On Christmas Day, an article was published in JAMA that confirmed what many of us had suspected for a long time. When hospitals are penalized for high 30-day readmission rates,...
Hospital wound care clinics are one of those unheralded parts of healthcare. As our population ages, gets more obese, and has more diabetes, chronic wounds are only going to become more common and having a location within the hospital system that can provide a comprehensive approach to healing wounds is important today but will be even more important tomorrow.
A lot of wound care is general medicine
Many hospital leaders think of wound care as being a part of surgery. And it is true that surgical management is an important part of a comprehensive wound care program. However, healing wound really requires optimizing the patient’s medical conditions:
- Controlling diabetes
- Smoking cessation
- Nutrition optimization
- Improving blood flow
- Controlling infection
Therefore, physicians, nurse practitioners, and physician assistants who are trained in diabetes management, tobacco treatment counseling, nutrition, and treatment of infections are frequently in the best position to help optimize the patient’s ability to heal wounds. In other words, wound care is a perfect fit for general internists and family physicians.
Wound care does not mean “wound stare”
In order to really heal wounds, it is necessary to debride dead tissue. It is not enough to simply look at a wound every week without doing any intervention – the the patient’s regular primary care physician can already do that. A study in JAMA Dermatology showed that for 321,744 wounds at 525 wound centers in the United States, about 70% of wounds healed and required a median number of 2 debridements per wound. Wounds that were debrided more frequently healed faster and patients who were seen at least weekly in the wound centers had better outcomes.
Hyperbaric oxygen treatment uses a hyperbaric chamber where 100% oxygen is delivered under high pressure. These are body-sized tube-like chambers that the patient can lay in, typically for periods of 60 – 90 minutes at a time. Hyperbaric oxygen can promote wound healing by promoting angiogenesis and fibroblast proliferation. Patients return for repeated hyperbaric treatments as the wound heals. This requires a hyperbaric technician (often a respiratory therapist or EMT) to monitor the patient and manage the hyperbaric “dives”. Hyperbaric oxygen has been demonstrated to be effective in radiation injuries, osteoradionecrosis, osteomyelitis, threatened skin flaps, and diabetic ulcers. Generally 12-15% of would care patients benefit by hyperbaric oxygen treatments.
Wound care nurses
Wound care is more than just the doctors. Having wound care nurses who are trained and experienced in wound care is essential to a high-functioning wound care center. These are truly nurse specialists – it is not sufficient to use general outpatient nurses from medical or surgical clinics. Although a physician/NP may spend 10-15 minutes with each patient, the entirety of that patient’s visit is typically 45-60 minutes when vital signs, positioning, dressing removal, wound cleansing, patient education, and wound photography is factored in.
Sufficient space to practice in
Most primary care offices are set up with 2-3 exam rooms per physician. An effective wound center needs much more, typically 4-6 rooms per practitioner, since a lot of the actual care of the patient is actually done by the wound nurses rather than the physicians. Additionally, there needs to be a room large enough to co-locate 2-3 hyperbaric oxygen chambers so that a single hyperbaric technician can oversee multiple chambers at one time. The rooms need to be large enough to accommodate gurneys since many patients are non-ambulatory. Because wound care requires a lot of supplies, there has to be abundant storage space.
Staying financially viable
Wound centers should be able to at least break-even financially and most should be able to maintain a positive margin. However, to do so, there has to be more than just evaluation and management (E/M) billings. Wound care centers have a higher overhead than a typical primary care or medical specialty clinic given the higher nursing staffing and the higher equipment & supply costs. Therefore, a wound center that relies on E/M billing only will lose money. This is where hyperbaric oxygen treatments and debridements can help maintain sufficient income to offset the loses that would be incurred from E/M visits alone. Therefore financial viability requires a balance between E/M visits and hyperbaric/debridement services. Fortunately, since those hyperbaric treatments and the debridement procedures also improve patient outcomes, it is a win-win, for both the hospital and the patient. And, because hyperbaric treatments and debridements are also financially beneficial for the doctors, it is actually a win-win-win all the way around.
