Tomorrow’s Wound Care: Q&A With Industry KOL

  Today’s Wound Clinic clinical editor Caroline E. Fife, MD, FAAFP, CWS, FUHM, speaks with author D. Scott Covington, MD, FACS, CHWS, about the future of wound clinics and the industry.

  Caroline Fife (CF): How could provider alliances play out in the next 3-5 years?
  D. Scott Covington (DSC): Strategic provider associations will be critical to the evolution and advancement of specialty wound care. Ultimately, the “winners” will be those who deliver the highest clinical value at the lowest cost. To support these objectives, we will see the development of preferred relationships between hospital integrated delivery networks, payers, vendors, and providers. This will likely diminish the delivery choices and treatment modalities (eg, dressing selection) that providers currently enjoy. If these evolved care decisions are truly centered on the best evidence, this may ultimately be beneficial for all involved.

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  CF: What about the use of physician extenders? There is so much need to break down silos of care. Nurse practitioners seem ideal for that, but there are drawbacks. How do you see this playing out?
  DSC: A successful interprofessional wound care team requires a variety of members, each comfortable practicing within their respective scope and training, to contribute to effective patient care. This will mandate that physician and physician extenders learn to complement one another in sharing patient responsibilities, and ultimately outcome, meaningfully. Based on selected geography (eg, critical access hospitals), this may be the only meaningful alternative to our current physician-led care paradigm.

  CF: What effect will the increasing percentage of patients with Medicare HMOs have on the industry (eg, use of cellular products or hyperbaric wound therapy [HBOT]-covered indications)?
  DSC: Episodic payments and care bundling are clearly forthcoming in our Centers for Medicare & Medicaid Services-directed reimbursement model. Transitioning to value delivery at the lowest cost will be critical for successful future care. My prediction is that “high cost” wound products and hyperbaric medicine will be used differently and more effectively. We will focus more on “right patient and right time” rather than “right now.” My hope is providers won’t be penny-wise and pound-foolish in their selection and timing of more expensive tools and resources. Spending more money initially in a patient’s care course to bring about more rapid wound closure may ultimately generate cost savings by avoiding costly complications.

  CF: How are high-deductible insurance plans changing the outpatient clinic?
  DSC: High-deductible plans will likely result in more patient engagement and decision-making. If patients are aware of the cost associated with selected therapies, they may guide the provider down an alternative clinical pathway more aligned with the patient’s financial needs and goals. I am concerned that high deductibles may lead to a delay in care, as some individuals will be less likely to seek early care based on personal cost incentives.

  CF: There are a lot of threats to HBOT currently, and how they play out will have a profound effect on the industry. What will the effect of preauthorization be, particularly as it expands to a larger area?
  DSC: If the process is properly executed, prior authorization for HBOT may actually be beneficial for patients, providers, and payers. By definition, this serves as a forcing function to encourage thoughtful, accurate care decisions. If the provider must “defend” the clinical necessity for HBOT in the form of a prior authorization request, then less inappropriate or excessive hyperbaric prescriptions will likely be generated. After a payment affirmation, providers will be less concerned about post- payment review and associated penalties.

  CF: What is the likelihood that there will be a site-of-service adjustment for HBOT?
  DSC: We are already witnessing preliminary discussions around site-of-service adjustments. While there are reasonable arguments to be made in both directions, I think the point will ultimately be moot as care bundling and episodic payments become reality. Reimbursement will be a function of the end result (a timely-healed wound), not line item costs associated with the effort.

  CF: How do you see bundled payments or episodic care working in the clinic?
  DSC: Effective payment bundling will require a deeper understanding of patient comorbidities and disease stratification. Currently, we utilize antiquated grading systems (eg, Wagner scale) in an attempt to quantify the disease by severity. We must be more effective at risk prediction at the patient level using advanced analytical processes to synthesize pathophysiologic, sociologic, and demographic factors in order to understand who is at risk for poor outcomes. When we accurately understand these variables, episodic-care payments will be more meaningful. The “winners” will be those who deliver the highest quality of patient-specific care with satisfactory profits.

  CF: Which therapies will be used less in bundled payment, and which more?
  DSC: I think more effort will be directed toward cost-sensitive wound bed preparation and less will be spent on costly products that, while efficacious, may not create differential outcomes worthy of costs. Placental products are establishing a foothold, generally because they seem to work in situations where other products have failed. Fast forward to the future (when providers will cover the cost of dressings and advanced products): Will placental tissue derivatives remain a valued offering in clinic? Time and the vicissitudes of the national reimbursement machine will tell.