Developing and Integrating a Practice Model for Health Finance Reform into Wound Healing Programs: An Examination of the Triple Aim Approach

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1 Developing and Integrating a Practice Model for Health Finance Reform into Wound Healing Programs: An Examination of the Triple Aim Approach Anna Flattau, MD, MSc, MS; Maureen Thompson, BSN, RN, CWOCN; and Anne Meara, RN Abstract Throughout the United States, government and private payers are exploring new payment models such as accountable care organizations and shared savings agreements. These models are widely based on the construct of the Triple Aim, a set of three principles for health services reform: improving population-based outcomes, improving patient care experiences, and reducing costs through better delivery systems. Wound programs may adapt to the new health financing environment by incorporating initiatives known to promote the Triple Aim, such as diabetes amputation reduction and pressure ulcer prevention programs, and by rethinking how health services can best be delivered to meet these new criteria. The existing literature supports that programmatic approaches can improve care, quality, and cost, especially in the field of diabetic foot ulcers. Wound healing programs have opportunities to develop new business plan models that provide quality, cost-efficient care to their patient population and to be leaders in the development of new types of partnerships with payers and health delivery organizations. Keywords: wound healing, prevention, healthcare financing, accountable care organizations Index: Ostomy Wound Management 2013;59(10):42 51 Potential Conflicts of Interest: none disclosed What is the Triple Aim? Although the United States healthcare system spent $7,598 per capita in 2009 compared to $3,311 in the United Kingdom, 1 it often achieves suboptimal outcomes and provides poor care experiences. 2 The Triple Aim, a construct developed at the Institute for Healthcare Improvement, describes three goals for bettering healthcare services: improving the care experience for individuals, improving population health outcomes, and reducing per capita cost of care through better delivery systems. 3 The Triple Aim concept is explicitly tied to federal healthcare payment reform efforts that focus on new financing models, such as accountable care organizations, that tie payments to quality-of-care metrics and population-level outcomes instead of relying on fees for visits or procedures. 4 Accountable care organizations that demonstrate the ability to deliver high-quality, cost-effective care will have the opportunity to share in the savings that accrue to the Medicare program. 4 This incentivizes healthcare improvements that lower overall costs by mechanisms such as reducing the need for hospital admissions. In parallel, private health insurance plans increasingly offer contracts that include rewards for quality-of-care and population outcomes, with shared cost savings for more cost-effective care. A 2012 survey 5 of 39 health plans found 20% already had more than half their business supported by value-based payment models, 40% believed they would reach that point within 3 years, and 59% believed they would reach it within 5 years. Wound healing clinicians may be able to leverage the shifting financial environment in both the private and public sectors to identify and pursue opportunities to best serve Dr. Flattau is a family physician and Director of the Wound Healing Program, Montefiore Medical Center, Bronx, NY. Ms.Thompson is the Inpatient Wound Care Coordinator, Memorial Hospital of Salem County, Salem, NJ. Ms. Meara is Associate Vice President, Network Management, Care Management Organization, Montefiore Medical Center. Please address correspondence to: Anna Flattau, MD, MSc, MS, Montefiore Medical Center Wound Healing Program, 3335 Steuben Avenue, Bronx, NY 10467; aflattau@montefiore.org. 42 ostomy wound management october

2 Triple Aim approach their patients and communities. Healthcare systems that hold risk-sharing agreements for increasingly greater proportions of their patient bases may wish to integrate cost-savings innovations into affiliated wound healing programs as part of an overall accountable care approach. Organizations shifting to an accountable care model often are in the early stages of transition and may be seeking programs that can demonstrate quality improvements and cost savings within a relatively short time frame of several years. Private insurers who are pursuing value-based contracting may be attracted to programs with a focus on achieving the Triple Aim. Provider networks may be interested in partnerships with wound healing centers that directly target high-cost care patterns in their patients. Rethinking wound healing services from the perspective of the Triple Aim provides an opportunity for wound healing programs to evolve and thrive in the context of ongoing payment reform. Unlike the fee-for-service system, which rewards physician encounters, procedures, and hospitalizations instead of outcomes, an approach to health services delivery via the Triple Aim is intended to allow clinicians and administrators to focus on the objective of providing high-quality and cost-effective care for an entire patient population. This enables emphasis on areas not supported by fee-for-service reimbursement, such as continuity of care, communication, collaboration, self-management, prevention, community outreach, and reduction of waste. 6 The Triple Aim has been used to improve care and reduce costs in a variety of settings, including employer-based health plans, primary care systems, health services delivery for specific disease entities, transitions from hospital to community, and care management for complex chronic conditions. 