Navigating the Twists and Turns of Value-Based Care in Private Practice and Wound Care 

There are various monikers for wound care providers working outside of hospital settings. Whether you prefer the term private practice, wound care provider without walls, or contract provider, your responsibilities are the same. Between patient care, staffing, and a myriad of other activities, you have a lot on your mind and plate. 

One issue you may not have had time to think about over the last few years is value-based care (VBC). You may have told yourself, “Well, that doesn’t apply to me,” or “I’ll worry about that later; I’m too busy right now!” 

Well, it’s time to start thinking about it. As we noted in Chapter 1 of our value-based care series, Leveraging Technology to Reach Your Hospital Wound Care Goals, the Centers for Medicare and Medicaid Services (CMS) aims to transition all Medicare beneficiaries to some form of a value-based care payment solution by 2030. Medicaid and private payers will follow. And if you receive payments from any of those entities (and, of course, you do)—you need to get familiar with VBC. 

Embracing value-based care isn’t just about ticking boxes to meet regulations—it’s a game-changer for patients and the quality of care they receive.  

We know that wounds take a tremendous toll on patients—especially older and disproportionally affected populations. One of the more common conditions seen in wound care settings is pressure injury (PI). More than 2.5 million people will develop a PI this year. The AHRQ reports that the prevalence of PIs in long-term care settings is 7.5%, with an annual cost of $3.3B. Equally, or perhaps more troubling, is the rate of diabetic-related amputations. Those have increased by 50% in recent years, especially among disproportionately affected populations, a trend we must reverse. Statistics such as these are just some of the reasons CMS is championing the VBC model.  

Why VBC, and Why Now? 

What exactly is VBC, and why is it becoming such a crucial strategy for the success of wound care private practices? There are numerous explanations worth your time to review. Check out the one we developed based on research and discussion with industry experts, as noted in Chapter 1. 

Value-based care in wound care programs is a healthcare delivery model focused on improving care quality for patients with chronic wounds while simultaneously managing costs. It’s an approach that shifts the traditional fee-for-service model to a system where healthcare providers are rewarded for delivering high-quality care that leads to positive patient outcomes rather than merely performing more procedures. VBC aims to hold providers more accountable and links provider compensation to outcomes such as quality, equity, and cost of care for all patients.

Sources: CMS, Commonwealth Fund, NIH, Net Health 

From meeting needs to ensuring compliance with CMS, the time to explore VBC—and to transition your practice to this rapidly growing model—is now. However, there’s no need for panic. As the saying goes, keep calm and carry on, as there are steps you can take to prepare your practice for success.  

Start by familiarizing yourself with the fundamentals of VBC. Under the model, providers transition from payment by volume or transaction to reimbursement based on outcomes and quality of care. Those results can be quantified through coding, documentation, and reporting, especially when supported by specialty wound care technologies. 

Been There, Done That 

Most providers—no matter their setting—are already incorporating several VBC-related procedures and guidelines into their practices. Participating in VBC programs means tailoring what you are likely already doing to fit into the parameters outlined by CMS and other payers.  

What’s MIPS got to do with it? 

Consider CMS’s Merit-based Incentive Payment System (MIPS), one of many government programs focused on improving quality while emphasizing value. Under MIPS, program performance is measured in four categories: 1) quality, 2) cost, 3) promoting interoperability, and 4) improvement activities are analyzed. 

 Multiple quality measures are available under MIPS; 2024 marks the largest number of quality measures in the program’s seven-year history. For wound care providers, the big news is that specific wound care quality measurements were finally approved earlier this year. 

Various specialty organizations, including the Alliance of Wound Care Stakeholders and the U.S. Wound Registry, developed the quality measures listed below. Measures examined include:       

  • Nutritional Assessment and Intervention Plan in Patients with Wounds and Ulcers 
  • Non-Invasive Arterial Assessment of Patients with Lower Extremity Wounds or Ulcers for Determination of Healing Potential    
  • Diabetic Foot Ulcer (DFU) Healing or Closure        
  • Venous Leg Ulcer (VLU) Healing or Closure            
  • Pressure Ulcer (PU) Healing or Closure (not on the lower extremity)        

For a complete list—see here

Outcomes Data

When it comes to outcomes data, whether your clients are hospitals, skilled nursing facilities (SNFs), or other care centers, you already provide much of the data requested by VBC programs.  

