To survive HCFA payment changes, find best practices and be consistent

Efficiency will be rewarded, experts say

Wound care providers in all treatment settings face a complicated tangle of changes as a result of Medicare's new rules for reimbursement under the Balanced Budget Act of 1997. What's clear, say leaders in the field, is that those who are to survive - and even thrive - under the new payment systems must first get their businesses in order.

Better use of staff time, less waste of products, and perhaps most important, standardization of practice, are crucial for success under the interim and prospective payment systems, the experts maintain. With all the reimbursement turmoil, there's a strong possibility that inefficient facilities will not survive, notes Peggy Dotson, RN, BS, director of reimbursement and payer alliances for ConvaTec, a Bristol Myers-Squibb company in Skillman, NJ. (For a summary of the changes, see story, p. 87.) Providers who do survive must make themselves more efficient and organized so they can compete not only under Medicare, but also under managed care, she suggests. "It's an opportunity to improve your market position."

Before you panic over the new regulations, look closely at your financial data and become extremely efficient, advises Dotson, "Ask, 'Am I providing wound care that makes sense?' Do we purchase zillions of types of products? Do all our nurses do things differently? Am I getting consistent outcomes if everyone does [treatment] differently? Am I using the highest-quality approaches to get the best outcome?"

Start by understanding what your costs are, something there's been no incentive to do before, so you can improve your efficiency, she says. "The take-home message is that prevention of wounds should be a critical factor, and that prevention of further breakdown is even more important than in the past."

One of the problems with the new payment system is that most home care agencies and skilled nursing facilities don't have a clear understanding of their actual wound care costs, says Gwen Turnbull, RN, BS, CETN, a Yardley, PA-based nurse consultant who specializes in health care reform and reimbursement for ostomy and wound care. Providers have a tendency to look only at wound care supplies rather than at the whole process of providing wound care, she adds.

"They probably don't understand the true cost, nor do they understand the differences in cost of caring for different wounds, because they haven't had to until now," Turnbull says. "Home health agencies were being reimbursed on reasonable costs, and skilled nursing facilities were able to charge for ancillary costs, so they didn't have to look at this."

Under the prospective payment system (PPS) rates, she points out, providers aren't going to remain financially viable unless their costs are lower than their payment rate. Facilities are going to be paid a lump sum amount for the total care of the patient, Turnbull explains. Details will vary depending on the setting, but basically, a certain case mix will give a certain payment. If costs - not just of supplies, but of all the systems and processes involved in caring for the patient - are above that, the provider's in trouble, she adds.

However, reducing costs with simplistic short-term fixes is ultimately self-defeating, Dotson contends. For instance, using an inexpensive gauze dressing that must be changed several times a day instead of a more expensive but higher-quality moist-healing dressing that is changed every second or third day probably is not the wisest practice, she says.

With the gauze method, you're using more cleansing solution, more pads for the bed, and more gauze to clean the wound with each change, and there's always the risk of invading bacteria, Dotson points out. "Choose a product that initially costs more but requires less staff time and fewer ancillary products and that has better clinical results and better healing rates. That reduces cost of care and leaves more time for staff to chart correctly and do required documentation."

Educating employees is a big part of responding positively to the reimbursement changes, she says. "Get staff to understand that variation in what they do affects the bottom line, and that consistency and best utilization tie into getting results."

"Set protocols, set formulary of products," advises Kathy Schaum, MS, RD, president of Schaum Associates, a Lake Worth, FL, payment consultation company specializing in skin and wound care. "Rather than 15 types of foam dressings, use one. Train nurses and physical therapists in the latest wound therapy. You want the fastest outcome possible - outcomes are where it's at."