HealthTrust’s recent wound care summit brings fresh ideas to the forefront to improve treatment & cost management
A recent summit sponsored by HealthTrust on the state of wound care brought together 40 representatives from several health systems to review current practices in managing wound care patients, share knowledge and experiences, and establish the action plans for each of their health systems and/or facilities. The result was an impressive array of takeaways and next steps that have the potential to change the landscape of wound care.
Participants expressed several areas of opportunity for improving wound care, including communication; standardization of wound documentation, diagnosis, treatment, outcomes tracking, product utilization and cost effectiveness; and the impact of patient comorbid conditions.
A key revelation: Data is essential. “The biggest take-home from the meeting is that people need to make data-driven decisions about the products they buy and use,” says Caroline Fife, M.D., HealthTrust Physician Advisor and wound care expert.
Dr. Fife highlights several data-related issues in the wound care field:
- The lack of consistent, high-quality/evidence- based wound care
- Misrepresented outcomes or not reporting wound outcomes related to patient acuity:
For example, if healing rates of 90% or higher are reported, but the outcomes of the sickest patients are not, it’s impossible to explain to payers why expensive treatments were needed or justify their use
- The presence of monetary incentives to provide certain treatments regardless of whether they work, which can result in payers just saying “no”
- Insufficient knowledge as to what treatments or products are effective in practice because of a lack of risk stratification or real-world data
- A lack of understanding about the value of certain treatments (including cost savings from avoided complications)
Through brainstorming and discussions, the participants worked together to address some of these challenges.
Several summit participants reported using a combination of contracted and internally managed wound centers, typically staffed with registered nurses, licensed practice nurses and hyperbaric oxygen (HBO) technicians with physician oversight. In addition, there is a wide variety of data and analytic efforts among participants. At WellSpan, for instance, quality metrics and data required for registry reporting come directly from the electronic health record (EHR). Community Health Systems (CHS) in Franklin, Tennessee, uses a vendor to capture patient satisfaction, healing rates, median days to heal and outlier rates from the EHR.
Facilities under management contracts report the percentage of patients who are healed per month, as well as the days-to-heal per diagnosis. This data is benchmarked against the management company’s own internal data. The data is not stratified by wound or patient severity, however, so it can’t be compared to facilities outside of the contract, Dr. Fife notes.
The facilities also measure patient satisfaction and pain intervention as internal quality performance indicators. This enables physicians to compare risk-stratified wound healing rates as part of their quality reporting under the Merit Based Incentive Payment System (MIPS). Although Medicare has set national benchmarks for venous leg ulcer (VLU) and diabetic foot ulcer (DFU) healing rates based on a severity scoring system called the Wound Healing Index, few wound management practitioners report their data, Dr. Fife says.
TriStar Health, which has 10 outpatient wound clinics, reports four- and 16-week wound volume reduction, debridement rates, wound types, HBO complications and ancillary services used.
“There was huge variability in wound care programs from institution to institution on the level of service they offered,” Dr. Fife says. “And that has a big impact on what they perceive they need in terms of supplies.”
Denise Dunco, RN, MSN, a former Director of Clinical Research on HealthTrust’s Clinical Services team, adds that in some cases, a lack of data complicates matters. “People don’t know which product to use and which is best because of such limited data.”
HealthTrust Physician Advisor Dean Vayser, DPM, addressed product choice from the physician perspective at the summit. The key factor when choosing the right product should first be based on the evidence, he says. Next, consider the type of research conducted to demonstrate efficacy, followed by cost considerations. “We’re driven in the medical environment by cost, and I think that evidence and pricing are very important in selecting the product that will be the most beneficial.”
However, physician awareness of wound care products, evidence and pricing is very limited, Dr. Vayser adds. Doctors still obtain most of their information from pharmaceutical and medical supply companies. “Frequently, physicians are driven by what a supplier representative tells them but are not actually doing the due diligence of learning about the product and whether the outcomes are there to justify use of the products,” he says. “The physician needs to understand the etiology, the root problem of why the wound has occurred and what the product is supposed to do in order to choose the best product for that wound.”
