Prospective payment plan will boost wound care

More focus on effective cures coming

Wound care professionals should welcome the changes in reimbursement resulting from provisions in the Balanced Budget Act instead of dreading them, because they provide a golden opportunity to pursue aggressive, high-end wound therapy.

That's the opinion of Kathy Schaum, MS, RD, president of Schaum Associates, a Lake Worth, FL, payment consultation company specializing in skin and wound care. "I feel this is all positive," says Schaum, who is the reimbursement consultant for Johnson & Johnson Medical. "It's a chance [for providers] to truly look at wounds, look at patients, and train staff on much more advanced wound therapy. It will save the system money, but it will also save the patient from going through long therapy."

SNFs have the opportunity now to manage their own wound care, says Schaum. "In the past, SNFs have had outside companies managing their wound care. Very often, dressings and therapies were selected for the lowest cost but the highest reimbursement, and the nursing homes weren't totally in charge of making those decisions."

Before, many nursing homes had an outside, third-party biller do their billing, so it wasn't their main focus. "Now the entire rate they get paid is dependent on assessing patients early, getting therapy started, and doing it quickly and efficiently," Schaum explains. "The incentive is to do the protocols correctly, using a standardized formula. They don't want to [treat] with old-fashioned betadine and gauze because it takes too long."

Because SNFs will now be paid based on the patient's acuity (when it's highest, they make the most money and as the patient gets better, they make less), the incentive is to focus on healing that patient when he or she is in the most acute phase, Schaum points out.

In such a scenario, everybody wins, Schaum says. "The patient wins, and the facility wins because of the payment program and because the outcomes will be great." That's particularly important because of the requirement that Minimum Data Set-II (MDS-II) data set information and Resource Utilization Groups III (RUGs III) information be sent to the state government, she notes. "Your data will be compared with somebody else's who sees the same types of patients." (For more details on the MDS-II, see story, below.)

To survive the interim and prospective payment systems, home health agencies must become very efficient, complete the care in as few visits as possible, and empower the patient to take over his or her own care, Schaum emphasizes. As with SNFs, there's a chance to take wound care to a higher level of quality.

"The opportunity is there for a wound care specialist to go to an administrator and say, 'I know how to put in the most efficient, advanced wound care program and train an ET nurse to do the most aggressive therapy,'" Schaum suggests. Before, she adds, such a suggestion might have drawn a response like, "Our doctors say betadine and gauze are OK - and besides, more visits mean more money," but now the situation is the opposite.

"Somebody will rise up to be the owner and orchestrator of this advanced wound therapy program," she says. "It's a dream come true as far as wound care goes. A lot of agencies that wouldn't have questioned a doctor writing an order for gauze and betadine before will do so now. They won't be able to afford all those visits."

In the past, wound clinics - or what Schaum calls the "wild, wild West of reimbursement" - have been able to set their own charges without much control. But come Jan. 1, 1999, she points out, all procedures done in those clinics will fall into ambulatory procedure codes (APCs) that will determine the amount of payment.

"[Clinics] are going to have to document all the procedures they do," Schaum explains. "In the past, they could charge anything they wanted to and the patient had to pay 20% of those charges. Now the patient will only pay 20% of the rate schedule for APC."

As a result, she predicts, the clinics will become more efficient, decide early on what needs to be done, and - as with home care and SNFs - perform advanced wound therapy so wounds will heal faster.