1. VUCI © AAWC 2002AAWC Government & Regulatory Task Force15-Feb-04 1 AAWC Government & Regulatory Task Force Mission: Optimize government and regulatory policies to improve wound care practices

2. VUCI © AAWC 2002AAWC Government & Regulatory Task Force15-Feb-04 2 Focus Issue Is product/procedural reimbursement adequate to support :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

3. VUCI © AAWC 2002AAWC Government & Regulatory Task Force15-Feb-04 3 Task Force Goals Identify best practice wound management modalitiesIdentify best practice wound management modalities –First target: venous ulcer Explore reimbursement of evidence based practices in various healthcare settingsExplore reimbursement of evidence based practices in various healthcare settings Close evidence & reimbursement gapsClose evidence & reimbursement gaps

4. VUCI © AAWC 2002AAWC Government & Regulatory Task Force15-Feb-04 4 Multi-disciplinary AAWC Task Force Co-chairs: L. Corbett, APRN, MSN,CWOCN L. Bolton, Ph.D. 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

5. VUCI © AAWC 2002AAWC Government & Regulatory Task Force15-Feb-04 5 VUCI (Venous Ulcer Care Initiative): Methods Timeline: April, 2002 - December, 2003Timeline: April, 2002 - December, 2003 Funding: No industry funding to dateFunding: No industry funding to date –AAWC 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 process –Conducted literature searches –Compiled evidence & algorithm

6. VUCI © AAWC 2002AAWC Government & Regulatory Task Force15-Feb-04 6 VUCI: Methods Construct VU AlgorithmConstruct VU Algorithm –Combine VU algorithms published pre - 2002 –Highlight each step's reimbursement status Select evidence criteria Select evidence criteria –AHRQ (former AHCPR) levels of evidence Assemble evidence in the VU AlgorithmAssemble evidence in the VU Algorithm –Expanded MEDLINE, EMBASE searches –Best available evidence listed: up to 5 studies Illustrate reimbursement with scenariosIllustrate reimbursement with scenarios

7. VUCI © AAWC 2002AAWC Government & Regulatory Task Force15-Feb-04 7 VUCI: Results Annotated AlgorithmAnnotated Algorithm Evidence TableEvidence Table ScenariosScenarios Executive SummaryExecutive Summary

8. VUCI © AAWC 2002AAWC Government & Regulatory Task Force15-Feb-04 8 VUCI Results: Example Section of Annotated Algorithm

9. VUCI © AAWC 2002AAWC Government & Regulatory Task Force15-Feb-04 9 VUCI Results: Example Section of Evidence Table

10. VUCI © AAWC 2002AAWC Government & Regulatory Task Force15-Feb-04 10 VUCI Results: A-Level Evidence

11. VUCI © AAWC 2002AAWC Government & Regulatory Task Force15-Feb-04 11 VUCI Results: Example of A-Level Care An actual case of venous ulcer management using multi-layer compression wrapAn actual case of venous ulcer management using multi-layer compression wrap

12. VUCI © AAWC 2002AAWC Government & Regulatory Task Force15-Feb-04 12 VUCI Case study Ulcer Assessment Site Cleansing Skin Perimeter Care Ulcer Dressing: Alginate

13. VUCI © AAWC 2002AAWC Government & Regulatory Task Force15-Feb-04 13 VUCI Case study continued Absorbent Topper Padding Bandage Elastic Compression Conforming Bandage

14. VUCI © AAWC 2002AAWC Government & Regulatory Task Force15-Feb-04 14 VUCI Case study finality Bilateral Treatment Completed Treatment

15. VUCI © AAWC 2002AAWC Government & Regulatory Task Force15-Feb-04 15 VUCI Results: Scenarios Scenarios depicting real world impact of current reimbursement policiesScenarios depicting real world impact of current reimbursement policies –Various healthcare settings –Medicare Part A –Medicare Part B

16. VUCI © AAWC 2002AAWC Government & Regulatory Task Force15-Feb-04 16 VUCI Scenarios Medicare Part A Setting: Connecticut Home care agency 1Setting: Connecticut Home care agency 1 –Necrotic, infected VU DEBRIDING OPTION Autolytic or Enzymatic Autolytic or Enzymatic Loss per VU healed: ($2587 or $4157)Loss per VU healed: ($2587 or $4157) –With outlier adjustment ($2430 or $2744) 1 Costs include direct labor + administrative, general expenses of $131.45 per nursing visit (Amer. Assn. Homecare 2002 Financial Performance Survey)

17. VUCI © AAWC 2002AAWC Government & Regulatory Task Force15-Feb-04 17 VUCI Scenarios Medicare Part A Setting: Skilled Nursing FacilitySetting: Skilled Nursing Facility –Vanwert, OH Loss per VU healed: ($654)Loss per VU healed: ($654)

18. VUCI © AAWC 2002AAWC Government & Regulatory Task Force15-Feb-04 18 VUCI Scenarios Medicare Part A Setting: Acute Care HospitalSetting: Acute Care Hospital –St. Louis, MO Loss per VU healed: ($1155)Loss per VU healed: ($1155)

19. VUCI © AAWC 2002AAWC Government & Regulatory Task Force15-Feb-04 19 VUCI Scenarios Medicare Part A (Facility Fee Code) Medicare Part B (Professional Fee) Setting: Hospital Outpatient ClinicSetting: Hospital Outpatient Clinic –Missouri Loss per VU healed: ($1192)Loss per VU healed: ($1192)

20. VUCI © AAWC 2002AAWC Government & Regulatory Task Force15-Feb-04 20 VUCI Scenarios Medicaid with Medicare Part B Setting: Long Term Care FacilitySetting: Long Term Care Facility –Columbus, OH Loss per VU healedLoss per VU healed – ($2150)

21. VUCI © AAWC 2002AAWC Government & Regulatory Task Force15-Feb-04 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 careReduce economic burden of VU care Minimize wound painMinimize wound pain Foster healingFoster healing –49% of cost in supplies if A-Level practice is followed

22. VUCI © AAWC 2002AAWC Government & Regulatory Task Force15-Feb-04 22 CMS Saves $631.97 per VU healed using A-Level Care, plus more VUs healed in 12 weeks Kerstein MD et al. Dis Manage Health Outcomes 2001; 9(11):651-663. C-Level Gauze Dressing –39% heal in 12 weeks –4 dressing changes / week –12 week materials costs 1 dressing change $15.851 dressing change $15.85 Average total: $760.80Average total: $760.80 –12 week nursing costs Per nursing visit $ 11.52Per nursing visit $ 11.52 Average total: $552.96Average 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

23. VUCI © AAWC 2002AAWC Government & Regulatory Task Force15-Feb-04 23 VUCI Conclusions Gaps persist between evidence and practice, fueled by reimbursement gapsGaps persist between evidence and practice, fueled by reimbursement gaps Many facilities practicing quality VU care lose revenue even when reimbursedMany facilities practicing quality VU care lose revenue even when reimbursed Only in the physician office is revenue positive--more so with low quality careOnly in the physician office is revenue positive--more so with low quality care Improving VU reimbursement policies could save more than $632 per VU healedImproving VU reimbursement policies could save more than $632 per VU healed