Having established treatment protocols for common conditions one sees in practice can go a long way toward reining in costs and maximizing efficiency. This author offers insights on the benefits of these protocols and how to incorporate durable medical equipment (DME) into the equation.
A key impetus for reining in health care costs is based on the understanding that 50 percent of these costs go toward unnecessary administrative costs, excessive or unnecessary tests and other waste.
Increasingly, large healthcare delivery systems are racing to reorganize their approaches to care as part of their ongoing efforts to rein in costs. Change can be difficult even when the benefits are obvious and the required actions are not complicated. For example, a tremendous amount of infection is still the result of health care professionals not employing well-documented hand washing procedures.
Integral to this reform effort is the creation of practice protocols. An example of integrating practice protocols on a large scale comes from Intermountain Healthcare, which serves patients in Idaho and Utah.1 It determined that 90 percent of its caseload involves the treatment of 70 different conditions. For the majority of these conditions, Intermountain settled on established treatment approaches supported by robust scientific evidence.
Intermountain officials understood that the recommended standardized approach is usually appropriate when patients present with one of the 70 conditions though the standardized approach does not apply in every instance.1 Such an approach allows for more consistent delivery of care, more predictable outcomes, better defense in the event of medical malpractice accusation, more consistent billing practices and more accurate documentation.
Podiatrists can learn from Intermountain’s efforts to streamline its approach to care by adopting four key principles.
1. Manage the care. Select the most common conditions and settle on a treatment approach. The successful adaptation of treatment protocols requires acceptance by all members of the service chain. Applying evidence to practice requires standardization not just of operational routines but of the rules for making clinical decisions. The more detailed the descriptions in a series of tasks, the less decision making along the path and the more predicable the actions and the outcome. One must identify and address every symptom, observations and lab result.
2. Corral variability. Create mechanisms for addressing instances when the standardized approach is not appropriate or not successful. There are instances in which the presenting conditions are complicated, poorly understood and do not fit into expected protocols.
It is essential that practitioners have a way of addressing such instances and not continue in a way that is not predictable. Such an approach may entail alternative protocols, further testing or referral to an expert in the field. It is important to examine the incidence and reasons for conditions that fall outside of established protocols.
3. Reorganize resources. When practices redesign clinical protocols, they must also reconfigure the supporting infrastructure and routines. There must be a match of the staff, incentive systems, information technology (IT) systems, physical layout of the clinic and educational materials, all with the redesigned process in mind. When a practice does not adopt such a unified approach, podiatrists continue to perform work that they could delegate to medical assistants. Performance measures then remain focused on factors not critical to achieving desired outcomes.
It is essential that medical staff members receive training and stay up to date with educational materials and tools for each protocol. As the saying goes, “If you cannot measure it, you cannot manage it.” There must be mechanisms in place to determine if the staff is performing the desired procedures and mechanisms should be in place to ensure that this is the case. Determine the time, personnel and materials necessary for each approach.
4. Learn from everyday care. Continually monitor the results of the practice’s approach and integrate the lessons learned from cases when the standardized approach is not successful.
The structure and processes of the clinic must allow learning from the everyday work. The people designing the practice protocols must learn from every member performing the various tasks. The people designing the protocols must understand the demands for every service as well as how one performs the task. Such an approach will enable allocation of resources to best meet expected demand. Office managers should do ongoing reviews of charts to ensure that the practice is following treatment protocols and documentation is in order.
While streamlining care is designed to improve patient outcomes and reduce overall health care costs, there is also an opportunity to increase practice revenue. Incorporating durable medical equipment (DME) into our treatment protocols for conditions of biomechanical etiology requiring stabilization may be beneficial in several respects.
Durable medical equipment provides readily available modalities when the patient presents. Utilizing DME enables you to get immediate patient feedback on the comfort and benefits of the given modality. Additionally, the availability and demonstration of DME products in the office can help facilitate both patient adherence and patient satisfaction.
One of the fundamental concepts for integration of DME into practice is to identify the frequency of the most common podiatric biomechanical diagnoses you see in practice. These are the conditions that offer the greatest benefit of integrating a streamlined approach to care. If you recommend a prefabricated ankle-foot orthotic (AFO) as a part of the treatment protocol, there should be a direct correlation between the incidence of the condition and the number of DME items dispensed.
After identifying the most common diagnoses you see, determine the DME items to use with each. Create treatment protocols for each visit and vary these by severity. Create protocols for follow-up visits depending on how well the condition is improving.
The DME recommendations should be based on the concept of providing items that are therapeutically appropriate and the least expensive. Recognize that some conditions are best treated by an orthotist who has more experience in the range of customized orthoses and related products.
There are a number of factors to consider when selecting DME products. For ease of ordering, seek out products from as few distributors as possible in order to obtain the best pricing and streamline ordering and bill paying. Look for distributors to match manufacturer direct pricing.
