Issue: Volume 64 - Issue 10 - October 2018 ISSN 1943-2720

Index: Ostomy Wound Manage. 2018;64(10):16-17.

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The Alliance of Wound Care Stakeholders has been churning out comment letters to the Centers for Medicare and Medicaid Services (CMS) and other regulatory agencies at a staggering rate in 2018 in response to a tidal wave of policies that can negatively impact wound care patients and providers.

The Alliance unites wound care clinicians to advocate on public policy issues that could create barriers to patient care and access to treatments/services. Representing 20+ medical societies whose members treat patients with wounds, the Alliance has gone “on the record” and addressed issues that include:

wound care, debridement, and surgical dressing local coverage determinations (LCDs);

pressure injury and “hospital harms” quality measures;

hyperbaric oxygen therapy clinical coverage policies;

proposed rules for the 2019 Hospital Inpatient Prospective Payment System, the Hospital Outpatient Prospective Payment System, and the Medicare Physician Fee Schedule; 

preclaim review demonstration project or home health services;

the Lymphedema Treatment Act; and

cellular and tissue-based products (CTPs) for wound coverage policies.

The Best Defense is a Good Offense 

Data and research. To get the proverbial ear of policy makers and demonstrate why they should care about wound care, the Alliance sponsored the first comprehensive study documenting the economic impact of chronic wounds on the Medicare program. Findings showed that chronic wounds impact nearly 15% of Medicare beneficiaries (8.2 million) at an annual cost to Medicare conservatively estimated at $28.1 to $31.7 billion. This illuminated the need for more wound-relevant quality measures, payment models, and federal research funding. The findings (“An Economic Evaluation of the Impact, Cost and Medicare Policy Implications of Chronic Nonhealing Wounds,” published in Value in Health in late 2017) are still being actively disseminated by the Alliance and its members in support of our advocacy work. 

Pursuing coding reform. The current Healthcare Common Procedure Coding System (HCPCS) coding process used by Medicare, Medicaid, and commercial health plans (particularly for many of the durable medical equipment, orthotics, prosthetics, and supplies used in wound care) is not transparent, understandable, or predictable. This has created barriers to appropriate coverage and reimbursement for new technologies and products. This in turn can have a chilling effect on innovation by driving research and development  investments away from the wound care space. The Alliance has been proactive  throughout the year in advocating for HCPCS reforms to ensure appropriate coverage and reimbursement policies and patient access to quality care. 

Educating policy makers. In April, the Alliance convened medical directors and nursing staff of Medicare’s Pricing Data Analysis and Coding (PDAC) contractors for a full-day educational session that focused on surgical dressings, wound care, and wound healing topics. Recent surgical dressing policies have been problematic and illustrated to the Alliance a need to educate policy makers about surgical dressings and how they are used in real-world clinical practice. As part of the session, Alliance speakers circulated samples of different dressings so each PDAC attendee could see and touch the different sizes, shapes, and designs to better understand their uses and technology. The hope is that if policy makers are better attuned to wound care products and issues, future policy and coverage decisions will be more aligned with wound care practice. The session was well-received, and the Alliance has been asked to lead similar sessions for other policy-maker audiences.

Playing Defense 

Ensuring clinically sound, evidence-based coverage policies. Most Medicare coverage of products and services is guided by the LCDs of Medicare Administrative Contractors, the Physician Fee Schedule, and the prospective payment systems of inpatient, outpatient, and home health care. Problematic or overly restrictive policies directly impact the products, services, and technologies health professionals can provide to Medicare patients. The Alliance regularly comments on policies impacting the wound care space, addressing issues and impacts as they arise. In 2018, we’ve focused on: 

defending against the threats and challenges of exclusionary coverage and payment policies for CTPs, specifically the United Healthcare “skin and soft tissue” coverage policy and CMS’s Hospital Outpatient Prospective Payment System FY2019 proposed rule;

advising on the most appropriate elements for pressure injury quality measures, as part of our comments to CMS’ proposed FY2019 Hospital Inpatient Prospective Payment System and to the agency’s proposed “Hospital Harm-Hospital-Acquired Condition Pressure Injury measure”;

clarifying debridement and negative pressure wound therapy policies in a wound care LCD that went into effect in April 2018 from the Medicare Administrative Contractor Wisconsin Physician Services;

preventing a significant administrative burden on home health agencies as part of comments to CMS’s proposed Pre-Claim Review Demonstration for Home Health Services; 

advocating for Medicare coverage of compression bandages and garments for lymphedema via letters to Congress supporting the Lymphedema Treatment Act; and 

protecting against the proposed consolidation of Evaluation and Management (E/M) codes and the corresponding reduction in payment for E/M services via comments to the CMS’s proposed CY2019 Physician Fee Schedule that emphasize the wide range of patient visit complexity, time, and risk that is addressed by differing E/M levels.

Policies will continue to be issued, and the Alliance will continue to serve as a vocal, visible, and effective advocate on wound care issues. Stay tuned and keep up with Alliance advocacy, track relevant policies, and review our submitted comments at www.WoundCareStakeholders.org. 

 This article was not subject to the Ostomy Wound Management peer-review process.