Pursuing Value: The Clinical, Economic & Administrative Benefits of Utilizing an Integrated Wound Care Portfolio

There are numerous benefits that wound care clinicians and program directors can capitalize on through the utilization of an integrated wound care portfolio as part of the care-coordination process. This article will discuss the impact and provide a baseline for clinics to consider. 

The prevailing trend in healthcare delivery today is the shift from volume to value. Compensating clinicians for making their patients healthier — rather than for the sheer quantity of services they provide — generates cost savings and improved health outcomes. The logic is simple: better incentives mean better results. This paradigm shift has broad implications for wound care outpatient clinics. Not only is the prevalence of life-threatening chronic wounds on the rise, but wound care patients often present with multiple comorbidities and chronic conditions, all of which drive up the cost and complexity of care. The stakes are exceedingly high for patients, providers, and payers alike, as there is increasing pressure to close and heal wounds in an effective and timely manner while keeping medical expenses under control. The reimbursement evolution from volume to value requires wound care program directors, administrators, and clinical care teams to approach care delivery and outcomes in comprehensive terms with an emphasis on treating the person rather than the wound itself. Collectively, wound care professionals have the shared duty and responsibility to heal wounds and patients in a timely, cost-effective way. As outpatient wound clinic decision-makers strive to deliver on what the Institute for Healthcare Improvement’s Triple Aim (refining the patient experience, improving health outcomes, and cutting the per capita costs of healthcare) has established, a growing number of wound care programs are finding success by utilizing an integrated wound care portfolio. This article will discuss the clinical, economic, and administrative benefits of utilizing an integrated wound care portfolio in the outpatient wound clinic setting.

Clinical Benefits

Integrated wound care portfolios help clinicians more easily and successfully treat the many types of wounds that present in the wound care center. Each patient — and each wound — is different, so it’s important to work with a portfolio of products that addresses wound care needs across all phases of healing and gives clinicians the opportunity to manage all types of wounds.

For example, not all cellular and/or tissue-based products (CTPs), referred to as “skin substitutes” by the Centers for Medicare and Medicaid Services, or bioengineered skin substitutes, are created equally. An integrated wound care portfolio — one that includes CTPs from the various classes¹ — provides diversity and a variety of applications within the wound care arena. One of the additional keys to success with an integrated portfolio is to view the products as part of a step-wise approach to healing. Before thinking about which product to apply to the patient’s wound site, it’s important to review the patient’s contributing health circumstances and lifestyle factors that can interfere with the healing process. Clinicians should ask themselves:

• Is the patient going to require long-term care, and will the caregiver require specific instructions for wound management?  
• Is the patient living with diabetes and, if so, is he or she being treated by an endocrinologist or primary care physician? 
• Will the patient require home health to manage a heavily draining wound? 
• Does the patient have transportation and, if so, how far does the patient have to travel to and from the clinic? 
• Does the patient experience any physical impairment that would prohibit certain treatments? 
• Does the patient live with comorbidities or exhibit behavioral traits (eg, smoking, poor nutritional choices) that may impede wound healing?
• Is the patient adhering to the care plan? Is the patient making an effort to participate in his or her care?

The answers to these questions could significantly influence the applied product and treatment protocol. For instance, if a patient lives more than an hour from the clinic and has limited options for transportation and/or has no caregiver available, this may be an opportunity to leverage external resources such as home health or public transportation. Clinical leaders may find it helpful to develop and utilize a “Checklist for Healing” for common wounds that present in the wound care center to reinforce this step-wise approach to healing. (See Table 1.) Taking a diabetic foot ulcer (DFU) as an example, these factors may include ulcer infection, risks of osteomyelitis, ischemia, glycemic control, inadequate offloading, nutrition, and overall health management. Some of these factors must be addressed in conjunction with the products used to treat the wound. Other factors, such as bioburden, may be addressed with a specific product in the portfolio. Biofilm management is a common issue that presents in wounds and one that must be addressed before placing an advanced modality such as a CTP product on the patient. Many wounds stall in the inflammatory phase of healing due to bacterial bioburden and increased protease activity. Bioburden is an incredibly common complication (approximately 60% of chronic wounds possess biofilm²), so it’s imperative that clinicians have both the knowledge and the availability of a product in the portfolio that can specifically address this challenge. Even when bioburden is resolved, sometimes the wound stalls in the inflammatory phase due to the patient’s increased inflammatory cells and cytokine activity or impaired cellular signaling. In these cases, clinicians may choose to utilize advanced cellular technologies to stimulate healing. This concept of impaired wound healing holds especially true for hard-to-heal DFUs and venous leg ulcers, which represent a majority of wounds that present in the wound care center.^3,4 Put simply, having an integrated portfolio at the clinician’s fingertips with products designed to address specific healing challenges makes it easier to manage all types of wounds throughout the continuum of care. 

Assessing Evidence-Based Wound Care Products

Another clinical benefit of utilizing an integrated wound care portfolio is the ability to choose wound care solutions based on strength and quality of supporting evidence. (See Table 2.) Utilizing evidence-based products as designed will produce better clinical outcomes. When assessing evidence-based products, clinicians should assess both the quality and diversity of the data presented to them. Questions to consider include: 

• Does the product have strong clinical evidence demonstrating an ability to close wounds successfully and more quickly than other products?
• Is the product’s clinical efficacy and safety also validated by reliable real-world analysis?
• Would the product’s data be reviewed, accepted, and approved for treatment by the U.S. Food & Drug Administration (FDA)?  
• Are there well-powered studies to support the product’s usage, including randomized controlled clinical trials? 

