vuci © aawc 2002aawc government & regulatory task force15-feb-04 1 aawc government &...

VUCI © AAWC 2002AAWC Government & Regulatory Task Force

15-Feb-04 1

AAWCAAWCGovernment & Regulatory Task ForceGovernment & Regulatory Task Force

Mission:Mission:

Optimize government and Optimize government and regulatory policies to improve regulatory policies to improve wound care practiceswound care practices


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Focus IssueFocus Issue

• Is product/procedural reimbursement Is product/procedural reimbursement adequate to support :adequate to support :– State of the art wound care modalitiesState of the art wound care modalities– Aggressive management as indicated by clinical Aggressive management as indicated by clinical

presentationpresentation– Patient compliance with the prescribed treatment Patient compliance with the prescribed treatment

planplan– Complex high acuity wound care in all healthcare Complex high acuity wound care in all healthcare

settingssettings


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Task Force GoalsTask Force Goals

• Identify best practice wound Identify best practice wound management modalitiesmanagement modalities– First target: venous ulcerFirst target: venous ulcer

• Explore reimbursement of Explore reimbursement of evidence based practices in evidence based practices in various healthcare settingsvarious healthcare settings

• Close evidence & Close evidence & reimbursement gapsreimbursement gaps


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Multi-disciplinary AAWC Task Multi-disciplinary AAWC Task ForceForce

Co-chairsCo-chairs: :

L. Corbett, APRN, L. Corbett, APRN, MSN,CWOCN MSN,CWOCN L. Bolton, L. Bolton, Ph.D.Ph.D.

MembersMembersS. Alter, DPM

A. Batzler, MN, FNP

D. L. Bernato, RN, MN, WOCN

N.R. Bruno, RN, BSN, CETN

G. Chudleigh, MS, PT, CWS

P. Dotson,RN, BSN

P. Erwin-Toth, RN, MSN, CWOCN

G. Everhart, DPT

R.S. Jordan, RN, BSN, CWOCN

S.N. LaRaus, PT, CWS

S/K/ Lee, MD, FACS

C.H. Lyder, ND, APRN, CS, GNP

P. McNees, PhD

D.Merkle, APRN,MSN, MSHSA, CWOCND.Merkle, APRN,MSN, MSHSA, CWOCN

T. Mulloy, BSN,RN,CETNT. Mulloy, BSN,RN,CETN

M. Nusgart, RPhM. Nusgart, RPh

G.K. Patterson, MDG.K. Patterson, MD

T. Phillips, MDT. Phillips, MD

L. Dahl Popkes, RN, CWOCNL. Dahl Popkes, RN, CWOCN

P. Porter Riedesel, PT, CWSP. Porter Riedesel, PT, CWS

P. Sheehan, MDP. Sheehan, MD

S. Sinkovic, RN, BSN, CWOCNS. Sinkovic, RN, BSN, CWOCN

M. Southworth, MDM. Southworth, MD


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VUCI (Venous Ulcer Care VUCI (Venous Ulcer Care Initiative): MethodsInitiative): Methods

• Timeline: Timeline: April, 2002 - December, 2003April, 2002 - December, 2003

• Funding: Funding: No industry funding to date No industry funding to date – AAWC supportAAWC support

• Food during 2 meetings held at SAWCFood during 2 meetings held at SAWC

• Connections for 12 teleconferencesConnections for 12 teleconferences

• All Volunteer Task-ForceAll Volunteer Task-Force– Planned processPlanned process– Conducted literature searchesConducted literature searches– Compiled evidence & algorithmCompiled evidence & algorithm


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VUCI: MethodsVUCI: Methods

• Construct VU AlgorithmConstruct VU Algorithm– Combine VU algorithms published pre - 2002Combine VU algorithms published pre - 2002– Highlight each step's reimbursement statusHighlight each step's reimbursement status

• Select evidence criteriaSelect evidence criteria– AHRQ (former AHCPR) levels of evidenceAHRQ (former AHCPR) levels of evidence

• Assemble evidence in the VU AlgorithmAssemble evidence in the VU Algorithm– Expanded MEDLINE, EMBASE searchesExpanded MEDLINE, EMBASE searches– Best available evidence listed: up to 5 studiesBest available evidence listed: up to 5 studies

