Wound Care Maintenance From the Managed Care Perspective

Panelists consider, from the managed care perspective, how wound care is measured and can be improved.


Peter L. Salgo, MD: Let’s look at this from a different perspective. If the various specialties won’t organize, or can’t or haven’t historically, the 1 common funnel is money. Somebody who controls the purse strings could get on this and fix this. How is wound care maintenance measured from a payer perspective? Maybe that’s the answer.

Michael T. Kazamias, MS, DPM: Characteristically it’s been on a claims-made basis. They do claims analysis. The very structure of many managed care companies, based on the risk matrix in a particular geography will either incentivize the acquisition of codes, or disincentivize it based on who is treating the patient for the wound. For example, and not to get too far into the weeds….

Peter L. Salgo, MD: Oh, go ahead.

Michael T. Kazamias, MS, DPM: A managed care company will contract with podiatrists who have open access to wound care. Those doctors are being managed by a third-party administration group in order to manage the risk profile. That third-party manager has a pool of money to be able to work with, and they’re not as concerned with collecting granularity in codes for wounds as they are in paying for a top-line code. In other words, if the patient is seen in an office for a diabetic wound or for any type of a problem associated with the wound, there’s a treatment rendered and a code given for diabetes. It may not be specific or granular enough to code for the wound.

The physician isn’t going to be compensated for that. The third-party administrator isn’t going to provide that in their economic model. There is an unfortunate loss of detail on codes coming in. Add to that the complexity of what’s going on in home care. How do they report their clinical findings? Is it easy enough for someone at a health plan to be able to look across all of those spectrums of care in an area where chronic wound care is not carved out per se, and be able to identify individual cost? Very difficult.

Robert J. Snyder, DPM, MSc, CWSP, FFPM RCPS: Something else I would add, we’re moving from a fee-for-service model into a value-based model. I think that’s going to have significant implications as to how individuals are treated because we’re basically going to be looking at quality measures and outcomes. I think our payments very often are going to be predicated on how those shake out.

The 1 other thing I would say is that unlike a profession like cardiology that’s been looking at quality measures for probably decades, wound management is really behind the curve. We’ve only really been looking at quality measures for a few years, and there are very few quality measures that are now on the books with CMS [Centers for Medicare & Medicaid Services] for wound management.

Peter L. Salgo, MD: Let’s take a look at these, a few meatballs here if I can. Inpatient, outpatient costs with wound care, how do they compare?

Michael T. Kazamias, MS, DPM: As was alluded to earlier by Dr Snyder, very few people, if any, actually get admitted to a hospital for wound care. The costs for wounds are mainly incidental. They’re more often….

Peter L. Salgo, MD: If I may, that may be an artifact of coding. In other words, they may not admitted for wound care, but it’s the wound that’s driving them in.

Michael T. Kazamias, MS, DPM: Absolutely, I’ll give you an example. There was a study done about 6 years ago in a rather large group of home health agencies, a conglomerate that was under contract by a health plan in Texas. They had a very large population. What they found was 50% of their census was comprised of patients with chronic wounds.

Peter L. Salgo, MD: That was what I was getting at.

Michael T. Kazamias, MS, DPM: Of those, half of them went to the hospital for what was determined an unnecessary admission. Those are basically the logistics behind who’s treating the wound. For example, if there’s an actionable event that a nurse spots on a patient, is it relayed back to the physician in an appropriate amount of time? What happened subsequently to that to deal with that patient’s particular situation in that care level?

Peter L. Salgo, MD: Interesting stuff. I hate to admit this, but the salvation of this whole thing could be the insurance industry. They’re the guys, and women, with the purse strings, who can then parse it all out.

Michael T. Kazamias, MS, DPM: They have the latitude to do what Medicare can’t, which is curtail or optimally manage access to care so that they can look at redundant areas. They can look at areas that are across centers of excellence.

Samuel D. Young, MD, MBA, CPE, CHCQM: Medicare has looked at the data on the driving admitting diagnosis that’s attributable to wounds. This is going to underrepresent the true cost because we all have admitted here that often the wounds are unrecognized and part of a secondary diagnosis.

Michael T. Kazamias, MS, DPM: And hence they’re MRA [Medicare risk adjustment] in the top 5.

Samuel D. Young, MD, MBA, CPE, CHCQM: In the primary in-patient diagnostic setting, I

believe the figures per annum for fee-for-service Medicare, are in the $40 billion range.

Peter L. Salgo, MD: Billion.

Samuel D. Young, MD, MBA, CPE, CHCQM: Yes.

Peter L. Salgo, MD: With a B.

Samuel D. Young, MD, MBA, CPE, CHCQM: Yes.

Peter L. Salgo, MD: Those are federal numbers, man.

Samuel D. Young, MD, MBA, CPE, CHCQM: Yes.

Peter L. Salgo, MD: Was it Everett Dirksen in the ’60s who said, “A million here and a million there. Pretty soon you’re getting into real money?” Add a B not an M, and we’re in the 21st century.

Robert J. Snyder, DPM, MSc, CWSP, FFPM RCPS: I’m going to throw something else out, thinking in terms of home care and how these wounds are treated.

I did a study, 2010, looking at advanced therapies versus saline therapy for treating wounds, of course, which is something that is almost taboo in this day and age. We looked at the outcomes in 2 months and we found that at the end of 2 months only 7% of wounds had healed in the saline group at a cost of about $7000 per patient, versus 95% healing at a cost of $2000. Where was the cost? The driver of that cost was the nursing care. The nursing care that was done every day versus maybe once a week made an incredible difference in the amount of money that was actually spent.

Peter L. Salgo, MD: Fascinating, it really is.

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