7,8 The purpose of this review is to explain how the existing wound healing literature can give direction to the field in developing new clinical models that emphasize populationbased outcomes and cost-efficiency. Review of Best Practices in Wound Healing for the Triple Aim The wound healing literature documents initiatives that fit well with the Triple Aim, including programs that reduce diabetic foot amputations on a population level. 9 The US has a rate of 36 diabetic lower extremity amputations per 100,000 people age 15 and older, which is much higher than that of other developed countries such as the United Kingdom with nine, Canada with 11, or France with This implies the potential for improvement in diabetic foot care in this country. A fee-for-service system treating diabetic foot ulcers rewards high-volume outpatient centers, hospitalizations, surgical services, and hyperbaric oxygen therapy. The average cost of a diabetic ulcer episode has been estimated in past review articles 11,12 to range from $4,500 to more than $25,000 and amputation as nearly $45,000; inflation likely continues to increase costs. All effective limb salvage services Ostomy Wound Management 2013;59(10):42 51 Key Points Many new healthcare payment models are focused on outcomes instead of volume. In wound care, there is ample evidence to help clinicians improve patient outcomes. Based on available research, the authors provide examples for wound care clinicians to change to these new healthcare payment models. are justified for patients with severe ulcers. However, superior population-level outcomes can be achieved at lower cost through prevention and early treatment and through coordinated care of advanced ulcers. Multiple initiatives (see Table 1) suggest that communities amputation rates can be reduced through community outreach, 13 patient education, education or guidelines for primary care providers, 13,14,16,20,21 increased podiatry services or development of a foot clinic focused on prevention, 14,15,17,18,20-23 provision of preventive footwear, 14,15,17,20-23 and/or development of a multidisciplinary treatment team or establishment of specialist treatment guidelines. 15,17,20-23 In addition to dramatically improving population outcomes, these programs can improve individuals quality of care with consistent and timely preventive care, referrals, and treatment. Such programs can reduce healthcare utilization, including hospitalizations, skilled nursing facility stays, and emergency room visits, and cut total ulcer treatment costs. 15,17,20-23 Thus, these programs make not just clinical, but also financial sense in a reimbursement model that rewards cost savings and quality improvement. According to a review of the cost impact of interventions, 24 projected potential savings could reach $20 billion annually in the US. Preventing amputations reduces additional uncalculated costs to society, including lost economic productivity, disability payments, public assistance, and increased caretaking burden on families. 25 Pressure ulcer prevention is another well-documented wound care initiative that furthers the Triple Aim. Pressure ulcer incidence is an important marker of health outcomes in an inpatient population, and hospital-acquired ulcers represent an inarguably worse care experience for a patient. Effective prevention initiatives include a bundle of practices encompassing comprehensive skin exams, pressure ulcer risk assessments, pressure redistribution services, repositioning of patients, nutritional support, and incontinence management. 26 These interventions are not supported by fee-for-service reimbursement models, but they are cost-effective. 27 Therefore, a financing model that rewards the Triple Aim can support this work from both the healthcare system s and insurer s perspectives. Other drivers of pressure ulcer prevention programs include regulatory october 2013 ostomy wound management 43

3 Table 1. Documented effect of diabetic amputation reduction initiatives on outcomes and costs Reference, setting, and time frame Amputation reduction Other outcomes Cost analysis Study methodology Rith-Najarian 14 Rural Native Americans 5-year intervention Horswell et al 15 Treatment group in public hospital system in Louisiana; low-income African- American population 1-year intervention Jenkins et al 13 Rural North Carolina, African-American, multipayer coalition with community-academic partnership 10-year intervention Lavery et al 20 Managed care population 28-month intervention Litzelman et al 16 Primary care academic practice, poor African-American population 1-year intervention McCabe et al 21 United Kingdom, outpatient diabetes clinic Nason et al 17 Ireland, hospitalbased foot clinic x x x x 28% after 3 years 48% after 5 years 71% reduction in first amputations (patients without prior amputations) 27% reduction in major amputations Total of 639 diabetic patients in registry through baseline and intervention s x x x x 79% Hospital days decreased 82% Inpatient charges decreased 76%; ER charges decreased 50%; ER visits decreased 45 intervention 51% combined outpatient, patients compared ambulatory surgery, to 169 historical and foot-related controls hospital charges decreased 51% x x x x 44% x x x x 47.4% Foot-related hospitalizations decreased 37.8%; average length of stay decreased 21.7%; skilled nursing facility admissions decreased 69.8% x x Four amputations in control group versus two in intervention group x x x 23 in control group, 7 in treatment group (P <0.04) x x x x 12 in 2-year baseline, 4 in intervention Odds ratio for foot lesions 0.41 ( ) Ratio of above-knee to below-knee amputations decreased from 2 to 0.75 Cost-saving based on amputation reduction alone Cost-saving, mainly due to reduction in amputation-related costs Population-based data for African- Americans living in the target region N=2,738 in intervention program, 1,708 in pre-intervention Compared patients of two primary care teams doing intervention to two teams continuing prior standard care Total N=396 patients consented to participating in data collection for study Randomized controlled trial N=2,001 within a hospital system 313 patients treated during intervention Continued on page ostomy wound management october

