Medicare and Wound Care Coverage
Many Medicare beneficiaries wonder about the cost of wound care and question how doctors get paid when treating patients with Medicare. The real burden of wound care to Medicare has stayed hidden, and it is time we shed light on the subject.
The calculations and documentation of the economic costs can have implications for federal research funding and CMS policies, like the Medicare Access and the CHIP Reauthorization Act of 2015 (MACRA).
MACRA created a quality measure-based payment model that drives reimbursement; this is particularly challenging for wound care practitioners, with no reportable performance measures relevant to wound care under the Merit-based Incentive Payment System.
The Centers for Medicare and Medicaid Services (CMS) and health policy makers will to need to include wound-relevant quality measures in all care settings. This includes episode of care measures, chronic care models, and reimbursement models that drive better health outcomes and smarter spending in the category of wound care.
How Doctors Get Paid; Then and Now
In 2000, the mandates of the Balanced Budget Act of 1997 were implemented by Medicare. Every wound care provider, except physicians; were placed on a Prospective Payment System.
Over time the health care facilities learned exactly how much care they could afford to provide under the new Prospective Payment System. This led to patients being discharged from a site of care too early.
This also resulted in providers selecting products and procedures based on the availability and rate of reimbursement rather than on their clinical evidence and on the actual medical needs of the beneficiary.
Patients were also receiving more services than required just because the providers could charge them more.
In 2017, a new payment system for physicians was put into place. No longer will physicians receive payment based on the country’s economic growth. Physicians will also no longer receive Medicare Physician Fee Schedule increases/decreases at the end of 2018.
Medicare allowable rates will remain flat starting in 2019. This new Quality Payment Program will provide physicians with bonuses or deductions from their flat payment rates based on four performance categories:
- Advancing Care Information
- Clinical Practice Improvement Activities
- Total cost of care, not just the cost of an item or a procedure
Ideally, this new payment method will encourage physicians to focus on quality of care and total cost of care. Physicians will be more likely to make decisions based on clinical practice guidelines.
This new payment system should encourage physicians to make better use of electronic health records and communicate across the spectrum of care.
When health care providers are communicating with each other, the same tests are not done multiple times. Repeated testing wastes Medicare spending money and wastes time; repeated testing is not beneficial to anyone in the long run and can be avoided.
The new payment system is supposed to help prevent waste and increase quality of care. CMS and health policy makers need to design a clear payment and coding system for wound care that will benefit both the beneficiaries and the health care team.
It is necessary to pay healthcare providers a fair wage, and it is important that we do not overcharge for care. Patients need to receive sensible testing, and not excessive testing. Quality care is the biggest and easiest way physicians can be a part of reducing Medicare spending.
The Burden of Wound Care
The costs of wound care can certainly add up, and as we get older, our need for care increases. There is no doubt that a majority of those on Medicare are going to need some form of wound care at some point. This is part of the aging process; as we get older our bodies become more fragile and are more susceptible to wounds and injuries.
Wound care can be a simple treatment, chronic wounds are another story. Recent studies claimed 15 percent of Medicare recipients (8.2 million people) have been impacted by Chronic non-healing wounds. Many of these wounds could have been prevented.
When the wound is the primary diagnosis it is estimated that the annual costs of wounds is $28 billion. If the wound is a secondary diagnosis the costs are estimated to be $31.7 billion annually.
Hospital outpatient services have the greatest proportion of costs, there is a major shift in site-of-service costs from hospital inpatient and outpatient settings.
On an individual basis, Medicare spending per wound was $3,415 to $3,859. Pressure injuries and arterial ulcers were among the most expensive wounds per beneficiary.
Unfortunately, surgical infections were the largest prevalent category, followed by diabetic wound infections. Many of these infections could have been preventable.
Many of these numbers are believed to be on the conservative side, as expressed by researchers. These researchers looked at costs, both in aggregate and by care setting, for 12 types of wounds: arterial ulcers, diabetic foot ulcers, diabetic infection, pressure ulcer, skin infection, skin disorder, chronic ulcer, surgical wounds, surgical infection, traumatic wound, venous ulcers, and venous infections.
The Future of Wound Care
Wound care professionals will be adjusting their volume-based wound care business models to align with the new value-based focus of the physicians, patients, and payers. The new merit-based model will be more sustainable in the long run for those professionals in the wound care business.
Health care facilities are still a business and need a good business model to become or remain successful. Health care providers will need to consider quality ways to save money. Some studies have said that by having a registered dietitian nutritionist on staff, you will have healthier patients.
The American Journal of Managed Care suggests that timely nutrition intervention has the power to help a patient heal faster; this means financial savings for health care facilities and patients.
Giving patients with a proper diet (the right mix of macronutrients and micronutrients) will provide them with better overall health and body function.
Proper nutrition can also lessen the chance of a 30-day readmission to a hospital or health care facility. A speedy recovery benefits everyone; the patient suffers less emotional stress and the caregivers don’t get burnt-out. A quick recovery should be everyone’s main concern.
If nutrition can have an impact on reducing long term costs, it would be wise for health care companies to have a registered dietitian nutritionist on their team. This is an investment many facilities could benefit from.
The wound care professionals in the health care industry are educated on how to manage wounds from beginning to end and they will need to use that knowledge to care for the patients wherever they are, not just in one site of care. Ideally, this new merit-based payment model will benefit patients and bring compassion back into the health care industry.
Get Help With Your Medical Costs
Medicare beneficiaries are usually unaware that Part A and Part B only covers 80% of their medical costs. That’s why it’s important to have a supplemental plan to cover the remaining 20%. To compare Medicare Supplement rates in your area, click here.