Sad but true: Much of what we do as healthcare professionals is based on reimbursement. For nearly all the services and products we use in wound care and ostomy management, Medicare, Medicaid, and insurance companies control reimbursement. For many years, these payers have been deciding which interventions, medications, products, and equipment are the best, and then reimbursing only for those items. If we want to use something not on the list, we—or our patients—will have to pay for it out of pocket.
Consequently, many clinicians first check to see if a service or item is covered or reimbursed before even considering whether it’s the best choice for the patient. This has resulted in a “do it as cheaply as possible” mentality.
How did we get to the point where we make decisions based primarily on cost? It didn’t happen overnight, and we certainly weren’t taught this in school. Instead, it has been handed down to us by our employers, who’ve had to adopt this approach because of payers’ policies. None of the best-practice guidelines for wound care mentions reimbursability as the first priority in choosing interventions, products, or medications. Instead, we are guided to assess each individual patient’s needs and then select whatever will heal the patient’s wound as quickly as possible with minimal pain, distress, and scarring.
The 2010 Affordable Care Act (ACA) ushered in a new era of pay for performance, rewarding healthcare providers for delivering a higher quality of care and producing better outcomes, instead of reimbursing based on volume of services provided. As each year passes, new phases of the ACA are influencing more decisions that promote a higher quality of care, and other healthcare payers (such as private insurers) are adopting the pay-for-performance approach.
As wound and ostomy clinicians, we need to refocus on what we were taught and what our practice guidelines direct us to do—and reflect on why we became wound and ostomy specialists in the first place. Our priority is to heal our patients quickly and effectively. A good starting point is becoming acquainted with the most recent clinical practice guidelines from AHRQ and NPUAP. Also, we need to stay educated on cutting-edge interventions, products, and equipment. This will help us get out of the “How much does it cost?” rut and move toward an environment of improved patient outcomes.
Donna Sardina, RN, MHA,WCC, CWCMS, DWC, OMS
Editor-in-Chief, Wound Care Advisor
Cofounder, Wound Care Education Institute