In post-acute settings, the outcomes data you are likely already monitoring to manage risk include the percentage of residents or patients with pressure ulcers that are new or worsened during a nursing facility stay and diabetic foot ulcer closure.  

Confronting the VBC Challenges in Private Practice  

If you’re ready to start thinking about VBC, there are resources and solutions to help. That doesn’t mean you can sit back and wait for it to happen. There will be challenges when implementing or expanding VBC programs. Issues that will require your focus include: 

  • Ensuring coding and documentation are accurate  
  • Training staff to understand programs and ensure they follow all guidelines and regulations 
  • Acquiring and implementing optimal technologies to help you efficiently gather and report on required outcomes and data 
  • Planning and budgeting for technology, staff, training, and processes that are most relevant to your specific practice 

We’ll say it one more time; VBC does not mean reinventing the wheel. Remember that your current patient treatment and processes will remain the same. You are simply adjusting the care to ensure it produces the best outcomes, is provided most efficiently, and is documented, coded correctly, and reported. 

What is a Private Practice Wound Care Provider? 

There is no set term for wound care providers in non-hospital settings. These providers, encompassing physicians, nurses, and other practitioners, may own their practices or work for smaller privately owned clinics or large national providers. Some even operate mobile units, bringing their expertise directly to patients’ doorsteps. 

While many own their practices, the key differentiator lies in the diversity of their contracts. Most rely on a mosaic of agreements, spanning from Medicare and Medicaid to private insurers, all within the confines of their state. Their ability to secure these contracts and deliver exceptional outcomes and efficiencies leads to referrals from payers and is paramount to their survival. 

As the number of VBC contracts grows, this model’s importance to private practice is becoming increasingly evident. Your success will hinge on clinical acumen, the ability to navigate the shifting landscape of healthcare reimbursement, and your commitment to patients and payers. 

The Essentials: Private Practice Technology Features   

What’s the best way to adapt to the brave new world of VBC? The first step is to understand it, but the next steps are to acquire the technology and solutions that will streamline processes, create efficiencies, and integrate into your daily workflow. 

When looking for new technology—or when analyzing existing solutions—make sure the following features are available: 

  • Comprehensive specialty EHR platform. Almost all practices today have an EHR.Specialty EHRs that seamlessly integrate with your primary system are essential. Look for platforms that provide automatic coding for quick, comprehensive claim submissions, wound documentation, and reporting. Systems incorporating updates to trends data, regulations, and clinical standards will also benefit your practice. 
  • Robust digital imaging. Digital imaging platforms provide a plethora of features and value. Digital platforms like Net Health® Tissue Analytics accurately measure wounds and document vital data, including debridement, which is critical in value-based wound care programs. For VBC programs, digital imaging allows you to track, project, and formalize a process for capturing critical metrics that show how wounds heal over time. 
  • Accurate and timely billing. Most wound care private practices today use an outside billing company. However, you’ll still need to provide your biller with the correct information. Ensuring your EHR has up-to-date CPT-4 codes (Current Procedural Terminology®, Fourth Edition) is the easiest way. This uniform coding system, maintained by the American Medical Association (AMA), is used to identify medical services and procedures furnished by physicians and other healthcare professionals. Make sure your technology platform incorporates the latest CPT-4 codes and that your staff knows how to code to ensure your billing is accurate. It’s a complex task, but CMS, your technology vendor, consultants, and trade associations provide resources to help. 
  • Optimizing reimbursement. Given that reimbursement is critical to your operations, there is more about VBC and billing to consider. An essential feature of digital imaging technology is that it calculates and populates the number of billable units to the super bill and provides the all-important documentation you must have to support your billing under VBC programs. Another significant benefit of proper technology and imaging is that it helps to ensure compliance and mitigate denials, which are at the top of the list of priorities for private practice. 
  • Robust data and benchmarking capabilities. Access to robust wound-specific data will help with many areas of your practice as you develop your VBC capabilities. Become familiar with the measures and benchmarks that apply to your practice, and fully explore the guidelines and rules that will most impact your patient mix. Data is vital, as it allows you to measure and report on outcomes and compare your performance to similar practices. That data is not only a requirement for VBC; positive outcomes also help to market your practice and secure contracts. 

