There’s a contradiction in the field of wound care that we have got to come to terms with. The annual cost of caring for the 15% of Medicare beneficiaries with chronic wounds is at least $28 Billion per year, but it might be as high as $96 Billion per year, and most patients require treatment for at least a year. The majority of those Medicare dollars are spent in the outpatient setting, and yet the vast majority of outpatient wound centers tout healing rates of >90% within a few weeks. Both of these statements cannot be true. Either the majority of patients do not heal in a few weeks, or we are spending billions of dollars a year on advanced therapeutics that patients don’t need. Which is it? How can we tell?
Two weeks ago, I diagnosed a severe case of Polyarteritis Nodosa (which has been missed for 5 months), in a patient who also had severe peripheral arterial vascular disease with rest pain that had been ignored.

The same week I diagnosed a woman with antiphospholipid antibody syndrome which had been shrugged off as a simple stasis ulcer. (She had a history of stroke and miscarriage.)

I also saw a sweet little woman more than 85 years old with limb-threatening peripheral arterial disease whose rest pain was not identified by her physician,  who told her family to make her keep her foot elevated.

These are only 3 of the challenging yet typical cases I saw in a week. I work in a relatively quiet, suburban hospital. Am I seeing these patients because I am just so amazing that challenging patients come from miles away to see me? Absolutely not. In fact, I can prove that every other wound care practitioner has patients just as complex. Spend the evening with wound care practitioners and they discuss conditions from the Merk Manual of Rare Diseases, which they see routinely. Why? Because wounds are a SYMPTOM of disease, and sometimes several diseases.
I looked at my own Medicare data, and in 2017 CMS determined that the average age of my patients was 75 years, with 19.6% older than 84. Here are the prevalence rates of just a few major co-morbid conditions in my patients: hypertension 75%, hyperlipidemia 65%, chronic kidney disease 60%, diabetes 56%, ischemic heart disease 54%, rheumatoid arthritis and osteoarthritis 50%, atrial fibrillation 24%, Alzheimer’s 23%, asthma 26%, COPD 22%, Depression 18%, and cancer 16%. I know from looking at US Wound Registry (USWR) data that the majority of my patients have at least 3 serious conditions and they take an average of 12 medications. Yet, occasionally colleagues who are venous experts have suggested that the difficulty we have healing lower extremity ulcerations is because we delay making referrals for ablation. The truth is that our patients are, on average, sicker than those seen by a cardiologist. Half our so-called “venous ulcer” patients have atrial fibrillation and are in florid heart failure and their legs are actually splitting open from volume overload (they have lymphedema, too). We do not “keep” them because it’s lucrative, we keep them because the wound center is the only place able to manage their severe leg edema.
I am going to ask you 2 questions, the answers to which could determine the future of the field of wound care:  

  1. Do you think my patients are far more complex than those seen in outpatient wound centers everywhere?
  2. Do you think that I heal 95% of my patients, given their advanced age and the prevalence of serious medical conditions?

If you answered “no” to both of those questions, then you are correct, and that means we have a big problem in this field. If nearly all wounds heal, then our therapeutic interventions are not necessary, nor are our services. That’s what CMS seems to have concluded. We have only just begun to feel the impact of reduced access to HBOT and cellular products, to name only two modalities that are getting harder to provide and for which audits are becoming the norm. And why wouldn’t the payers find ways to reduce the use of these treatments? As far as they can tell, there is no need for them. We are busy creating fantasy healing rate reports to demonstrate to payers and hospital administrators that we provide high quality care. I wonder why the M.D. Anderson Cancer clinic one floor above the wound center is not required to produce a report stating that all cancers were cured this month?
In this month’s editorial for Today’s Wound Clinic, I explain Hierarchical Condition Categories (HCC), Medicare’s way of measuring the relative sickness of a given patient. The HCC is used to understand the average complexity of all the patients seen by a specific practitioner, and then the average HCC scores of all the members of a specialty can be used to create an average HCC for that specialty. Assuming of course, that you HAVE a specialty, which wound care does not.
Without the ability to explain how sick our patients are, we can’t explain to CMS or the private payers why the care of patients with chronic non-healing wounds costs so much. The only way to explain the cost of wound care to CMS is to get wider participation in the USWR, so we can explain the complexity of patients with chronic wounds. The various wound care clinical associations are not interested in this issue and there’s no physician specialty society to do it. That leaves me sounding like Linda Hamilton from the first Terminator movie, warning that the apocalypse is coming, while everyone acts like its business as usual, pretending we heal 95% of patients. On the other hand, “Report to the USWR if you want to live,” might work if I could get Arnold Schwarzenegger to say it.
Check out “visualizing the complex patient.” Do these look familiar?