Favor products from companies that support podiatry through the American Podiatric Medical Association (APMA), American Academy of Podiatric Practice Management (AAPPM), American Academy of Podiatric Sports Medicine (AAPSM) and young practitioners associations. Work with distributors that offer ready technical assistance.
For every patient, the front office should determine, in advance of the doctor seeing the patient, if the insurance plan covers DME and whether the podiatrist is allowed to provide the specific DME product. If the plan includes coverage and the podiatrist can dispense it, determine whether the plan has an annual deductible or lifetime coverage amount. If the patient has coverage and the podiatrist is not allowed to dispense the product, the patient needs a referral.
The medical assistant can do the initial intake. Based on an understanding of treatment protocols, the assistant can then make the DME products readily available for the physician to recommend. The physician should review the initial intake and perform an evaluation. The physician describes the plan of treatment and therapeutic objectives of DME. The medical assistant reviews the application of DME with the patient.
When a patient’s therapeutic needs are beyond the ability of the provider, make a referral for consultation or further treatment. Consider pedorthists, orthotists and other podiatrists for possible referral. If appropriate, the medical assistant issues instructions on referral.
For patients with commonly presenting foot and ankle conditions, there are a number of specific DME products that one can keep on hand.
Plantar fasciitis. One possible diagnosis code is 728.71 for plantar fascial fibromatosis.
At the initial visit for patients with plantar fasciitis, one may use an Airheel (Aircast), which has a possible HCPCS code of L2999. Patients may also benefit from a readymade insert such as Powerstep (Powerstep).
At the second visit, patients may use a posterior or dorsal night splint (possible HCPCS code L4396) or custom orthoses. Consider a low top pneumatic walker for severe cases (with a possible HCPCS code of L4360).
At the third visit for patients with plantar fasciitis, consider shockwave therapy if patients are not achieving adequate pain relief.
Ankle sprain (grade 1). Possible diagnosis codes include 729.5 for ankle pain; 719.07 for effusion of the joint, ankle or foot; and 845.02 for sprain and strain of ankle and foot, specifically the calcaneofibular ligament.
At the initial visit, one can use an Air Stirrup (Aircast) with a possible HCPCS code of L4350. Other options include a GameDay (Ossur) or Exoform (Ossur), both of which have the possible HCPCS code L1906.
Ankle sprain (grade 2). As with grade 1 sprains, possible diagnosis codes include 729.5 for ankle pain; 719.07 for effusion of the joint, ankle or foot; and 845.02 for sprain and strain of ankle and foot, specifically the calcaneofibular ligament.
At the initial visit for grade 2 ankle sprains, one may prescribe a pneumatic walker with a possible HCPCS code of L4360. The DME products in this category include the SP Walker (Aircast), the XP Walker (Aircast) and the Air Walker (Ossur).
For a follow-up visit, patients may benefit from a semi-rigid shell with compression, such as the AirSport (Aircast), with a possible HCPCS code of L1906.
For subsequent visits, patients with grade 2 ankle sprains may use a wobble board or A60 (Aircast), which has a possible HCPCS code of L1902. Other DME products are a GameDay (Ossur) or Exoform (Ossur), which both have the possible HCPCS code of L1906.
Ankle sprain (grade 3). This is associated with fracture and there are number of possible diagnosis codes as follows:
• 845.01 (sprain and strain of ankle and foot, deltoid ligament)
• 719.07 (effusion of joint, ankle, foot)
• 729.5 (ankle pain and support)
• 824.2 (ankle fracture, lateral malleolus only)
• 824.6 (ankle fracture, trimalleolar)
• 845.02 (sprain, strain, calcaneofibular ligament)
At the initial visit, patients with grade 3 ankle sprains can use a pneumatic walker, with a possible HCPCS code of L4360. Durable medical equipment options in this category include the SP Walker (Aircast), the XP Walker (Aircast) and the Equalizer (Ossur).
At the follow-up visit, one can prescribe an AFO with multi-ligamentous ankle support with a possible HCPCS code of L1906. One such AFO is the AirSport (Aircast).
For subsequent visits, DME options for patients with grade 3 ankle sprains include a wobble board. Other options are the A60 (Aircast), with a possible HCPCS code of L1902, or the Exoform (Ossur), with a possible HCPCS code of L1906.
Tarsal tunnel syndrome. Possible diagnosis codes for this condition are 726.79 for tarsal tunnel syndrome or 719.47 for pain in the joint, ankle or foot.
At the initial visit, DME options are the GameDay (Ossur) or Exoform (Ossur), both of which have the possible HCPCS code of L1906.
At the follow-up visit, consider a non-pneumatic walker (with a possible HCPCS code of L4386) for severe cases. One can also cast custom orthoses.
Increasingly, solo DPMs and small groups of practioners are collaborating with large group practices. Increased size offers greater negotiating power with third-party payers as well as cost efficiencies that come with size. Such an approach also offers greater opportunity to streamline treatments to deliver optimal care in the most cost-effective manner.
Dr. White is the President and Founder of SafeStep. He is the Chairman of the DME Sub-Committee of the American Podiatric Medical Association.