AAWC Government & Regulatory Task Force

1. AAWCGovernment & Regulatory Task Force Mission: Optimize government and regulatory policies to improve wound care practices AAWC Government & Regulatory Task Force

2. Focus Issue • Is product/procedural reimbursement adequate to support : • State of the art wound care modalities • Aggressive management as indicated by clinical presentation • Patient compliance with the prescribed treatment plan • Complex high acuity wound care in all healthcare settings AAWC Government & Regulatory Task Force

3. Task Force Goals • Identify best practice wound management modalities • First target: venous ulcer • Explore reimbursement of evidence based practices in various healthcare settings • Close evidence & reimbursement gaps AAWC Government & Regulatory Task Force

4. Co-chairs: L. Corbett, APRN, MSN,CWOCN L. Bolton, Ph.D. Members S. 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, CWOCN T. Mulloy, BSN,RN,CETN M. Nusgart, RPh G.K. Patterson, MD T. Phillips, MD L. Dahl Popkes, RN, CWOCN P. Porter Riedesel, PT, CWS P. Sheehan, MD S. Sinkovic, RN, BSN, CWOCN M. Southworth, MD Multi-disciplinary AAWC Task Force AAWC Government & Regulatory Task Force

5. VUCI (Venous Ulcer Care Initiative): Methods • Timeline: April, 2002 - December, 2003 • Funding: No industry funding to date • AAWC support • Food during 2 meetings held at SAWC • Connections for 12 teleconferences • All Volunteer Task-Force • Planned process • Conducted literature searches • Compiled evidence & algorithm AAWC Government & Regulatory Task Force

6. VUCI: Methods • Construct VU Algorithm • Combine VU algorithms published pre - 2002 • Highlight each step's reimbursement status • Select evidence criteria • AHRQ (former AHCPR) levels of evidence • Assemble evidence in the VU Algorithm • Expanded MEDLINE, EMBASE searches • Best available evidence listed: up to 5 studies • Illustrate reimbursement with scenarios AAWC Government & Regulatory Task Force

7. VUCI: Results • Annotated Algorithm • Evidence Table • Scenarios • Executive Summary AAWC Government & Regulatory Task Force

8. VUCI Results: Example Section of Annotated Algorithm AAWC Government & Regulatory Task Force

9. VUCI Results: Example Section of Evidence Table AAWC Government & Regulatory Task Force

10. VUCI Results: A-Level Evidence AAWC Government & Regulatory Task Force

11. VUCI Results: Example of A-Level Care • An actual case of venous ulcer management using multi-layer compression wrap AAWC Government & Regulatory Task Force

12. VUCI Case study Ulcer Assessment Site Cleansing Skin Perimeter Care Ulcer Dressing: Alginate AAWC Government & Regulatory Task Force

13. VUCI Case study continued Absorbent Topper Padding Bandage Elastic Compression Conforming Bandage AAWC Government & Regulatory Task Force

14. VUCI Case study finality Bilateral Treatment Completed Treatment AAWC Government & Regulatory Task Force

15. VUCI Results: Scenarios • Scenarios depicting real world impact of current reimbursement policies • Various healthcare settings • Medicare Part A • Medicare Part B AAWC Government & Regulatory Task Force

16. VUCI Scenarios Medicare Part A • Setting: Connecticut Home care agency1 • Necrotic, infected VU DEBRIDING OPTION Autolytic or Enzymatic • Loss per VU healed: ($2587 or $4157) • With outlier adjustment ($2430 or $2744) 1Costs include direct labor + administrative, general expenses of $131.45 per nursing visit (Amer. Assn. Homecare 2002 Financial Performance Survey) AAWC Government & Regulatory Task Force

17. VUCI Scenarios Medicare Part A • Setting: Skilled Nursing Facility • Vanwert, OH • Loss per VU healed: ($654) AAWC Government & Regulatory Task Force

18. VUCI Scenarios Medicare Part A • Setting: Acute Care Hospital • St. Louis, MO • Loss per VU healed: ($1155) AAWC Government & Regulatory Task Force

19. VUCI Scenarios Medicare Part A (Facility Fee Code) Medicare Part B (Professional Fee) • Setting: Hospital OutpatientClinic • Missouri • Loss per VU healed: ($1192) AAWC Government & Regulatory Task Force

20. VUCI Scenarios Medicaid with Medicare Part B • Setting: Long Term Care Facility • Columbus, OH • Loss per VU healed • ($2150) AAWC Government & Regulatory Task Force

21. VUCI Scenarios Medicare Part B Setting: St. Louis, MO Physician’s Office • No incentive to adopt A-Level care to: • Reduce economic burden of VU care • Minimize wound pain • Foster healing • 49% of cost in supplies if A-Level practice is followed AAWC Government & Regulatory Task Force

22. C-Level Gauze Dressing 39% heal in 12 weeks 4 dressing changes / week 12 week materials costs 1 dressing change $15.85 Average total: $760.80 12 week nursing costs Per nursing visit $ 11.52 Average total: $552.96 MD debridement: $710.34 ___________________________ TOTAL $2024.10 A-Level Dressing 51% heal in 12 weeks 1.6 dressing changes/week 12 week materials costs 1 dressing change $23.99 Average total: $460.61 12 week nursing costs Per nursing visit $ 11.52 Average total: $221.18 MD debridement: $710.34 ___________________________ TOTAL $1392.13 CMS Saves $631.97 per VU healed using A-Level Care, plus more VUs healed in 12 weeksKerstein MD et al. Dis Manage Health Outcomes 2001; 9(11):651-663. AAWC Government & Regulatory Task Force

23. VUCI Conclusions • Gaps persist between evidence and practice, fueled by reimbursement gaps • Many facilities practicing quality VU care lose revenue even when reimbursed • Only in the physician office is revenue positive--more so with low quality care • Improving VU reimbursement policies could save more than $632 per VU healed AAWC Government & Regulatory Task Force