No Country for Old Wound Care

It doesn’t seem like it’s been nearly 20 years since a pharmacologically-based company called Curative began working with hospitals to create outpatient wound care centers and expanded to manage nearly 200 such centers across the country.

Remember back then? It was a time when outpatient wound care centers were often initially embraced by smaller, community hospitals, filling a need for their patient base and creating a new revenue stream. However, the senior management teams of most large, metropolitan, tertiary hospitals turned their noses up at wound care. The understandable focus of these major hospitals was on large clinical service lines and the specialists who drove their financials. That was then. Now, we are likely to see an outpatient wound care center in every hospital with 200-staffed beds within the next five years.

It was also a time in which many knowledgeable, and self-sacrificing, ETs and PTs devoted unbelievable amounts of their own time and effort to create hospital-based wound centers. These programs typically delivered excellent care to an ever-growing chronic wound care market. However, the programs at best broke even financially. In most cases it was a significant drain on both hospital resources and these great care givers themselves. CMS—by the way in which it has structured reimbursement—is now in this author’s opinion obviously directing that wound care should be delivered in a hospital outpatient department and that the physicians direct care. The same treatments performed by a physician are being reimbursed at a rate of over twice that of a nurse or physical therapist. And, to a lesser degree, reimbursement is also higher than for a nurse practitioner.

Even as physicians have become more involved, wound care has continued to be an area of medicine where hands-on care is seen as being delivered by “part timers”. It would seem logical for a hospital to staff a full-time outpatient wound care center with as many interested staff physicians as possible. That is a means of not turning any staff physicians away, easily providing coverage for all wound care clinics, and capturing all of those physicians’ patients. However, it is not the optimal approach for creating a true, and medical staff perceived, center of excellence. The future of wound treatment will be in the hands of sub-specialists—certified physician wound care specialists. Individuals who are building their specific knowledge, skills, volume, and careers focused on practicing and delivering evidenced based medicine.

That resulting wound care center of excellence is a team effort of three groups of specialists—the physician certified wound specialist, the wound ostomy continence nurse, and the physician specialists who are referred to for their own specialization.

Building this two-way specialty referral base is critical for a wound center—whether that be for vascular surgery, infectious disease, orthopaedics, plastic surgery, endocrinology or podiatry. And, equally important, is close communication with the patient’s primary care physician, taking care to alert the patient’s family practice or internal medicine physician to changes or needs, but referring back to them for any treatment outside of wound care.

This is how a true wound care center of excellence builds volume. If the physicians practicing in the center are wound specialists, or primarily practicing there, they are not seen as competition by the rest of the medical staff. In fact, it’s optimal if they do not even have another office where they could refer a patient. They are not doing wound care part time. They are specialists building a practice in wound care. They will be recognized that way by the rest of the staff—seen as the “wound doc” and referred to in that way.

Think of the emergency department as a model. The ED specialist does evaluation and management, treats appropriately and refers out to specialists as required.

So, what has happened in wound care during those 20 years? Modalities of care, dressings, physician specialists, and reimbursement have all evolved. Unfortunately, the number of patients in need has also grown and is now expanding exponentially.

The drivers of this expanded need are pretty obvious and compounding—age, obesity, limited mobility, lifestyle, diversity and the largest contributor is the underlying disease state of diabetes!

The overall number of patients with chronic wounds is over seven million. The total wound healing billings in the United States is now over $8 billion a year. And, what could now be called an industry is growing at a rate nearing 20% per year.

In too many geographic markets, this equates to large numbers of underserved patients. Patients who have decided that they just have to live with these non-healing wounds, patients who are languishing in primary care offices or patients who are misusing hospital resources, the ED or other outpatient areas.

For hospital administrators evaluating their own market need, a highly successful wound care program requires about 300 new patients per year. A program can produce strong financial results based on between 200 and 250 new patients annually. Simply looking at one component of the patient demand—diabetes, a hospital with a service area of 200,000 would only have to capture 12% of the potential diabetic wound patients. And, that does not even take into consideration the other large drivers of wound care need—venous, arterial and pressure ulcers, as well as post operative, compromised skin grafts, radiation tissue damage, and trauma.

Wound care is worthy of a new look, or possibly a new approach in 2010.

To develop and implement a plan for outfitting and staffing the clinic portion of a wound center is relatively straightforward. However, the technical and safety components of hyperbaric medicine, build out requirements and training are new to most hospitals and staffs, as are both wound care and hyperbaric protocols to physicians. Because of the lack of awareness and misinformation in the overall medical community, this is not a service that can be viewed as “build it and they will come”. Wound care has not been a traditional or historic hospital service, so the department requires a consistent commitment to outreach and medical community education in order to build a referral structure and sufficient volume.

There are a number of resources available to assist hospitals from demonstrably well-qualified wound management companies. These firms can assist with a range of services from assessment, to implementation to turnkey management.

In addition, a hospital may benefit from outside help in two specific areas. One key for both clinical and administrative management is a single entry electronic medical record. This provides tracking and billing, includes wound photography and captures physician documentation. Plus, it is an excellent tool to help maintain the relationship with referring physicians.

The second area is specialized reimbursement training. A well-managed wound center should provide a new, or significantly enhanced revenue stream, as well as incremental ancillary revenue. It is tempting to downplay or make assumptions about this area. The hospital must bill for these outpatient treatments and procedures. So, additional training is definitely recommended for both the accounting staff and physicians to make certain that they are documenting appropriately.

As a final note, especially for innovative systems or forward looking hospitals, the real future issue is going to become optimal care for patients with chronic ailments!

There is need, opportunity and a coming mandate to treat patients in the most cost effective setting. This is true for a growing number of areas of chronic care—congestive heart failure, stroke, kidney disease, oncology, diabetes, arthritis and alzheimers, as well as wound care. Most hospitals will not be able to rationalize continuing to use precious capital resources to build freestanding centers for each of these specialties. Consider a comprehensive outpatient center offering state of the art care in all of these areas. It could develop significant synergism, as well as providing major economies of scale.

It just requires a change in the way we view outpatient treatment—from ancillaries and same day surgery to chronic interventions.