4 Continued from page 44 Table 1. Documented effect of diabetic amputation reduction initiatives on outcomes and costs Reference, setting, and time frame Patout et al 23 Prevention in public hospital system in Louisiana, low-income African-American population 1-year intervention Rerkasem et al 18 Thai hospital Rizzo et al 22 Italy, universitybased diabetic foot clinic, included only patients at high risk for ulceration 3-year intervention, but follow-up poor after first year Scharer 19 Alaskan Natives, rural population with geographical isolation Amputation reduction Other outcomes Cost analysis Study methodology x x x Ulcer days decreased 49%; hospitalizations decreased 90%; ER visits decreased 300 patients 81%; antibiotic courses enrolled in the prevention clinic, 197 decreased 57%; completed followup; baseline data foot surgeries decreased 87% derived from same (All P <0.01) individuals, based on their health history the year before enrollment x x x 70% major amputations 60% minor amputations x x After first year, 38.6% standard group and 11.5% treatment group had ulcerations (P <0.0001) x x x x x Amputations reduced 7.6/1,000 in patients with diabetes to 2.7 Components of intervention: 1. Community outreach education 2. Patient education 3. Primary care education or guidelines 4. Prevention clinic or increased podiatry services 5. Preventive footwear 6. Multidisciplinary treatment team and/or treatment guidelines in specialist setting oversight, impact on hospital reimbursement, and concerns about medicolegal liability. Rethinking Wound Healing Services from a Quality-of care and Population Perspective Wound healing programs often are based on a high-volume outpatient clinic model. However, a population perspective facilitates consideration of the outpatient center as only one component of a program that optimally manages Significant reduction persisted for years 2 and 3 in patients who continued follow-up Cost-saving 73 patients in intervention group, 110 in group Randomized controlled trial N=298 Populationbased data from healthcare system registry; 5,908 diabetic personyear intervention, 4,227 person-years in control a population s chronic wound needs through different care settings and in the community. Programs that provide integrated care across settings into home care, nursing homes, and hospitals will be able to reach even the most vulnerable patients where they live and follow individual patients through different care settings. Wound healing programs with best-practices for service delivery may offer community-based health promotion activities, specifically address patients psychosocial challenges and care preferences, and 46 ostomy wound management october

5 Table 2. Examples of how to frame service improvement proposals in the language of the Triple Aim Proposed intervention Potential improvement in quality of care Potential improvement in population health outcomes Potential reduction in overall healthcare costs Focus on population-level outcomes for the entire community Development of strategies for early detection of incident ulcers (pressure, leg, diabetic) Patients benefit from outreach for their condition before progression or complications Ulcers heal faster with fewer complications when treatment initiated early Assistance to address social barriers to care for wound healing patients, such as food aid to assist with nutrition, cell phones for patients who are otherwise unable to reach their providers, or housing assistance Training of community members to educate peers about wounds and offer screening (eg, neuropathy screening with monofilaments) Access to care enabled for patients with severe social barriers Patients obtain screening and education Self-management of disease within the community is promoted Support for multidisciplinary care approaches Increase support for social Patient obtains access to the work and nutrition resources counseling, resources, and support needed for optimal healing, and receives assistance in overcoming social and environmental barriers to care Integration of care strategies across multiple settings Primary care clinical pathways Earlier referral allows for treatment before ulcer progresses promoting early intervention and/or referral for diabetic foot ulcers Home visiting service providing all multidisciplinary services typically available in outpatient wound centers to homebound patients Wound healing program constructed as an integrated delivery system where outpatient, inpatient, long-term care, and home care providers are a single program jointly responsible for both outcomes and costs Use of electronic records to facilitate communication among team members Homebound patients have access to care The patient s care plan and provider team can follow the patient regardless of where he or she was being cared for at that point in time. This would enable continuity and consistency and reduce the potential for medical errors during transitions in care Patient able to access/coordinate continuous care over multiple visits and as he/she moves between settings Faster healing, fewer complications and advanced ulcers Reduction in diabetic foot ulcers and in amputations Earlier healing, less progression, fewer complications Reduction in ulcer severity and in amputations Standard of care applied to all subgroups in the population allows for improvement in outcomes Faster healing, fewer complications Early and coordinated management of complications improves outcomes Reducing insurance barriers to needed services or equipment Coverage for advanced topical wound dressings Patient is treated with the dressing most appropriate