Better Outcomes & Lower Costs: Reigning in Overutilization of Hyperbaric Oxygen Therapy
Excessive utilization of hyperbaric oxygen therapy (HBOT) is a driver in uncontrolled wound care spending. This treatment modality involves breathing 100% oxygen at high pressure while enclosed in a chamber. Initially used for treating decompression sickness (commonly known as the bends) experienced by scuba divers, HBOT is approved by Medicare for 14 different health conditions. These include treatment of some types of wounds, such as certain diabetic foot ulcers, failing skin flaps, and wounds caused by radiation damage.
The idea behind HBOT involves using pressures at 2-3x normal to concentrate blood oxygenation. Essentially, super oxygenating the blood to saturate the patient’s tissues to improved oxygen delivery to wounds in an oxygen-starved state. HBOT is a life-saving treatment for divers suffering from the bends and for those with carbon monoxide poisoning. However, it is an expensive and time-consuming adjunctive treatment for wounds that remains controversial and delivers inconsistent results.
In practice, the best healing outcomes are the result of eliminating the cause of the wound and optimizing the patient’s health. Wound practitioners typically strive to manage a patient’s co-morbidities while focusing on targeted wound treatments. These include relieving pressure from diabetic foot wounds and restoring blood flow for failing skin flaps. HBOT, as an adjunctive treatment, should be reserved for those patients who fail standard wound care and are expected to benefit from the therapy.
Health plans have started and should continue to demand better outcomes for wound patients by taking a hard look at overutilization of HBOT. This comes down to four key areas.
Hyperbaric Treatments Drive Wound Centers’ Profitability
Unfortunately, wound clinicians often experience pressure from employers or wound management companies to increase HBOT treatments. This is due to their high reimbursement rates, effectively changing this adjunctive treatment into an expensive first line treatment. Many wound clinics, especially those involved with wound management companies, create a targeted quota for hyperbaric usage, in some instances pushing a minimum of 15% treatment utilization.
HBOT has become such a financial driver for wound clinics that it alone can turn a facility into a profitable venture. That leads many clinicians to justify treating patients in the hyperbaric chamber. This is because of the lack of logic for the treatment and the uncertainty of the outcome.
Hyperbaric Oxygen Therapy is a Heavy Lift for Patients
HBOT poses multiple challenges for patients. Daily treatments last around 2.5 hours and the typical course of therapy involves 30 sessions, lasting a total of 6 weeks. That is a massive time commitment, particularly when treatment effectiveness isn’t guaranteed. In addition, if a patient doesn’t carry secondary health insurance, they must pay daily copays. Essentially, patients could commit to 6 weeks of treatments and pay 6 weeks worth of daily copays. They may still end up with the same wound healing problems they had before they started therapy.
More Research is Needed
Treating the root cause of the wound often makes HBOT for wound healing unnecessary. Medicare has made strides to curtail the use of HBOT in numerous states. Unfortunately, more needs to be done to ensure HBOT is used for the right patient, for the right wound, at the right time. I’ve observed clinicians prescribing hyperbaric treatment to address a wound in or around a prior skin flap site years after the flap was placed. That creates a false narrative. A true failing flap presents itself shortly after surgery, not years after the flap has successfully healed.
We need more research to understand HBOT’s effectiveness in wound healing and what patient characteristics portend the best outcomes. The evidence currently used to support HBOT in wound treatment remains controversial and is often dated. In truth, wound clinicians are relegated to recommending HBOT while advising patients there is no guarantee it will be effective.
Stronger Approval Criteria & Formal Reviews
From the health plan’s perspective, stringent criteria should be required to approve HBOT for adjunctive wound treatment. It should also involve regular audits to ensure guideline adherence. This could include evaluating wound photographs, determining if health conditions impacting wound healing were addressed, assessing the wound’s healing trajectory, and documenting adherence to the treatment plan and failure of wound healing while following industry standards of care.
If treatment beyond 30 sessions is recommended, a formal peer review process needs to exist. Too often, wound clinicians use colleagues to perform cursory chart reviews so the peer review requirement, in theory, is fulfilled. Health plans can play a vital role in establishing a formal review process. This curtails excessive treatments when they are not medically indicated.
Achieving better wound healing outcomes in HBOT-targeted populations and improving healthcare spend are not mutually exclusive. Using HBOT adjunctively in situations where patient and wound characteristics strongly suggest treatment efficacy. As indicated by more robust research, it would result in less strain on patient resources and reduced secondary complications such as expensive hospitalizations and amputations. Truly, what is best for the patient aligns with what is best for the health plan. After additional HBOT research is completed, I anticipate a lot more empty hyperbaric chambers.