A Deeper Understanding of Wound Care - Episode 7
Shared insight on the patient perspective with regard to the impact of wounds and wound care coverage.
Peter L. Salgo, MD: Before we leave all of this, I know there’s a difference in the way people are covered, the way things are paid—inpatient versus outpatient; formulary in-house versus pharmacy costs outside. What does this mean to the total healthcare bill? What does this mean to patients? Do they pay more if they’re outpatients, or pay less?
Samuel D. Young, MD, MBA, CPE, CHCQM: It depends on the funding source. If you’re a Medicare beneficiary, you pay more typically on outpatient coding, just because of the way that traditional Medicare is structured. Under a Medicare Advantage plan, that’s not necessarily the case. It could be a difference to you in terms of where you are in your deductible and so forth, whether it’s an outpatient versus an inpatient.
Peter L. Salgo, MD: Right. I guess what I’m asking is, I’m Joe Ulcer, or Jane Ulcer. I can go and get outpatient therapy and go to my pharmacy and get a prescription, get that filled, with some sort of deductible. Or I can get admitted and have the bill covered by my insurance in a different way. What turns out to cost more for the insuree, do we know? Does anybody know?
Michael T. Kazamias, MS, DPM: The lack of coordination of care at the outpatient level [costs more]. In many instances a lot of care and wound care is redundant. They’ll get redundant orders for supplies. They’ll get redundant care. They’ll see specialists who had a focus on radical debridement of a wound, and then later on they’ll see another specialist who focuses on exudate management for a wound.
There are attendant supply costs for both of them; the surgical intervention has an entirely different set of supplies and management from an exudate perspective. Then when we look at how does home health do that? Well, that’s predicated entirely on the expertise of the ordering physician. Is that ordering physician a wound care specialist? More often than not they aren’t. They’re a gatekeeper in a risk environment, who is not a specialist in wounds, who is focusing on the comorbidity and not so much on the actual treatment of the wound. These are cost drivers.
Peter L. Salgo, MD: I don’t want to leave this topic without explicitly mentioning something that you brought up, and I didn’t really focus our viewers on at the time, but I haven’t forgotten it. At the end of the day, whether it’s sepsis, or a nonhealing wound or, purulence, or everything else, a lot of these patients are looking down the barrel of an amputation, because that’s the end of the line for a diabetic patient.
Do the patients understand that? Do the primary care physicians understand that? Do the people in the emergency departments understand that, that if you do this wrong, of course sometimes if you do it right, that’s where we’re headed?
Robert J. Snyder, DPM, MSc, CWSP, FFPM RCPS: The answer is, it depends.
Peter L. Salgo, MD: Thanks a lot.
Robert J. Snyder, DPM, MSc, CWSP, FFPM RCPS: It depends on several factors. First and foremost, the protoplasm of the patient, the underlying comorbidity of that patient. As far as educating them to the risk of amputation, that’s something that we have to do really on the front end. Unfortunately, even someone who comes in with a relatively new wound problem who’s diabetic, who has a hemoglobin A1C of 9, as an example, or has peripheral arterial disease, I think that wound can escalate very rapidly to something extraordinarily devastating for that individual.
Peter L. Salgo, MD: I’ve seen patients come in who know they have diabetes, and they’ve come in very early with a very small lesion, and they go, “Boy, this scares me because I’m worried what’s going to happen.” And I’ve seen people come in, in extremis, “I’m not worried at all. Give me some antibiotics, it’s all going to go away.” To some degree is that because we’re training them wrong? Or because they’re hearing it wrong?
Robert J. Snyder, DPM, MSc, CWSP, FFPM RCPS: There are personality differences as well. There are people who are very proactive and who have families that are very proactive, they have a very strong support system, which is extraordinarily important. Then you have individuals who don’t have that expertise, who may not be well educated, in general. They may not have a good support system, they’re living by themselves, they’re elderly as an example, and they certainly are at much greater risk, ultimately making it much more difficult to manage.