Dr. Fife also noted the lack of any type of “game-changing” technology since Negative Pressure Wound Therapy became the standard in the 1990s. An even older treatment, the total contact cast (TCC), heals about 80% of DFUs in an average of 40 days. “No new technology has beaten that,” she explains, noting that she helped bring two biologics to market and neither was as effective as TCC.
The cost of wound care in the U.S. is unsustainable, Dr. Fife says. Estimates are that Medicare spends between $28.1 billion and $94 billion a year on wound care, with nearly 15% of Medicare beneficiaries suffering from a chronic wound.
One major challenge in the wound care world, Dr. Fife adds, is reimbursement. For instance, Medicare covers cellular- and/or tissue-based products (CTPs) primarily for DFUs and VLUs. However, highly restrictive criteria limits coverage to the least serious wounds in relatively healthy patients based on the criteria used in clinical trials. While the number of cellular products is growing all the time, Dr. Fife says, “payers are limiting coverage for them, citing a lack of evidence for their effectiveness.”
Reemphasizing the necessity for data, Dr. Fife told participants of the summit that healthcare systems also require a method to collect and analyze CTP data, because the products are expensive for hospitals to purchase. They vary in price from $30 to $700 per square centimeter, yet no data is available to justify this price differential among patients.
“CTPs also have the most challenging documentation, reimbursement and coding requirements of anything I can think of,” she says. “They can help patients yet negatively impact hospital finances at the same time. We have to have a way to understand the most appropriate utilization and make sure that we use them in a way that allows us to get paid for our services.”
Solving the problems
Dr. Fife points to several potential solutions to the issues facing wound care today. Her recommendations include:
- Report wound care quality measures using risk stratification.
- Move to different reimbursement models, including bundled payments (something Medicare is likely to do within the next year or two).
- Collect real-world data from wound registries to report clinical effectiveness.
- Find partners that care about wound care costs, such as group purchasing organizations and state agencies, to help implement these approaches.
One of the highlights of the meeting came from the solutions-driven small group discussions. Members developed action plans to take back to their organizations, outlining goals, strategies and next steps around coverage and reimbursement, clinical evidence and practice, data and analytics registries, and organizational change/ program implementation.
They also strategized on ideal education and awareness initiatives for wound care, a management approach for standardizing care for patients with chronic wounds, strategies for measuring and evaluating success for enhancing wound care, and proposals to engage physicians in implementation.
The action planning process was a “very valuable” part of the summit, says Cindy Christofanelli, MS, RN, CVAHP, Divisional Director Clinical Resource Management at Hospital Sisters Health System. “It allowed us to think about what we’ll do when we go back to our organizations and engage our stakeholder groups, put together goals, identify the purpose of our team, and develop a timeline and deliverables to address our challenges.”
HealthTrust conducted a follow-up conference call in December with participants to check on the progress of action plan implementation. Stay tuned for additional updates in future editions of The Source.
- Patient issues, including multiple comorbidities, nonadherence to care plans, missed appointments, transportation issues and educational gaps in their understanding of wound causes and treatment
- Insurance coverage and reimbursement
- System support, including appropriate staff and provider coverage and specialist partnerships Variability in the supply chain between facilities
- Lack of inpatient/outpatient coordination and continuity of care using clinical pathways Decentralization within the hospital system
- Lack of standard protocols and processes
- Patient out-of-pocket costs
- The need for a robust and cost-effective product portfolio
- Managing complex and expensive regenerative tissue therapies
- Physicians who don’t provide timely documentation or follow clinical practice guidelines
- Coding and documentation issues
- Lack of wound care training for home health aides
- Lack of efficacious CTP options for patients with larger wounds
- Inadequate off-loading in the home and in long-term care facilities
- Lack of consistent prevention practices