From the physician (or NP/PA) standpoint, there is strong incentive to participate in wound care in terms work RVU generation. The table below lists the common services and procedures performed in wound care (the dollar amounts are the Medicare reimbursable for 2019 in Ohio).
The most common procedure at most wound centers is simple debridement (99597) and skin & subcutaneous tissue debridement (11042). Tobacco cessation is an often-overlooked service in wound care since many patients with chronic wounds are smokers and it is easy to spend at least 3 minutes discussing smoking cessation strategies with the patient, often while doing a debridement.
Hyperbaric oxygen oversight is associated with a relatively large number of work RVUs (2.11) and is billed per treatment. This is different than the facility bill for hyperbaric oxygen which is billed for every 15 minutes of time that the patient is in the hyperbaric oxygen chamber. A patient who is in the chamber for 60 minutes is billed 4 units by the hospital (facility) and 1 unit of 99183 by the physician (or NP/PA). Since hyperbaric treatment oversight generally occurs at the same time that the physician is seeing patients in the wound center, this allows for a surprisingly large number of work RVUs to be generated in a single day of outpatient care.
So, how does wound care compare to regular outpatient practice for a family physician or internist? Assume that the primary care physician is in the office all day seeing level III return visits every 20 minutes. That equates to 23.28 work RVUs or 34.56 total RVUs ($1,217 in Medicare reimbursable dollars). If that physician is working in a wound clinic and doing 1 subcutaneous debridement for every 2 patients plus supervising 4 hyperbaric oxygen treatments, then this adds up to 43.84 work RVUs, 68.16 total RVUs, and $3,163 in Medicare reimbursement! In other words, wound care is one of the most lucrative things a family physician or general internist can do and can be a great way to supplement a traditional primary care practice.
Inadequately treated foot and ankle wounds often result in osteomyelitis and leg amputations. A major goal of wound care is preventing amputations by “salvaging” the leg. Ideally, this requires a coordinated multidisciplinary approach including primary care physicians (or NPs/PAs), vascular surgeons, infectious disease specialists, and podiatrists. By making the wound center a “one-stop-shop” where the patient with a foot ulcer or wound can see multiple specialists, the care can be optimized and give that wound the best chance to heal without having to resort to amputation.
A natural fit for podiatrists
In most wound centers, diabetic foot ulcers are a major indication for services. This fits perfectly with podiatrists’ scope of practice. In Ohio, one limitation is that podiatrists cannot oversee or bill for hyperbaric oxygen treatments (although nurse practitioners can). An additional advantage that podiatrists have over other practitioners is that they are surgeons who spend a significant amount of their time in the operating room. In other words, the podiatrist has one foot in the ambulatory clinic and one foot in the OR (so to speak) which can facilitate comprehensive care of those foot wounds that require more debridement or surgical care than can be done in the wound center and which require surgical debridement in the operating room.
A multi-disciplinary approach
A high-functioning and effective wound center needs to have easy access to consultation by many types of physicians. Although the main providers responsible for the regular wound care visits may be general internists, family physicians, or nurse practitioners, there are a whole group of specialists whose availability is necessary for comprehensive care of the wound. These specialists may not necessarily practice in the wound center but there needs to be easy access to them, ideally in same facility, such as a hospital outpatient building. These include: plastic surgeons, podiatrists, orthopedic surgeons, vascular surgeons, infectious disease specialists, dermatologists, and endocrinologists. Other healthcare providers needed on-site include physical therapists, orthotists/prostesthetists, nutritionists, radiology services, and occupational therapists.
In summary, a comprehensive approach to wound care is an increasingly necessary part of the overall care provided by hospitals. To be effective, a wound center requires a considerable financial investment and then needs to maintain a coordinated multidisciplinary group of healthcare providers to optimize wound healing rates. Fortunately, under current Medicare reimbursement rates, wound care is financially attractive to physicians, particularly general internists and family physicians.
October 12, 2019