Tag Archives: healthcare costs

Doing it cheaply vs. doing what’s best for patients

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

Clinical Notes

Diabetes carries high economic burden

According to a study published in Diabetes Care, the economic burden associated with diagnosed diabetes (all ages) and undiagnosed diabetes, gestational diabetes, and prediabetes (adults) exceeded $322 billion in 2012, amounting to an economic burden exceeding $1,000 for each American.

The authors of “The economic burden of elevated blood glucose levels in 2012: Diagnosed and undiagnosed diabetes, gestational diabetes mellitus, and prediabetes” note that the $322 billion number, which comprises $244 billion in excess medical costs and $78 billion in decreased productivity, is 48% higher than the $218 billion estimate for 2007.

Review article on lymphedema published

Recent progress in the treatment and prevention of cancer-related lymphedema,” published in CA: A Cancer Journal for Clinicians, reviews recent developments in the diagnosis, treatment, and prevention of cancer-related lymphedema, including breast cancer and other cancer types—melanoma, gynecologic, genitourinary, and head and neck.

The article also discusses the issue of insufficient insurance coverage for the diagnosis and treatment of lymphedema. The authors emphasize the importance of early identification of the condition and early referral.

Preventing breast cancer

Risk determination and prevention of breast cancer,” published in Breast Cancer Research, estimates that half of breast cancers might be prevented in women at high and moderate risk by using chemoprevention (tamoxifen, raloxifene, exemestane, and anastrozole). For all women, lifestyle measures, including weight control, exercise, and moderating alcohol intake, could reduce breast cancer risk by about 30%.

Ostomy can hinder goal attainment in cancer patients

Changes in cancer patients’ personal goals in the first 6 months after diagnosis: The role of illness variables,” in Supportive Care in Cancer, notes that overall, patients reported a “decrease in illness-related hindrance, higher attainability and likelihood of success, a decrease in total number of goals, goals with a shorter temporal range, and more physical and fewer social goals.”

However, patients with more advanced stages of cancer, rectal cancer, or a stoma and receiving additional chemotherapy or radiotherapy reported more difficulty attaining their goals because of their illness. Only patients with a stoma reported “lower attainability, likelihood of success, and more short-term goals.”

Device to prevent parastomal hernia studied

In “A promising new device for the prevention of parastomal hernia,” in Surgical In­novations, researchers from Switzerland report their experience with a new stoma­plasty ring (KORING) that they invented. The ring, which has been used only once, is intended to prevent parastomal hernias.

CDC releases guideline on preventing HIV transmission from those with HIV

The Centers for Disease Control and Prevention (CDC) has released “Recommendations for HIV prevention with adults and adolescents with HIV in the United States, 2014.” The guideline includes recommendations about biomedical, behavioral, and structural interventions that can help reduce the risk of human immunodeficiency virus (HIV) transmission from persons with HIV by reducing their infectiousness and their risk of exposing others to HIV.

Rate of rising healthcare costs slows

The Centers for Medicare & Medicaid Services reports U.S. healthcare spending in 2013 increased 3.6% to $2.9 trillion, or $9,255 per person. “National health spending in 2013: Growth slows, remains in step with the overall economy,” published in Health Affairs, notes that spending slowed by an 0.05 percentage point, compared with 2012. Health care has been 17.4% of the gross national product since 2009.

The slower growth is consistent with slower growth in private health insurance and Medicare spending. Other reasons include slower growth in spending for hospital care, investments in medical structures and equipment, and spending for physician and clinical care.

Low-glycemic index diet doesn’t improve cardiovascular risk factors

Overweight and obese persons who eat a diet that has a low glycemic index of carbohydrate don’t have improvements in insulin sensitivity, lipid levels, or systolic blood pressure, according to a study in JAMA.

Effects of high vs low glycemic index of dietary carbohydrate on cardiovascular disease risk factors and insulin sensitivity” concludes that “using glycemic index to select specific foods may not improve cardiovascular risk factors or insulin resistance.”

DISCLAIMER: All clinical recommendations are intended to assist with determining the appropriate wound therapy for the patient. Responsibility for final decisions and actions related to care of specific patients shall remain the obligation of the institution, its staff, and the patients’ attending physicians. Nothing in this information shall be deemed to constitute the providing of medical care or the diagnosis of any medical condition. Individuals should contact their healthcare providers for medical-related information.