for care as determined by clinician Fewer days with ulceration Treating ulcers before development of complications reduces overall cost Cost of social support interventions less than cost of ongoing care of nonhealing wounds, urgent visits, and hospitalizations Reduction in treatment costs associated with ulcers and amputations Shorter time with ulcer leads to fewer visits and services; avoiding wound complications leads to reduced hospitalizations; social work resources may help avoid institutionalization Reduction in costs associated with more advanced ulcers and with amputations Reduction in emergency room visits and hospitalizations; preventing complications Integrating care across settings may reduce multiple visits and redundant roles Cost of care under one umbrella, allowing for delivery design that does not simply shift costs to a different setting Reduction in redundant tests and interventions, expedited and coordinated care plan, resulting in fewer complications and hospitalizations Coverage without preauthorization or copays for orthotic inserts or shoes for diabetic patients with neuropathy Faster access to care with fewer logistical barriers Reduction in ulcers and in amputations due to wider use of preventive intervention Overall reduced cost for episode of care due to faster healing time and fewer visits Reduction in costs associated with ulcers and amputations Continued on page ostomy wound management october

6 Continued from page 48 Table 2. Examples of how to frame service improvement proposals in the language of the Triple Aim Proposed intervention Coverage for compression garments for patients with history of leg ulcers and edema at risk for recurrence Potential improvement in quality of care Patient has control of lower extremity edema and reduced risk of recurrent ulceration use population-level data to design interventions that meet communities and patients needs. To the extent that these innovations improve outcomes and care and lower overall costs, they can be financially supported in a Triple Aim payment model. Table 2 identifies potential areas for improvement of wound services delivery in the transition from a fee-forservice model to a financial model that emphasizes quality and population health outcomes and where investment in preventive or treatment strategies can save costs by avoiding downstream complications. These are examples of how a shift in approach can lead to new proposals for improved care. Each proposed intervention requires planning for outcomes measures and financial metrics in order to enable evaluation of its effectiveness. Individual health systems may choose different areas of focus based on their capacities and the needs of their communities. However, structuring proposals in the language of the Triple Aim may allow for more effective dialogue with insurers and healthcare systems that partner with wound healing programs. Table 2 describes a population-based focus, multidisciplinary care approaches, integration of care across settings, reduction of insurance barriers to necessary components of care, and integration of wound care into skilled nursing facilities as areas that merit specific investigation as potential effective and cost-saving new care models in wound healing. Conclusion: The Role of Wound Clinicians in Health Services Delivery Reform Health services delivery in the US has an opportunity for transformative change as business models strive to reward good care, good outcomes, and efficient resource use. Wound healing programs can build successful new models by identifying strategies to reach patients who are poorly served in the current system, focusing on early detection and secondary prevention of complications, building stronger partnerships with communities, looking outside the Potential improvement in population health outcomes Lower incidence of recurrent ulcerations Building effective wound care delivery systems in skilled nursing facilities (SNFs) Protocols and training that strengthen wound care skills by primary care providers within the SNF Earlier, integrated, and higher quality care by primary provider Improved adherence to bestpractice guidelines will improve outcomes Access to wound specialists within SNF Patients can receive timely care without burden of traveling and with integration into primary care needs Timely and consistent specialist care, when needed, resulting in better outcomes Potential reduction in overall healthcare costs Reduction in cost of care associated with ulcer recurrence More effective care may save costs; reduction in specialists visits and hospitalizations; better management of vendor relationships Elimination of transportation costs walls of the comprehensive outpatient center to address the wound-related health needs of populations across settings, and improving the quality of care within existing clinical sites. These changes will require skills in epidemiology, population health, business modeling, health services delivery design, operations, and assessment. New partnerships may be required with public health professionals, implementation scientists, and health services researchers. As a community, wound healing providers will benefit from becoming active shapers of this process. This can be done by testing, sharing, and diffusing strategies for health delivery systems that optimize care experiences and health outcomes in ways that also contain cost by improving care for patient populations. n References 1. Kaiser Family Foundation. Health care costs: a primer. May Available at: Accessed July 9, Committee on Quality of Health Care in America, Institute of Medicine. Crossing the Quality Chasm. Washington, DC: National Academies Press; Berwick DM, Nolan TW, Whittington J. The Triple Aim: care, health, and cost. Health Affairs. 2008;27(3): Center for Medicare and Medicaid Services. 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