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Special to OWM: Reimbursement Changes Provide Opportunities for Wound Care Professionals
Wound care professionals are skilled not only at managing wounds from inception to closure, but also in preventing wounds. Therefore, the paradigm shift to reimbursement based on value from reimbursement based on volume will provide new opportunities for wound care professionals if they proactively seek them.
Currently, most wound care professionals are working in vertical silos where they do not have control over a patient’s entire wound management or wound prevention. In addition, each silo of care is driven by a different payment system, and the payment system may not be aligned with evidence-based wound prevention and management. The following are some real-life examples wound care professionals have shared with me.
Acute care. In acute care hospitals where the Medicare payment system is based on multiple admissions into the same bed in a week, wound care professionals report they often have a hard time getting multilayer, high-compression bandage systems for their patients with venous ulcers. They are sometimes told to let patients wait until they are discharged to the next site of care.
Skilled nursing facilities. In skilled nursing facilities whose Medicare Part A payment system provides them a fixed per diem rate based on the level of skilled resources needed from day 1–15, day 15–30, day 30–60, day 60–90, and day 90–100, wound care professionals report they often have a hard time getting appropriate surgical dressings for their patients. Sometimes they are told to wait until the patient converts to Medicare Part B; then the durable medical equipment supplier will purchase the dressings and bill Medicare Part B and the patient for the dressings.
Home health. In home health agencies whose Medicare Part A payment system provides them 1 payment for a 60-day episode of care, wound care professionals report they often have a hard time getting appropriate surgical dressings for their patients and are often given no choice but to use nothing but gauze and tape.
Outpatient facilities. In hospital-based, outpatient wound care departments whose Medicare payment system is based on services and procedures performed, wound care professionals report they often are encouraged to select products with the highest reimbursement and/or to perform procedures that have the highest reimbursement.
Clinical professionals. Qualified health care professionals (QHPs) such as MDs, DOs, DPMs, NPs, PAs, and CNSs whose Medicare payment system is based on the number of services and procedures performed report they gravitate to products and/or procedures that have the highest reimbursement.
Wound care professionals know they can deliver better patient-centered care, but these disparate volume-driven Medicare payment systems often get in the way of doing what wound care professionals know is best for the patient. Many wound care professionals have expressed a wish to develop an evidence-based care plan for each patient they could manage across the continuum of care. The good news is the new value-based payment systems facilitate those wishes, but they require wound care professionals to consider how they can manage wounds across the continuum of care and to sell the concept to the new practice models surfacing in their health system and in their communities.
As accountable care organizations (ACOs), patient-centered medical homes (PCMHs), bundled payments, and other paradigms develop, wound care professionals should seek out the directors of these models and educate them as to how multidisciplinary wound care case management teams led by QHPs can develop wound care plans and manage the patients in the alternative payment model across the continuum of care. Together with the directors of the new practice models, wound care professionals will be able to step out of their current silos and follow their patients across the continuum of care. Together you will uncover rewarding opportunities that you never dreamed were possible.
In fact, when you carefully read the Centers for Medicare and Medicaid Services’ (CMS) definition of an ACO (“. . . groups of doctors, hospitals, and other health care providers, who come together voluntarily to give coordinated high quality care to their Medicare patients”) and CMS’ goal of coordinated care (“ . . . to ensure that patients, especially the chronically ill, get the right care at the right time, while avoiding unnecessary duplication of services and preventing medical errors”), you will quickly learn they describe your dream wound care services. It is easy to visualize working together with a multispecialty team that coordinates care across specialties and settings to deliver quality care to the whole person. The more you learn about the shift from volume-based to value-based reimbursement, the more excited you will become about this professionally rewarding opportunity.
Some readers may be apprehensive about the reimbursement changes from volume to value and about the development of all the new practice models. Therefore, it is very important to educate yourself about these new practice models and to think outside the box about practicing wound care in an entirely new way. Also, think how you can use your electronic data to demonstrate your ability to improve outcomes at a lower total cost of care across the continuum and with excellent patient satisfaction — the “Triple Aim” of value-based reimbursement systems. Then, you should communicate your capabilities and your worth to as many people in the new practice models as possible. You and they quickly will find wound care professionals know how to provide value-based care that is right for the patient, right for the practice, and right for the payer.
As a wound care reimbursement strategy consultant, I am excited to work with wound care professionals during this time of change. Together we will continue to learn about coding, coverage, and payment in our volume-based payment systems and to follow a parallel path to payment in the value-based alternative payment systems. One thing is certain about wound care reimbursement: it is always changing. You can count on me to help you down this parallel path to reimbursement.
