Paula Erwin Toth, RN, MSN, FAAN
By Lydia Corum RN MSN CWCN
The times are changing in the world of wound care. There used to be a time when there were no problems with reimbursements, as long as the doctor wrote the order. Today, the Centers for Medicare & Medicaid Services (CMS) regulations confuse clinicians and make the world of healing wounds much more difficult. The changes are in the area of denials with not enough information given for choosing dressings, use of negative pressure therapy and hyperbaric oxygen therapy. Are all these changes needed? Why are these changes happening? What can hospitals and wound clinics do to make things better?
There is a belief that financial stewardship is just a matter of finding ways to cut costs whenever and wherever possible. But this is a short-term solution and fails to take into account the long-term effects on the patient and the economy at large. A better method of financial stewardship is to use evidence-based practices at every stage of wound healing. By using evidence-based practices, wound care professionals can increase the likelihood of good outcomes for patients as well as avoid redundant or unnecessary complications.
There has been an increase in the amputation rate of people younger than 45 years old from 2.1 in 2009 to 4.2 in 2015. In 2009 amputations cost approximately $8.3 billion. Lifetime health care costs for people with limb loss is $509,275 compared to $361,200 for the average person. Taking into account there are 185,000 amputations each year, that adds approximately $27 billion to the already crushing Medicare/Medicaid budget. This cost plus the increases in other parts of wound care is why CMS is changing how payment is being made for patient care.
Hypothetical Case Study
A patient enters the hospital. He had been working on a construction site and accidentally stepped on a nail. The nail went through his shoe sole to the ball of his foot. He went to the emergency department as instructed by his boss. There, he received a tetanus shot, orders to use peroxide, triple antibiotic cream, and gauze dressing. He was given instructions to change dressings daily and watch for signs and symptoms of infection. The patient went home and then continued to work.
Two weeks later, he was unable to walk or put weight on his foot and he returned to the emergency department. On examination, the patient was found to have an infection that included most of the foot. The patient was worked up for surgery, laboratory samples were drawn, and a magnetic resonance imaging scan was done.
When the laboratory test results came back, the patient was found to have a very high blood glucose concentration and an elevated hemoglobin A1c. The patient had unknowingly had diabetes for some time. Surgery was scheduled, and the patient had a below-knee amputation. The amputation could possibly have been prevented if the doctors' had looked at limb salvage technology. The patient was in the hospital for a few more days and then was discharged for further wound care and rehabilitation.
By electing to pursue amputation for this patient, rather than limb salvage options, the total cost to the hospital was less; however, the cost to the health care system was much greater. The loss for this patient is beyond computation. The patient was fitted with a prosthesis and now had to find a new line of work. This patient ended up with another amputation two years later and faces being unable to work for the rest of his life. The original decision to amputate the leg did not include the damage to the economy in the long run.
I believe similar stories happen every day. When making decisions on the care of the patient, health care professionals need to think how best to serve the patient. The nurse or doctor needs to ask the patient a few questions to be sure the dressing selection is correct. How easy is it for the patient to obtain this dressing? What is going to be the cost to insurance, the patient, the facility, the home care agency or whoever is responsible for supplying the dressing? Is there a generic dressing that can be used? Will different products really affect healing differently? Are they using evidence-based wound care, or are they using the research provided by the supplier? Answering these questions with true thought will give insight into how to be financial stewards.
Financial stewardship is a quality indicator. For wound care, the quality indicators in lower leg wounds include offloading of diabetic foot wounds, compression of venous stasis, and studies for blood flow. It seems to me that such elementary wound care is often forgotten, and it is now seen as better to amputate than to take the more time-consuming steps needed to heal a wound.
Wound care, unlike many health care issues, is the last to be limited and overseen by CMS. So much incorrect documentation for use of dressings, advanced procedures and advance devices. When wound care is done correctly and all boxes checked, using hyperbaric oxygen therapy, debridement, and negative pressure therapy, healing becomes fast and to the benefit of the patient. Wound care needs to be for the patient, evidence-based and using financial stewardship.
Wound care is important, proper wound care is more important, and evidence-based care is the most important. When looking at the patient as an essential component of the quality indicator, financial stewardship, and lasting outcomes must be considered. This patient with amputation did not have a good outcome. The amputation was not absolutely necessary—it was just the easiest choice.
"15 Limb Loss Statistics That May Surprise You." Access Prosthetics, 1 Mar. 2019, accessprosthetics.com/15-limb-loss-statistics-may-surprise/.
Administration, Web. "Limb Loss Statistics." Amputee Coalition, 7 Oct. 2015, www.amputee-coalition.org/resources/limb-loss-statistics/.
"Diabetic Amputations May Be Rising in the United States." AJMC, www.ajmc.com/newsroom/diabetic-amputations-may-be-rising-in-the-united-s....
Fife, Caroline E., et al. "Wound Care Outcomes and Associated Cost Among Patients Treated in US Outpatient Wound Centers: Data From the US Wound Registry." Wounds Research, 1 Jan. 2012, www.woundsresearch.com/article/wound-care-outcomes-and-associated-cost-a....
Nussbaum, Samuel R., et al. "An Economic Evaluation of the Impact, Cost, and Medicare Policy Implications of Chronic Nonhealing Wounds." Value in Health, Elsevier, 19 Sept. 2017, www.sciencedirect.com/science/article/pii/S1098301517303297.
About the Author
Lydia Corum RN, MSN, CWCN has been in the nursing profession since 1996 and has been in wound care for over 15 years. Ms. Corum is currently a Wound Care Coordinator for West Hills Hospital & Medical Center. Having worked as a clinical manager in wound clinics and hyperbaric centers, she has developed a strong passion for education through her positions and within the wound care community at large. Ms. Corum currently has her Masters in Nursing from Keiser University. Her background in multiple care venues and educational roles professionally gives her expertise in a wide range of patient care situations. Her nursing philosophy to "heal wounds as quickly as possible" is the guiding force behind her educational pursuits, both as a teacher and a student.
The views and opinions expressed in this blog are solely those of the author, and do not represent the views of WoundSource, Kestrel Health Information, Inc., its affiliates, or subsidiary companies.