Healthcare policy is often viewed as the foundation on which decision are made in healthcare, as related to reimbursement. The policies created involving Medicare and Medicaid reimbursement are decided at the federal level. These policies are aimed at improving the health of the nations population by encouraging healthcare providers to utilize the most effective and efficient methods possible (Nieseen, Griiseels, and Rutten, 2000). However, is this outcome truly being accomplished? Or are these healthcare policies forcing providers to simply use the least expensive method possible so that they are not placed in a position to assume the expense of the treatment? Weinstein and Skinner (2010) deliberated over these questions by inquiring whether there is a positive or negative association between cost of treatment and outcomes, which are measured by the quality-adjusted life-year (QALY) gained.
The concept of cost vs. QALY can be applied to the Center of Medicare and Medicaid Services’ (CMS) decision to change the reimbursement model for the use of skin grafting from a fee-for-service model to a bundled payment plan. Skin grafting is a very expensive therapy, however, if utilized properly it can significantly reduce the length of healing time of a chronic wound (Haft, Williams, Kyramarios, and Temar, 2003). With this understanding of improved healing time with the use of skin grafting therapy, the question has to be raised as to whether a low-medium priced therapy with a longer healing time is more conducive than a high priced therapy with a shorter healing time. With the new changes in reimbursement a healthcare provider may be forced to utilize the low priced therapy, which requires that the patient suffer from their chronic wound longer, so that the provider’s company can continue to be profitable and remain in business.
The challenges of navigating the healthcare policies to ensure that adequate reimbursement is obtained can potentially place healthcare providers in an ethical dilemma. In the wound care specialty, a patient may present to your clinic with a chronic wound that you are confident you can heal. However, you have to decide if you are going to approach the patient about using the expensive therapy that may potentially heal the wound faster (while understanding that you may lose money with this therapy) or do you neglect to mention this option and use the less expensive therapy that you know will require the patient to live with this wound longer.
Ultimately, healthcare policies have a substantial impact on the quality of care that is delivered in the United States. To ensure that we continue to have access to high quality health care the nations citizens must remain active in advocating for effective and efficient policies that promote the patient as the top priority.
References
Haft, J., Williams, A., Kyramarios, C., & Temar, K. (2003). Are Tissue Replacements Cost Effective? Podiatry Today, 16(7), 64-70.
Niessen, L. W., Grijseels, E. W. M., & Rutten, F. F. H. (2000). The evidence-based approach in health policy and health care delivery. Social Science & Medicine, 51(6), 859-869. doi:http://dx.doi.org.ezproxy1.lib.asu.edu/10.1016/S0277-9536(00)00066-6
Weinstein, M. C., & Skinner, J. A. (2010). Comparative effectiveness and health care spending — implications for reform. N Engl J Med, 362(5), 460-465. doi:10.1056/NEJMsb0911104
CMS Reimbursement For The Use Of Skin Grafting Therapy 
Hi Peter,
Thanks for the interesting post. I had no idea the reimbursement for skin grafting was changed. I’ve seen really incredible results from this therapy as we have a wound care clinic associated with our medical center and the surgeries are done here. As a case manager, we arrange the outpatient care for patients post grafting. I’ve seen this surgery change lives, especially those that have dealt with chronic wounds due to long term immobility, usually para- or quadriplegia. The quality of life is significantly improved, not only for the patients, but for their caregivers.
Will be interested in following your thoughts on this throughout the semester.
Robyn
Hi Robyn,
Thank you so much for your response! Skin grafting, although not 100% effective, is definitely a wonderful option for patients suffering from chronic wounds! You bring up a wonderful point that skin grafting not only improves the life of the patient but also of the caregiver! Chronic wounds often come with increased pain, odor and drainage, which can be extremely troublesome for caregivers. I truly believe that these are the added benefits that policy makers often are not aware of.
Thanks again for your wonderful response!
Peter,
This reply is from Virginia R. from DNP 711. From what I understand in your post you stated that the more expensive therapies for wounds such as skin grafting might result in faster healing and less expensive therapy may result in a prolonged healing process. I wonder if there is a balance of cost in the “long run” or if the more expensive treatments really do result in cost savings?
I found a review that discussed inpatient versus outpatient skin grafting. The purpose of the study was to assess patient outcomes and cost related burn injuries without hospitalization. The results of the study showed that reduced hospitalization for skin grafting greatly reduces health care cost (Dennis, 1997). This statement seems obvious as one could assume that any hospitalization would be less expensive than an outpatient procedure. But, in addition the study found that delaying operative care such as to an outpatient procedure can decrease residual burn areas that is ultimately skin grafted (Dennis, 1997). This would result in less of an area needed to be skin grafted. This review brings about an interesting point that possibly a non-aggressive skin care plan followed by skin grafting may be a cost reduction overall as less area may need to be grafted. Though, the review didn’t compare non-skin graft costs, it may be indicating that a not so aggressive intervention initially may be an economical decision. It could be that combined therapies of aggressive and non-aggressive wound care may have better results. I think policy makers need to be aware of these studies in order to make the best decisions. What are your thoughts on the results of this study?
References
Gore, D. C. (1997). Outcome and cost analysis for outpatient skin grafting. The Journal of Trauma, 43(4), 597-600; discussion 600-2.
Hi Virginia,
Thank you for your reply! You are absolutely correct in saying that a combination between non-aggressive and aggressive therapies need to be implemented for the best possible outcomes, as the use of non-aggressive therapies are required on chronic wounds before skin grafting will be approved. However, the dilemma comes from the new reimbursement model (the bundled payment plan) where a provider will only be reimbursed a certain amount for a particular wound regardless of any complications or added therapies and therefore removing all incentive for using the more expensive therapy. Thank you again for your response!
It sounds to me like this new reimbursement model is a non-healthcare savvy (or competent) policy makers attempt to control wound care cost without understanding the complexities of the issue. I fear that this kind of reimbursement model/policy is the wave of the future and will place providers in a difficult position. While many do not want to acknowledge it, healthcare is a business that has to generate revenue to run (how else can providers/practices pay their overhead?). These policies run the risk of forcing providers to choose low cost less effective therapies to maintain their bottom line.