Economic Benefits

Clinical use of advanced therapies as part of an integrated portfolio can increase healing times and reduce complications while improving patient outcomes. These clinical benefits translate to economic benefits when better health outcomes reduce the long-term costs of care. A recent economic analysis⁵ by Rice et al finds that, when used as part of the integrated wound care portfolio, certain advanced therapies reduce complications (eg, amputations and osteomyelitis) and ease medical expenses. On this point, the data are impressive. First, patients treated with products approved by the FDA (along with premarket approval) used in the initial phase of DFU treatment had statistically significantly lower amputation rates (27.6%), fewer hospitalized days (33.3%), and fewer emergency department (ED) visits (32.3%) than their respective matched controls. Patients treated with a second, similar high-evidence-based modality product also had lower amputation rates (22.2%), statistically significantly fewer hospitalized days (42.4%), and fewer ED visits (25.7%) than their respective matched controls. These impressive health outcomes can produce dramatic cost savings to the healthcare system. Indeed, those treated with evidence-based modalities had per-patient average healthcare costs ranging between $5,000 and $7,000 less than patients treated with conventional care alone — and that was only in the first 18 months following treatment. Evidence of the healthcare system’s shift toward value-based and outcomes-driven care can be found in the coverage and reimbursement parameters set by both Medicare and private insurers. Payers understand that high-evidence products help to reduce long-term healthcare costs through decreased complications, improved patient experiences, and better health outcomes. Local coverage determinations (LCDs) are increasingly focused on healing times. In fact, some Medicare Administrative Contractors are now listing the levels of clinical data associated with each of the products included in their LCDs. By utilizing an integrated portfolio backed by strong evidence, outpatient wound care clinics will be better equipped during the transition to accountable care. Finally, we can’t overlook the fact that patients who are healed in a timely manner can more quickly return to their activities of daily living, which often means returning to the workforce and positively impacting the economy. Clearly, the use of an integrated portfolio backed by strong evidence will become increasingly important to achieve both clinical and economic goals. (See Table 3.) 

Administrative Benefits

While we’ve looked at the big-picture gains associated with an integrated wound care portfolio, the practical, office-level benefits are also important to consider. Care coordination and use of an integrated portfolio ultimately means working with select vendors offering effective solutions, which ultimately translates to less paperwork and reduced administrative hassles. Enhanced “benefit verification” (ie, verifying coverage for specific treatments) is a perfect example of this. Once an integrated portfolio is adopted, office members need only look in one place; they don’t need to make multiple calls or embark upon lengthy forays on the Internet to determine if a patient’s wound care product will be covered by insurance. Another administrative advantage is improved supply chain management. Selecting vendors that can provide an integrated portfolio of products may offer a more programmatic approach to wound care and, therefore, less clutter. Practitioners understand how significant this is — having too many products from too many vendors makes it physically difficult to figure out what’s available for use.  However, using select vendors often eliminates the guesswork and results in a supply closet that’s been properly vetted and inventoried. Finally, the offer of comprehensive customer support services from some vendors can provide a dependable counterpart for clinic staff. Customer care centers, patient-focused programs, and technical assistance are uncommon yet meaningful support services for busy clinicians (and patients). In the end, this all means that doctors need not waste any more of their time behind a desk or sifting through supplies and instead focus on taking care of the patients. When assessing the administrative benefits and services of a particular vendor relationship, administrators should look for the following:  

• Reimbursement support center that provides help with benefit verification/prior-authorization claims review; predetermination; and coding, coverage, and payment tools.
• Medical and technical support that includes product field support and assistance with resolving/preventing Joint Commission issues.
• Patient-focused programs including education materials and initiatives, alternative funding, and copay-assistance programs.
• Online customer portals, hotlines, and other solutions to quickly and effectively answer questions about products.
• Cost-effective options or solutions in purchasing wound care products (eg, consignment, packaged orders).

Conclusion

Wound care clinicians and program directors would be well served to capitalize on the clinical, economic, and administrative benefits of utilizing an integrated wound care portfolio as part of the care-coordination process. From where we stand, integrated care is the future and will impact all stakeholders in measurable ways. It will help providers deliver more efficient care, set patients on a path toward healthier lives while not being weighed down by constant trips to the doctor’s office, and guide the healthcare system toward a more sustainable future. These seemingly lofty goals for the future can be achieved in the present by wound care leaders, but the time to act is now. Acting now is good for patients, for clinicians, for taxpayers, and for the integrity of healthcare delivery.

Han Hulen is medical director at the Center for Wound Care and Hyperbaric Medicine at Medical City Dallas (TX) and chief executive officer at Wound Integrity, Dallas, TX. Harry Goldsmith is chief executive officer at Codingline, Cerritos, CA. Scott Alan Filgo is executive director of the wound care and hyperbaric oxygen centers at WellStar Health System, Marietta, GA.  

References

1. Halim AS, Khoo TL, Yussof SJM. Biologic and synthetic skin substitutes: an overview. Indian J Plast Surg. 2010;43(Suppl): S23–S28.

2. Hübner NO, Kramer A. Review on the efficacy, safety and clinical applications of polihexanide, a modern wound antiseptic. Skin Pharmacol Physiol. 2010;23(Suppl):17-27. 

3. Abbade LP, Lastória S. Venous ulcer: epidemiology, physiopathology, diagnosis and treatment. Int J Dermatol. 2005;44(6):449-56.

4. Olin JW, Beusterien KM, Childs MB, Seavey C, McHugh L, Griffiths RI. Medical costs of treating venous stasis ulcers: evidence from a retrospective cohort study. Vasc Med. 1999;4:1-7.

5. Rice JB, Desai U, Ristovska L, et al. Economic outcomes among medicare patients receiving bioengineered cellular technologies for treatment of diabetic foot ulcers. J Med Econ. 2015;18(8):586-95.