Pay For Performance: How Will It Impact Diabetic Foot Care?

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Basic Interventions For Diabetic Foot Ulcer Care

• Prescribe offloading
• Screen for osteomyelitis in high risk wounds
• Monitor hemoglobin HbA1c (Level of evidence = C)
• Consider the use of growth factors for Wagner grade I or II ulcers. (Level of evidence = A)
• Consider hyperbaric oxygen therapy (HBOT) for Wagner grades III and IV(WOCN). (Level of Evidence =A)

The list above represents an abbreviation of the Wound Ostomy Continence Nurses (WOCN) guidelines for diabetic foot ulcer care. They are stratified according to the American Heart Association’s “Levels of Evidence” system.

Pay For Performance: How Will It Impact Diabetic Foot Care?
Pay For Performance: How Will It Impact Diabetic Foot Care?
Pay For Performance: How Will It Impact Diabetic Foot Care?
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Author(s): 
By Caroline E. Fife, MD

A dilemma of modern medicine is that reimbursement has become procedurally based. Clinicians are paid for what they do for patients, not for what they refrain from doing. Accordingly, the system, by its very nature, encourages intervention. Indeed, when one considers the combination of high patient expectations, the availability of technology, the economic pressures to generate revenue for economic survival and the litigious nature of society, the result is a higher probability of medical interventions.

   For this reason, Medicare and other payors are experimenting with pay for performance and other systems that hope to reward clinicians for knowing when advanced technology is really necessary and when high quality conservative care is sufficient.
Most doctors try to deliver the highest level of medical care they can. However, the late Ron Bangasser, MD, one of the architects of pay for performance in California, pointed out that while most patients rate their doctor as 4+ out of 5, they think healthcare in America is bad and they are right.

   Studies show approximately 50 percent of patients do not get good quality medical care. There is also the low use of evidence-based medicine relative to national or regional benchmarks. Physicians are unable to track or even find their lab tests. Eighty-five percent of physicians in 2005 could not generate a registry list, a list of test results or a list of current medications. In addition, 33 percent of physicians repeat tests because results are unavailable; 15 percent of observed abnormal tests were not followed up; and only 18 percent of physicians have data on patient outcomes.

   The fact is clinicians cannot keep track of everything they need to do for every patient. For example, in a study in which an electronic medical record (EMR) was used to provide point of service reminders, 51 percent of eligible patients got the flu vaccine versus 30 percent without a reminder. If physicians need a point of service reminder to perform one simple task for their patients, what about the myriad of practice guidelines currently available for conditions ranging from diabetic foot ulcers to neuromas?

   With today’s focus on evidence-based care and practice guidelines, clinicians must retain an unmanageable amount of knowledge to deliver consistent care.1 Simple reminders generated at the moment of care in EMR systems have led to providers performing actions that would have otherwise been overlooked.2 When EMR incorporates clinical practice guidelines, it can streamline care, reduce costs and improve outcomes.

A Closer Look At Evolving Quality Improvement

Quality improvement programs began with reviewing the “bad outcome cases” and punishing the “bad” doctors. This progressed to quality improvement “protocols” (standard protocols particularly for conditions such as myocardial infarction or pneumonia that require hospitalization) and then outpatient registries (such as for registries for preventive care like mammograms).

   What defines quality healthcare? According to Terris King, who is with the Office of Clinical Standards and Quality at the Centers for Medicare and Medicaid Services (CMS): “Quality health care means doing the right thing at the right time in the right way to the right person and having the best results possible.” This does not mean that all our patients get well. It does mean that we perform the right diagnostic tests, make the right diagnosis, implement the correct treatment plan and provide the best possible care in a timely fashion.

   There were a variety of factors that led to the development of pay for performance. Among these factors were employer and government concern over rising healthcare costs and deficiencies in the United States healthcare system. The U.S. has a $1.7 trillion health-care industry that still largely records patient information with pen and paper.

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