Net Health is the largest single source of wound care benchmarking data in the nation. That means you’ll have access to a wealth of patient information, allowing for comprehensive analysis of various factors influencing wound care outcomes, such as patient demographics, wound characteristics, treatment modalities, clinical outcomes, and more. 

Documentation and Medical Necessity 

There are other valuable features that wound care technology should offer. For example, under VBC programs, multiple rules and caveats are associated with using skin substitutes in nursing facilities. Procedures conducted in a hospital and clinic may not be covered in a SNF setting. Your EHR vendor must be tuned to VBC guidelines so that you will be compliant and fully compensated for the care provided.  

Requirements for medical necessity and related documentation are two other areas to closely follow. CMS has clearly outlined this area, so strive to follow their lead. 

Without the capability to monitor and improve outcomes and accurately document and report on the care you provide, your practice is no better than the one with the worst outcomes. 

Wound Care Medical Necessity Guidelines 
For reimbursement of wound care services under value-based care, the treatment modality must be deemed medically necessary based on the following criteria: 

  • Wound Severity 
  • Patient Health Status 
  • Evidence-Based Guidelines 
  • Therapeutic Goals  
  • Cost-effectiveness  

For more information, check out this resource.  

One Day, One Step at a Time 

If you’re getting the picture that now is the time to start transitioning your practice to be ready for VBC, congratulations. It’s an important step. You are now ready to initiate the actions that will help to ensure the success of your practice. Here are five to get you started. 

  1. First and foremost, staying informed is crucial. Regulations and requirements, especially for SNFs, frequently change. Establish a reliable method for staying up to date with the latest guidelines. Your EHR vendor and consulting organizations can offer valuable guidance and technology tools to simplify compliance. 
  1. It’s essential to have a deep understanding of your payer, your patients, and the processes within your practice. Thoroughly analyze that information and consider how you can position yourself for success. 
  1. You’re not alone in this journey. Many other healthcare providers are navigating similar challenges. Seek out partners who can offer guidance and support throughout the process. They can help you anticipate potential obstacles to VBC and make necessary adjustments, allowing you to focus on your practice. 
  1. Keep in mind that the processes involved in VBC are not only requirements for the program but also critical for securing contracts and referrals. Prioritizing these processes will help safeguard the sustainability of your practice in the long run. 
  1. Find ways to engage your patients—another area measured by VBC programs. Digital imaging solutions are a great way to keep patients informed and involved in the progress of their wounds’ healing. 

It’s Time to Transition Your Private Practice to VBC 

The day is fast approaching—and for some already here—when your reimbursement will directly hinge on patient outcomes and the value you deliver to both patients and payers. 

The programs, processes, and solutions are available today to help you succeed. Take those critical first steps and embrace the processes and solutions that will make VBC viable for your practice.  

Most importantly, shift your thinking on VBC. Consider the value it was designed to bring to patients and payers and how you can tap into the features that will help your practice thrive. Now is the time to equip your practice for the transformative landscape of value-based care. 

RevCycle Intelligence, Understanding the Value-Based Reimbursement Model Landscape, December 2023 
Agency for Healthcare Quality and Research (AHRQ), Pressure Ulcers, October 2017 
AHRQ, AHRQ’s Safety Program for Nursing Homes: On-Time Pressure Ulcer Prevention, May 2016 
ProPublica, The Black American Amputation Epidemic, May 2020 
Physicians Practice, How specialty practices can succeed in MIPS and value-based care, January 2024 
US Wound Registry, Measure The Right Thing: Quality Measures, January 2024 
CMS, Healthcare Common Procedure Coding System (Hcpcs) Level Ii Coding Procedures, December 2022 

The Path to Effective Quality Measurement and Value-Based Care Private Practice and Wound Care: Pathway to a New Era 

Learn more! Check out these resources.