How To Integrate DME Into Treatment Protocols – Part 1

Having established treatment protocols for common conditions one sees in practice can go a long way toward reining in costs and maximizing efficiency. In this 7 part series, I will offer 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.

Four Pertinent Principles In Streamlining Health Care Delivery

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.

The Times of Our Lives

Being a supplier of Medicare Durable Medical Equipment entails a long list of ever changing deadlines and timeframes.  While it may seem difficult to keep track of them all, failure to keep abreast can easily result in claims denials and even exclusion from the program.  In order to help suppliers keep fitting and getting paid, the following are dates and timeframes that all should be familiar with.

  • January 1: Every patient eligible for new shoes if documented need for replacement
  • 3 months: Time allowed from when certifying physician signs certifying statement to when shoes must be fit.
  • 3 months: ADA recommended frequency for comprehensive diabetic foot exam for patients of foot risk category 3 (history of ulceration, amputation)
  • 6 months: Amount of time condition requiring stabilization could justify utilization of custom made AFO.
  • 6 months:  Time prior to fitting shoes that patient needs to have been seen by the physician managing their diabetes
  • 6 months: ADA recommended frequency for comprehensive diabetic foot exam for patients of foot risk category 2 (neuropathy present)
  • 1 year: Interval when Medicare DME supplier number will become inactivated if no DME if billed to Medicare. Reactivation required resubmission of supplier application.
  • 1 year: ADA recommended frequency for comprehensive diabetic foot exam for patients of foot risk category 0 (No neuropathy, protective sensation intact)
  • 3 years: Interval when Medicare DME suppliers must have supplier information revalidated. Registration every three years requires payment of $505 payment and may entail visit from inspector.
  • 3 -5 years: Amount of time custom made durable medical equipment is expected to last unless there is change in patient’s condition such that there is justified new reason of “medical necessity”
  • 2030: Time by which Medicare population is expected to double versus 2000 levels*

*MedPAC Report to Congress: Promoting Greater Efficiency in Medicare, June 2007. Washington DC: Medicare Payment Advisory Commission, June 2007.