What The Affordable Care Act Means For Wound Care Practitioners


The 2012 presidential election has passed. Gone with it is any chance that I would expand my practice in the foreseeable future.

Similar to many other businesses, I have been in a holding pattern with regard to hiring more physicians and staff. I was waiting to see if a new administration could repeal the Affordable Care Act or if it would be here to stay. Now that the election has determined the outcome, I am not planning on growing my practice by hiring additional podiatrists, nurses, physicians or other staff. The cost of doing so would be prohibitive. It would not be worth the aggravation and increased liability among other things.

I do think it is safe to say that most healthcare providers went into medicine because of a calling to help their fellow man. I would also surmise that most physicians have provided occasional pro bono services to those in need because it is the right thing to do. “Writing off” or forgiving collections to those in need is the extension of empathy that most caregivers possess. There is nothing more frustrating than determining access to care by the type of insurance a patient carries. Note that I did not say whether a person has insurance coverage or not, but what type of insurance he or she carries.

So here we are at the crossroads. The healthcare system has been under fire for many years. Many perceive doctors as only being in it for the money and perceive the medical device companies, among others, as being driven by greed and the demands of their shareholders.

What comes next? None of us can tell but as we look toward a new year, I would like to make several predictions, based on a glimpse into our future that I had while traveling abroad.

I have visited two countries that have universal public healthcare, Brazil in 2007 and the Bahamas in 2012. I quickly learned that this does not mean private healthcare no longer exists in these places. The creation of a public healthcare system means that private healthcare will continue for those who can afford it, thus creating a two-tiered system.

The public and private healthcare systems in Brazil and the Bahamas showed me a firsthand account of what is likely in store for the U.S. I will say from what I have seen, it is potentially bleak. Being the eternal optimist, I believe that the American spirit and ingenuity will rise to the occasion over time.

Healthcare Predictions For The New Year

As we head into a new year, here are a few predictions to consider.

1. Universal health coverage will not be the answer to create a more efficient system. It will create further division, envy and resentment among the socioeconomic classes.

2. Patients who have the means and insight will maintain their own private health insurance.

3. Patients with private healthcare insurance will demand and pay for better quality of care as well as the utilization of emerging technology.

4. Publicly insured patients will not receive anything above and beyond minimal to average care. Their frustration will grow as they wonder why those with private insurance get the best care and services.

5. We will see the distinct establishment of separate public and private hospitals. Any guesses as to where the government officials will be treated? Hint: it will not be public hospitals.

When I visited two public hospitals in Brazil, I was alarmed at what I observed. They had one hospital with more than 500 beds in Sao Paolo. It had a “wound center” that consisted of a wooden bench in a shower stall, where doctors performed debridement and irrigated wounds with a showerhead attached to a hose. The rest of the wards and emergency areas were filled with downtrodden souls—six beds to a room.

On a recent trip I made to the Bahamas, I found a similar system wherein the public hospitals are only permitted the use of gauze, saline and betadine for wound care. Additionally, they grind papaya skins for application to wounds. In the meantime, private hospitals have the technology that is the norm in the U.S., including negative pressure wound therapy, Apligraf (Organogenesis), Dermagraft (Shire Regenerative Medicine) and Versajet (Smith and Nephew) as well as other advanced dressings and topical modalities.

6. Physicians will discourage their own children from a career in medicine. This will add to the trend of fewer medical students coming up through the ranks and will further worsen a physician shortage.

7. More physicians will continue to sell their practices to large healthcare systems as the frustration mounts for them in running their own private practices. As they become employees, they also become expendable over time and further disillusionment ensues. Many other physicians will leave medicine and there will be a further increase in the demand for nurse practitioners and foreign-trained physicians.

8. Medical device companies will continue layoffs and cut investment in research and design.
If you think this is unlikely, consider that Cook Medical has already scrubbed plans to build five new plants in the Midwest that would have meant the creation of 1,500 new jobs.1 The reason for this is the implementation of the new medical device tax that begins in 2013. The medical device tax will reportedly levy a 2.3 percent tax on the gross revenues of medical device makers, whether or not they generate profits.2 This is especially damaging to start-up and small companies that may have important new technology but minimal profits to show. They may end up in the red due to the additional tax exceeding their profits. For more on the 2.3 percent tax, see http://www.ofr.gov/OFRUpload/OFRData/2012-29628_PI.pdf .

9. New opportunities will emerge but it will take the ingenuity and vision of those who see beyond government employees to affect real change in healthcare delivery. The Affordable Care Act will prove to be another tax that will go away as well as a wake-up call to those providers to stay strong and committed. Providers will figure out ways around the government system and will find new ways to deliver healthcare in a system that rewards excellence and compassion.

It will take some time and effort, but I see a bright future beyond the impending immediate mess that is upon us. Stay strong and let us get the creative process ramped up.
Wishing you and yours a happy and healthy holiday season.

1. Wall JK. Cook Medical shelves Midwest expansion plans. Indianapolis Business Journal. Available at http://www.ibj.com/cook-medical-shelves-midwest-expansion-plans/PARAMS/a... . Published July 27, 2012. Accessed December 6, 2012.
2. Medical Device Manufacturers Association. Health care reform, device tax. Available at http://www.medicaldevices.org/issues/Health-Care-Reform,-Device-Tax . Accessed Dec. 4, 2012.


The Affordable Care Act may remove the wound care fee-for-service treatments and substitute, in an effort to curtail cost, a global fee.

For instance, many providers benefit from frequent, or as needed, debridements, incision and drainage, and the supplies and equipment.

Many providers have made "diabetic wound care" central to their practice and, as "limb salvation experts," built practices based upon third-party payments for sometimes staggering fees.

The Act may very well eliminate this and replace it with either the lump sum per patient, or provide for an alternative in which physician extenders, ancillary care providers, or other service providers tend to "wound care" under the supervision, in most cases, of a physician MD/DO.

In some states ARNPs, PAs, and DNPs have established wound care facilities providing wound care independently.

Is this a trend toward non-DPM providers performing the same or similar duties?

There is no answer at this time. However, this is something to follow.

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