Overcoming Challenges in the Wound Clinic in 2023 and Looking to the Future

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Q: What were the most significant clinical challenges you faced in 2023?

A: “Patients keep getting sicker and more complicated, more frail and often more obese,” says Caroline E. Fife, MD, FAAFP, CWS, FUHM.

As Dr. Fife notes, physicians need larger waiting room furniture, larger exam tables, lifts, and more staff members to safely care for larger patients, but since reimbursement is going down, staffing levels are going down. She says there are some patients who are simply too expensive to see such as those who are paralyzed, or patients who require multiple staff members to move them. “And yet, those are the patients who most need our services,” says Dr. Fife.

Jayesh B. Shah, MD, MSc, UHM ABPM, CWSP, FAPWCA, FCCWS, FACHM FUHM, FACP, also cites an ongoing decline in reimbursement coupled with a continuous increase in overhead costs. He says this made it increasingly challenging for small practices to remain viable. Therefore, he sees an “urgent need for Medicare payment reform to ensure the survival of such practices.”

One challenge for Leah Amir, MS, MHA, is the “epidemic” denials of medical care from the Medicare Advantage plans, when Medicare Fee for Service does cover care. She notes the Prior Authorization process is preventing access to care, calling this “among the biggest challenges I have seen.” Another challenge for Amir is hospital administration and those running practices providing a solid budget to the wound care departments.

Q: What were your primary reimbursement and operational challenges in 2023?

A: The Centers for Medicare and Medicaid Services (CMS) “seem to be intent on drastically cutting reimbursement to wound physicians and other healthcare professionals at all levels,” says Shaun Carpenter, MD, CWSP, WMS. He notes this affects practice settings such as hospital outpatient departments, hyperbaric oxygen therapy centers, private office skin substitute services, long-term acute care hospitals, and skilled nursing facilities.  

“With reimbursement going down across the board and the inflationary cost of doing businesses rising dramatically,” asks Dr. Carpenter, “how does our specialty survive?”

An operational challenge for Dr. Shah this year was the impact of Prior Authorization.

“This significantly impeded the timely delivery of care to our patients, often resulting in delayed treatments and, in some cases, adverse outcomes,” notes Dr. Shah. “Overcoming these hurdles became a critical focus for our practice.”

Dr. Fife has had challenges with the “bizarre and unrealistic” staffing models used to determine staffing levels in part because the facility doesn’t understand outpatient services and attempts to apply inpatient staffing models. “Their expectation is that we can have a patient with a chronic wound and mobility issues in an out of a room in 20 minutes,” she notes.

When a patient requires bilateral compression wraps, Dr. Fife says the hospital considers applying the second wrap to be half the work of the first. As a result, she notes physicians can only do unilateral wraps, even in patients who need bilateral wraps.

Dr. Fife says the hospital contracting process is not keeping up with the complexities of Medicare Advantage plans so contracts may write off the highest cost procedures or leave the patient to pay out of pocket for many common services like compression wraps. In the hospital-based outpatient department, she has found that many lower cost cellular- and tissue-based products work as well as higher cost ones, but says Medicare Advantage plans will not allow physicians to use equally effective low-cost products. Documentation burdens are increasing as a result of Medicare audits, notes Dr. Fife.

Q: What are your aspirations for wound care in 2024?
 
A: Looking ahead to 2024, Dr. Shah for the elimination of Prior Authorization requirements in the coming years. He is also optimistic about comprehensive Medicare reform that addresses the current financial strain, with the Medicare trust fund projected to be insolvent by 2028.
 
“Structural reforms are crucial to ensuring the long-term sustainability of the Medicare program for the benefit of healthcare providers and patients alike,” says Dr. Shah.
 
For Dr. Fife, a “completely unrealistic hope” is for Medicare to pay for nutritional supplementation, calling this—not more complicated and expensive dressings—the key to healing many patients. She also hopes Medicare Advantage plans would follow Medicare coverage policies.

Leah Amir, MS, MHA, is the CEO of VantageLinks, LLC and VantageView. She is the Executive Director of the Institute for Quality Resource Management.

Shaun Carpenter, MD, CWSP, WMS, is the Chief Medical Officer of MedCentris Wound Healing Institutes throughout rural Louisiana and Mississippi.

Caroline E. Fife is Chief Medical Officer at Intellicure Inc., The Woodlands, TX; executive director of the U.S. Wound Registry; medical director of St. Luke’s Wound Clinic, The Woodlands; and co-chair of the Alliance of Wound Care Stakeholders.
 
Jayesh B. Shah is Immediate Past President of the American College of Hyperbaric Medicine and serves as medical director for two wound centers based in San Antonio, TX. In addition, he is president of South Texas Wound Associates, San Antonio. He is also the past president of both the American Association of Physicians of Indian Origin and the Bexar County Medical Society and Current of Board of Trustees of Texas Medical Association.