Don't let HCFA deny progress.

The cumulative research of the past three decades has ushered in a new era in wound care management, with innovative dressings that accelerate healing, reduce suffering, and provide long-term monetary savings. Ironically, though, even as wound care finally comes of age, millions of elderly patients are being denied access to critical aspects of treatment.

A Health Care Financing Administration (HCFA) initiative intended to improve Medicare claims processing and curb fraud and abuse is already systematically eliminating benefits for chronic wound sufferers.

The new policies were set into motion in October and now affect 41 states. By March 1 of this year, wound dressings now covered under Medicare Part B will be severely restricted for some patients and curtailed completely for chronic wound sufferers, who comprise approximately 80% of all wound patients.

The initiative is set forth as follows:

COVERED:

* True surgical wounds, closed and uncomplicated: one week of dressings.

* True surgical wounds with complications (ie, infection that results in reopening): primary surgical dressings until healed.

* Nonsurgical debrided wounds (such as pressure ulcers): dressings for two weeks after debridement. The wound then reverts back to its chronic status and coverage is terminated unless and until the wound is debrided again.

NO LONGER COVERED:

* Dressings for any type of chronic wound. All nonsurgical, non-debrided wounds, including pressure ulcers, leg ulcers, burns, skin tears, etc.

The reorganization--called Carrier Consolidation--began with the identification of four regional carriers--replacing 34 independent carriers--called Durable Medical Equipment Regional Carriers (DMERCS). These four have the authority to process all durable medical equipment prosthetics, orthotics, and supplies (DMEPOS) claims under Medicare part B, and to write policy for that coverage. While HCFA does not dispute the medical indications for dressings for nonsurgical wounds, they claim their refusal to cover is based on strong statutory legal grounds. Another view, however, is that it is based largely on semantics. HCFA cites the Social Security act of 1965 in which reimbursement was specified for "surgical" rather than "wound" dressings, and chooses to ignore the widely accepted genetic use of the term "surgical" (as in "surgical supply house.") They go on to describe 25 years of wound dressing reimbursement as a mistake and an example of the fraud and abuse that the DMERC Consolidation is attempting to curb.

Grandfathering: Permitted, but Flawed

In December, in response to inquiries about patients now receiving benefits, HCFA unveiled its grandfathering policy. For at-home patients currently receiving benefits, the policy mandates continued coverage--whether or not allowable under the new policy--for the duration of healing. But for residents of long-term care facilities, benefits will be curtailed as of April 1, even for those in mid-treatment.

Because this policy discriminates on the basis of setting, its detrimental impact will be far-reaching. For example, the policy can be interpreted as providing incentives for physicians to resort to unnecessary surgery to eliminate the need for dressings -- or even to create surgical wounds to obtain reimbursement. In addition, the lack of coverage will likely dissuade nursing homes from admitting chronic wound patients. This will, in turn, set up a domino effect in which back-ups in acute care facilities lead to premature discharge without adequate care programs. Those chronic wound patients who are admitted to nursing homes will likely receive the least expensive (gauze) and least effective dressings, setting the stage for increased morbidity and rehospitalization.

Ultimately, the costs formerly incurred by Medicare Part B will be shifted to Part A in the form of rehospitalizations. Experience with similar decisions suggests, though, that a rollover of the same policies into Medicare Part A, Medicaid, and secondary payers is imminent, probably within one year.

A Call to Action

In light of these developments, a diverse group of health care providers is involved in ongoing meetings with HCFA. Among those expressing concerns about the new policies are the American Medical Association, the National Pressure Ulcer Advisory Panel, the Wound/Ostomy/Continence Nurses' Society, the Home Care Coalition, several nursing home groups, and representatives from industry. The hope is for a hold on policy and an administrative fix until the issues can be resolved in patients' best interests.

This can best be accomplished by expressing our concerns to HCFA either through our congressmen, or directly, by writing:

Thomas Ault, Director of the Bureau of Policy Development or Carol Walton, Director of the Bureau of Program Operations: HCFA, 6325 Security Blvd, Baltimore, MD, 21207.

Diane Krasner, MS, RN, CETN, is a member of the National Pressure Ulcer Advisory Panel (NPUAP). She has been an independent ET nurse consultant for acute and long-term care facilities for the past four years and has an additional three years experience as an acute care ET nurse. Ms. Krasner is a Contributing Editor and Editorial Advisory Board Member for Ostomy/Wound Management. She is a doctoral student at the University of Maryland School of Nursing.