• Illustrate reimbursement with scenarios Illustrate reimbursement with scenarios


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VUCI: ResultsVUCI: Results

• Annotated AlgorithmAnnotated Algorithm

• Evidence TableEvidence Table

• ScenariosScenarios

• Executive SummaryExecutive Summary


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VUCI Results: VUCI Results: Example Section of Annotated AlgorithmExample Section of Annotated Algorithm

B iophys ica l M oda litiesE lec trica l s tim u la tion (A ) [MD Office, Out-patiend clinic APC]

F eederJA e t a l (R C T)K lo th LC (R C T)

V acuum (N ega tive P ressu re (B ) [HH]E vans D ,Land L (R C T--Insu ffic ien t da ta fo r e fficacy)A rgen ta L M orykw as M (E O )M orykw as M , e t a l. (A M R C T)

W arm ing (C ) [None]R ob inson C , S an till S . (R C T--S a fe ; insu ffic ien t e fficacy da ta )S an till S M e t a l. (E O )

E lec trom agne tic / R F s tim u la tion (A ) [None]K enkre JE (R C T)S tille rM J (R C T)Ie ran M e t a l (R C T)Todd D J e t a l (R C T--E ffec t no t s ign ifican t)C anedo-D oran tes L (E O )

Lase r o r IR s tim u la tion (e .g . m onochrom atic ) (C ) [None]F lem m ing K , C u llum N (N o t E fficac ious)

H yperba ric O xygen (C ) [MD Office, Out-patiend clinic APC]F ishe r B H (E O )

U ltrasound s tim u la tion (C ) [None]P resco tt R J (R C T)

W h irlpoo l (C ) [MD Office, Out-patiend clinic APC]M cC u lloch J (R C T) --N o e fficacy reduc ing edem a


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VUCI Results: VUCI Results: Example Section of Evidence TableExample Section of Evidence Table


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RESULTS: A-Level Evidence Support for Venous Ulcer Algorithm Items

Step in Algorithm Items with A-Level Support History Lower leg edema Differential diagnosis Ankle:Brachial Index, Plethysmography, TCPO2 Physical exam CEAP, Edema, Measure ulcer size, Location Remove cause: Aid venous return and Provide Skin Care

Patient education, Elastic compression bandages or stockings, Non-elastic compression bandages: though less healing than elastic

Wound cleansing, Debridement Autolytic debridement Manage excess exudate Alginate or Hydrofiber® Dressings Maintain moist wound environment

Hydrocolloid Dressings

Antimicrobial products (topical) Iodine-containing dressing Biologic Dressings None with A-level evidence. Surgical options, including grafting, CEA, SEPS

SEPS, Superficial vein surgery

Biophysical modalities Electrical or electromagnetic stimulation, Pharmaceutical options Pentoxifylline Wound care above until healed Diagnosis/exam, compression, A-level local care Care above to prevent recurrence

Diagnosis/exam, compression, A-level local care

VUCI Results: A-Level EvidenceVUCI Results: A-Level Evidence


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VUCI Results: Example of A-Level CareVUCI Results: Example of A-Level Care

• An actual case of An actual case of venous ulcer venous ulcer management using management using multi-layer multi-layer compression wrapcompression wrap


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VUCI Case studyVUCI Case study

Ulcer Ulcer AssessmentAssessment Site CleansingSite Cleansing

Skin Perimeter CareSkin Perimeter Care Ulcer Dressing: AlginateUlcer Dressing: Alginate


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VUCI Case study continuedVUCI Case study continued

Absorbent TopperAbsorbent Topper Padding BandagePadding Bandage

Elastic CompressionElastic Compression Conforming BandageConforming Bandage


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VUCI Case study finalityVUCI Case study finality

Bilateral TreatmentBilateral Treatment

Completed TreatmentCompleted Treatment


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VUCI Results: ScenariosVUCI Results: Scenarios

• Scenarios depicting real world Scenarios depicting real world impact of current reimbursement impact of current reimbursement policiespolicies– Various healthcare settingsVarious healthcare settings– Medicare Part AMedicare Part A– Medicare Part BMedicare Part B


