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Here are links to information about the Medicare Physician Fee Schedule and Quality Payment Program and the Medicare Hospital Outpatient Prospective Payment System (OPPS) final rules:

CMS will be moving forward with general supervision for all outpatient services beginning January 1, 2020. This means that even for hyperbaric oxygen therapy, the doctor does not have to be physically present. Providers have the flexibility to establish what they believe is the appropriate level of physician supervision for these procedures, which may well be higher than the requirements for general supervision.

CMS also evaluated all the comments received on the cellular and/or tissue based product (CTP) payment methodology.  For the time being everything is status quo. I think it will move to episode based payment eventually but not in 2020. Two weeks ago CMS rejected the quality measures that would probably be needed to make episode based payment work. CMS rejected the “appropriate use of CTP” quality measure that was suggested in the proposed rule and I said, “I guess you guys have inside intel that CTP’s are not moving to episode based payment, so we don’t need this measure.” Yep.

I’ll try to sort through the meaning of these final rules in future blogs. However, I think this is the death knell of hospital-based wound management and hyperbaric medicine, at least for physicians. Over time, it is unlikely that physicians will continue to be present in hospital-based centers, because eventually physician payment rates will reflect the fact that CMS does not think the physicians need to be there.  At least for a while, “dressing change” centers will continue to exist, with care provided by nurses.

As physicians we have failed to provide sufficient justification for the reason a knowledgeable physician should see chronic wound patients in order to diagnose the reasons they have failed to heal. This month my clinic is full of patients with previously undiagnosed vasculitis, pyoderma gangrenosum, nutritional deficients and underlying diseases (including genetic diseases like Ehler Danlos Syndrome). I would be using those patients as evidence to say, “I told you that a doctor needed to be there!” except that the patients came from wound centers with doctors who apparently were not able to make these diagnoses.

I will post a series of these cases to illustrate. But, meanwhile, I guess I’d better figure out the doctor’s office setting.

More on the implications for hyperbaric medicine later.

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