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

By Caroline E. Fife, MD

How Will Pay For Performance Work For Diabetic Wound Care?

It is generally agreed that healthcare providers should perform certain clinical interventions for certain medical problems, in certain patients, and within a specific time or in a specific sequence. Implementing this requires the following things:    •    an agreement regarding what care one ought to provide for a given clinical problem (clinical practice guidelines);    •    the selection of specific performance criteria to decide upon the care provided; and    •    a method of clinical surveillance to determine if the performance criteria were met.    Most pay for performance strategies focus on various aspects of primary care. However, when reviewing a list of the 10 diagnoses for which CMS expends the largest amount of its budget, three of them are related to diabetes. It is estimated that $8.5 billion is spent for wound care products and services, according to the transcript of the March 29, 2005 Medical Carrier Advisory Meeting (MCAC). Two percent of all chronic ulcerations are caused by diabetes. The prevalence of diabetes in the population is increasing at 14 percent per year and diabetic wounds represent 80 percent of all chronic wound costs. It seems inevitable that pay for performance will reach diabetic wound care in the near future.    At this time, several national organizations have established evidence-based guidelines, all of which are available online. Those created by the Wound Ostomy Continence Nurses (WOCN) are available at The National Quality Forum is an organization that endorses national consensus standards for measuring and publicly reporting on performance. The National Quality Forum endorsed standards will become the primary standards used to measure the quality of health care in the United States. At this time, there are only a few standards pertaining to diabetes.5-7 For an abbreviation of the WOCN guidelines for diabetic foot ulcer care, see “Basic Interventions For Diabetic Foot Ulcer Care” below.

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