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VUCI ScenariosVUCI Scenarios

Medicare Part AMedicare Part A

• Setting: Connecticut Home care agencySetting: Connecticut Home care agency11

– Necrotic, infected VU Necrotic, infected VU DEBRIDING OPTION DEBRIDING OPTION

AutolyticAutolytic or or EnzymaticEnzymatic

• Loss per VU healed: ($2587 or $4157) Loss per VU healed: ($2587 or $4157) – With outlier adjustment ($2430 or $2744)With outlier adjustment ($2430 or $2744)

11Costs include direct labor + administrative, general expenses of $131.45 per Costs include direct labor + administrative, general expenses of $131.45 per nursing visit (Amer. Assn. Homecare 2002 Financial Performance Survey) nursing visit (Amer. Assn. Homecare 2002 Financial Performance Survey)


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• Setting: Setting: Skilled Nursing FacilitySkilled Nursing Facility– Vanwert, OH Vanwert, OH

• Loss per VU healed: ($654) Loss per VU healed: ($654)


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• Setting: Setting: Acute Care HospitalAcute Care Hospital – St. Louis, MO St. Louis, MO



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Medicare Part AMedicare Part A (Facility Fee Code) (Facility Fee Code)

Medicare Part BMedicare Part B (Professional Fee) (Professional Fee)

• Setting: Setting: Hospital OutpatientHospital Outpatient ClinicClinic – MissouriMissouri



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Medicaid with Medicare Part BMedicaid with Medicare Part B

• Setting: Setting: Long Term Care FacilityLong Term Care Facility – Columbus, OH Columbus, OH

• Loss per VU healedLoss per VU healed– ($2150) ($2150)


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Medicare Part BMedicare Part B

Setting: St. Louis, MO Physician’s Office Setting: St. Louis, MO Physician’s Office – No incentive to adopt A-Level care to:No incentive to adopt A-Level care to:

• Reduce economic burden of VU careReduce economic burden of VU care• Minimize wound painMinimize wound pain• Foster healingFoster healing

– 49% of cost in supplies if A-Level practice is 49% of cost in supplies if A-Level practice is followed followed


15-Feb-04 22

CMS Saves $631.97 per VU healed using A-Level CMS Saves $631.97 per VU healed using A-Level Care, plusCare, plus more VUs healed in 12 weeks more VUs healed in 12 weeks Kerstein MD Kerstein MD et al. Dis Manage Health Outcomeset al. Dis Manage Health Outcomes 2001; 9(11):651-663. 2001; 9(11):651-663.

C-Level Gauze DressingC-Level Gauze Dressing– 39% heal in 12 weeks39% heal in 12 weeks– 4 dressing changes / week4 dressing changes / week– 12 week materials costs12 week materials costs

• 1 dressing change $15.851 dressing change $15.85

• Average total: $760.80Average total: $760.80

– 12 week nursing costs12 week nursing costs• Per nursing visit $ 11.52Per nursing visit $ 11.52


– MD debridement: MD debridement: $710.34$710.34

______________________________________________________

TOTALTOTAL $2024.10$2024.10

A-Level DressingA-Level Dressing– 51% heal in 12 weeks51% heal in 12 weeks– 1.6 dressing changes/week1.6 dressing changes/week– 12 week materials costs12 week materials costs

• 1 dressing change $23.991 dressing change $23.99


– 12 week nursing costs12 week nursing costs• Per nursing visit $ 11.52Per nursing visit $ 11.52


– MD debridement: MD debridement: $710.34$710.34

______________________________________________________

TOTALTOTAL $1392.13$1392.13


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VUCI ConclusionsVUCI Conclusions

• Gaps persist between evidence and Gaps persist between evidence and practice, fueled by reimbursement gapspractice, fueled by reimbursement gaps

• Many facilities practicing quality VU care Many facilities practicing quality VU care lose revenue even when reimbursedlose revenue even when reimbursed

• Only in the physician office is revenue Only in the physician office is revenue positive--more so with low quality carepositive--more so with low quality care

• Improving VU reimbursement policies Improving VU reimbursement policies could save more than $632 per VU healedcould save more than $632 per VU healed

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