In a time when quality of care impacts reimbursement and reimbursement affects quality care, all parties in the healthcare system feel the impact and the frustration. What’s best for the patient isn’t always reimbursable, which can place them at odds with payers and, subsequently, providers.
According to Health Management Policy & Innovation (HMPI) at Northwestern University, in 2013 dollars medical supply expenses averaged 15 percent of total hospital expenses. The average patient admission required $4,470 of supply expenses. To try and curb costs in situations like this, guidelines are put in place to set standards and contain expenditures. If guidelines are rigid, however, it can make it diffi cult to comply with the Hippocratic Oath every physician takes, “First do no harm.” This not only imposes confl icts of interest but places all parties at risk.
According to Centers for Medicare & Medicaid Services (CMS) guidelines, a diabetic patient is entitled to wound debridement every 10 days, known as the “global period.” Many podiatrists treating diabetic patients are working to maintain quality of life and avoid amputations. This is made diffi cult, however, because they might have to see a patient three or four times in a week to not only remove the bandage but eliminate dead skin, which is often necessary to promote proper healing and wound health. To limit such visits and comply with the global period might mean jeopardizing a patient’s health. So, dressings often stay on wounds longer than they should, causing infections and worse. The irony is that many actions necessary to avoid amputations are not covered under CMS guidelines although amputations are covered.
Care should not be dictated by reimbursement. Often a patient’s care will require additional services and products beyond what reimbursement guidelines allow. In an ideal world, reimbursement and patient care should align to adjust for optimum patient outcomes.
Here are four steps healthcare providers and purchasing professionals can take to lower costs while working to protect quality of care:
1. Clinical/vendor purchasing collaboration
Clinical reviews help bridge the gap between medical knowledge/experience and purchasing. At GPOs and the purchasing level of any healthcare organization, clinicians help review and evaluate a variety of products. Clinical buy-in and acceptance, based on patient outcomes, is key.
The role of clinical teams cannot be underestimated in this process, as they help determine relevance, viability, ease-of-use, durability and effi cacy. As a critical care nurse, in the areas of surgical, trauma and medical ICUs I have been involved in trials of new product considerations for various facilities. With advanced woundcare products and capital equipment, the clinical reviews I was involved with helped identify quality product options, which saved money.
Getting nurses and other clinical staff involved in the process can help clearly identify specific usage requirements/ needs and viable alternatives. However, because clinical teams are so far removed from the financial aspects of providing patient care, there are still major disconnects.
One logical solution that can save money, while maintaining quality health delivery outcomes, is to provide incentives to practitioners/clinicians for evaluating and selecting equal to or better than products, which in turn will save money and maintain quality outcomes. This partnership between clinical and purchasing can and should deepen to more meaningful levels. Applying bonuses based not only on health outcomes but related to savings is a smart way of strengthening collaboration.
Once decision makers and clinicians are “in the room where it happens,” with aligned interests and innovative compensation models, formularies can be reviewed, and generics considered – with patient outcomes remaining the number one priority.
2. Clinical protocols & in-house clinical trials for generics
Brand names are often part of protocols. While generic orders are mentioned as well, there should be greater emphasis on these alternatives. Once protocols and orders are written, changing them can be diffi cult, which means overcoming signifi cant obstacles to explore worthwhile, alternative options isn’t always possible. Many times, the appropriate protocol can be addressed with brand names and generic products, which can offer a signifi cant savings to the patient and the system.
In an ideal world, clinical reviews/trials should be done with more frequency to test new products. Though generic equivalents cost less, they cannot be considered until clinical teams and purchasing work together on periodic in-house trials to ensure patient care is at the forefront of purchasing decisions. Once the clinical trial has been completed, decisions can be made based on other factors.
3. Keep up with changes in reimbursement
Based on the frequency of changes in reimbursement and the potential implications, it is more important than ever before to stay current on CMS/payer guidelines.
The Open Payments Program, launched in 2013 by CMS, offers two mobile apps. This “national disclosure program” provides insight into the payments reporting process and the relationship between physicians, teaching hospitals and manufacturers, such as medical device companies.
CMS releases quarterly modifi cations to the Healthcare Common Procedure Coding System (HCPCS) code set. These changes are posted to the HCPCS Quarterly Update website.
As billing and purchasing professionals know, descriptions and criteria are constantly changing for HCPCS codes. Moreover, suppliers must regularly check with the pricing, coding analysis, and coding (PDAC) contractor to CMS. The PDAC is responsible for providing suppliers and manufacturers with assistance in determining which HCPCS code should be used to describe Durable Medical Equipment, Prosthetics/Orthotics & Supplies items for the purpose of billing Medicare. In addition, the PDAC publishes a product classification list on its site, which lists individual items and the corresponding code categories. The PDAC helpline for this purpose is (877) 735-1326.
4. Reevaluate medical supply & DME formularies
Quality suppliers stand behind their products and have no qualms about their products being tested by professionals. When considering medical supplies and devices, prior to clinical trials, look for ISO 13485 registration to ensure “Quality Management Systems — Requirements for Regulatory Purposes.” After clinical trials are complete, formularies can be modified to incorporate smart substitution choices. Off-brand products that are selected by the clinical team that clearly demonstrate quality should then be shared/reviewed with all staff. Adoption and buy-in at all levels is key to ensuring proper usage and adherence to protocols. Depending on product category, training may be in order.
To maximize effectiveness in this area, it is imperative to conduct periodic quality checks and clinical evaluations (with cost analyses) to identify product alternatives. These options can improve quality of care and save costs.
Undoubtedly, ever-changing reimbursement and quality guidelines cause confusion and jeopardize quality of care. With more out-of-pocket burden resting upon patients and their family members, it is important for providers to find new methods of collaboration between clinical and purchasing. This should also include incentives for clinical staff to review products that deliver quality care and save money.
