media interventions to facilitate this process may aid our effort. TV, internet or other media outlets can educate people about when to seek help but then there is the question of where they to go are and who is going to be able to treat them in the most cost effective manner.

    • While the infrastructure has yet to be established to achieve these large scale objectives, there appears to be a growing awareness of the need to so. Wound care clinicians as subject matter experts, teamed with consumers and policy makers, are in a unique position to help develop solution sets that will help bridge the gaps in present day wound care delivery.

  Returning again to our example of the VLU patient, there is considerable support in the literature for the effects in terms of the human as well as the dollar cost associated with a chronic wound. Consider the less tangible but no less destructive effects of social isolation, pain, constant foul odor, embarrassment, fear of amputation or being forced into a nursing home or even bankruptcy resulting from a hospital admission. It’s no wonder we also frequently see chronic depression and anxiety associated with these issues especially when accompanied by decreased ability for independent self care.

    • Treatment of chronic wounds such as VLUs lends itself well to a community outreach program and is the standard way these patients are managed in the U.K. To reduce the patients’ fear of the unknown and concern that their only solution is amputation, education could be provided explaining what they should expect during a visit to the wound clinic.

    • For the visually and hearing impaired, accommodative formats would be helpful such as use of videos and large fonts for printed materials.

    • Engaging family members or significant others in this educational process is key to promoting effective long-term management and fostering an effective wound healing team.

  Understanding treatment choices and payment options that may be available can improve the patient’s likelihood of seeking wound care from the clinic. Wound care therapies that bridge home care and the wound clinic, when ordered by the primary care provider or physician, provide an adjunct to treatment by certified wound care specialists who follow the patient when their return to the wound care clinic for evaluation and treatment. Home based therapies such as doing home dressing changes, can engage the patient and family members to become actively involved in their treatment plan.

  As peer reviewed clinical evidence from randomized controlled clinical trials is reported on advanced wound care drugs and devices, the economic rationale for reimbursement may provide improved treatment options for the insured and to a lesser extent, the underinsured. Clinically relevant outcome data from controlled trials that can lead to positive coverage and payment decisions would help providers avoid telling their patients to do the best they can with what is available from their local grocery or drug store. Some wound clinics serving patients in economically deprived regions have created a training program for family members using the least expensive products available, albeit not the best choice of treatment options. Successful home treatment may be the beginning of engaging the patient in a positive approach to their chronic disease, improve the patient’s overall health and reduce the hospitals and physicians exposure to financial loss.

  Regional solutions notwithstanding, public policy advocates, hospital administrators, and directors of clinical programs need to organize and develop a common message that highlights the needs of the growing chronically ill patient population having little means of payment. Healthcare management and care providers face the difficult decision to treat a patient or maintain fiscal viability. It is the healthcare providers’ obligation to balance their need to maintain fiscal responsibility with their mission and values to provide medical care to improve the health of their communities. Given the current economic crisis additional assistance is needed to support the viability of the healthcare system and that of the population. President Barack Obama has allocated additional funds to states to pay for treatment of under and uninsured patients. He has stated frequently the mission to “…Create a healthier America...” How wound clinics may contribute to help solve this problem at the regional and national level is a timely topic and will continue to be developed. We welcome policy makers from President Barack Obama’s team to engage in a dialogue that addresses patients with chronic conditions exacerbating chronic wounds.

  Leah Amir, MS, MHA, is CEO and President VantageView and VantageLinks, LLC, and Executive Director, Institute for Quality Resource Management. Leah is located in St. Louis, MO, and can be reached via email at LeahAmir@VantageView.com. Mary A. Nametka, MSN, CWS, CWCN, FACCWS, ARNP-C, has practiced in a wide variety of settings including inpatient, long-term, psychiatric and home care. After relocating to Oregon in 2000, Mary has been working at the Portland VA, and developed an outpatient wound care clinic within the Portland VA Primary Care Division. In 2007 Mary completed requirements to become licensed and certified as a Family Nurse Practitioner and recently accepted a position at the Seattle VA where she will be supporting development of an integrated wound/skin care program. Nametka can be reached at nametka.mary@gmail.com.

References

1. The U.S. National Center for Health Statistics, 2007.

2. 2004–2006 National Health Interview Survey estimates projected to year 2007.

3. Wolfskill SJ. Caring for the uninsured; a financial executive's top 10 list. Healthcare Financial Manage. 2007 Mar;61(3):58-65.

4. For Uninsured Young Adults, Do-It-Yourself Health Care. New York Times February 18, 2009.

5. Bernheim SM, Ross JS, Krumholz HM, Bradley EH. Influence of patients' socioeconomic status on clinical management decisions: a qualitative study. Ann Fam Med. 2008 Jan-Feb;6(1):53-9.