Medicare Severe Wound Care: Spending Declines May Reflect Site of Care Changes; Limited Information Is Available on Quality

What GAO Found

GAO’s analysis of Department of Health and Human Services (HHS) Centers for Medicare & Medicaid Services (CMS) data show that in fiscal year 2018, 287,547 Medicare fee-for-service beneficiaries had inpatient stays that included care for severe wounds. These wounds include those where the base of the wound is covered by dead tissue or non-healing surgical wounds. About 73 percent of the inpatient stays occurred in acute care hospitals (ACH), and a smaller percentage of stays occurred in post-acute care facilities. Specifically, about 16 percent of stays were at skilled nursing facilities (SNF), and about 7 percent were at long-term care hospitals (LTCH).

CMS data show that Medicare spending on stays for severe wound care was $2.01 billion in fiscal year 2018, representing a decline of about 2 percent from fiscal year 2016, when spending was about $2.06 billion. Spending declined as a result of decreases in both the total number of these stays, as well as spending per stay, which both decreased by about 1 percent. The decrease in per stay spending was likely driven, in part, by a change in where beneficiaries received care. CMS data show fewer severe wound care stays in LTCHs, which tend to be paid higher payment rates. At the same time, more severe wound care stays were at two other types of facilities that tend to be paid lower payment rates: ACHs and inpatient rehabilitation facilities.

GAO’s analysis of CMS data also show that, while the number of LTCHs that billed Medicare for severe wound care decreased by about 7 percent from fiscal years 2016 to 2018, Medicare beneficiaries continued to have access to other severe wound care providers. For example, CMS data show that most beneficiaries resided within 10 miles of an ACH or SNF that provided severe wound care in fiscal year 2018.

Figure: Percentage of Medicare Fee-for-Service Beneficiaries Residing within 10 Miles of a Health Care Facility That Provided Any Severe Wound Care, by Facility Type, Fiscal Year 2018

Note: The “other” category includes facilities such as psychiatric hospitals or units.

There is limited information on how or whether the decrease in LTCH care for severe wounds may have affected the quality of severe wound care Medicare beneficiaries receive. For example, CMS collects information on the percentage of patients with new or worsened pressure ulcers at post-acute care facilities, but it does not measure the quality of care they receive.

Why GAO Did This Study

Medicare beneficiaries with serious health conditions, such as strokes, are prone to developing severe wounds due to complications that often lead to immobility and prolonged pressure on the skin. These beneficiaries may require a long-term inpatient stay at an ACH or a post-acute care facility, such as an LTCH. LTCHs treat patients who require care for longer than 25 days, on average. In 2018, LTCHs represented about $4.2 billion in Medicare expenditures.

Prior to fiscal year 2016, LTCHs received a higher payment rate for treating Medicare beneficiaries than ACHs. Beginning in fiscal year 2016, a dual payment system was phased in that paid LTCHs a rate similar to ACHs for some beneficiaries and a higher rate for beneficiaries that met certain criteria. As this payment system has moved from partial to full implementation, lawmakers had questions about how it may affect beneficiaries’ severe wound care.

The 21st Century Cures Act included a provision for GAO to review severe wound care provided to Medicare beneficiaries. This report describes facilities where Medicare beneficiaries received severe wound care, Medicare severe wound care spending, and what is known about the dual payment system’s effect on access and quality. GAO analyzed Medicare severe wound care access and spending data for fiscal years 2016 and 2018 (the most recent data available); reviewed reports; and interviewed CMS officials, researchers, and national wound care stakeholders.

HHS provided technical comments on a draft of this report, which were incorporated as appropriate.

For more information, contact James Cosgrove at (202) 512-7114 or cosgrovej@gao.gov.

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    In U.S GAO News
    The Defense Health Agency (DHA) within the Department of Defense (DOD) has established processes for preventing and responding to quality and safety concerns about individual providers delivering health care in military treatment facilities (MTF). Specifically, DHA's August 2019 policy standardized processes for managing health care quality in the Military Health System, which superseded the policies of each of the military services (Air Force, Army, and Navy). These processes include 1) initial and ongoing monitoring of providers; 2) taking action to deny, limit, or remove individual providers' ability to practice, known as adverse privileging action; and 3) reviewing the care delivered by individual providers involved in certain patient safety events, known as potentially compensable event reviews. For example, DHA policy establishes requirements for taking adverse privileging actions against a provider that either limit the care a provider is allowed to deliver at a facility or prevent the provider from delivering care altogether, when warranted. In particular, DHA policy specifies that the provider's privileges should be placed in summary suspension—a temporary removal of all or a portion of the provider's privileges—while a peer conducts an investigation of the concerns. DHA policy also specifies that summary suspensions lasting greater than 30 days, as well as any final adverse privileging actions, must be reported to the National Practitioner Data Bank (NPDB). The NPDB is an electronic repository that collects and releases information on certain adverse actions and medical malpractice payments related to providers. According to DOD officials, 27 DOD providers were reported to the NPDB for a summary suspension lasting greater than 30 days between February 1, 2020—when this requirement was implemented—and September 30, 2020. DHA supports the delivery of health care to servicemembers and their families throughout the Military Health System. As in all health care delivery settings, concerns may arise about the quality and safety of care delivered by individual health care providers at MTFs. For example, patient safety events—incidents that could have resulted or did result in harm to a patient—may occur during the course of providing health care services and may raise questions about the quality and safety of care delivered. DHA is responsible for ensuring the quality and safety of health care delivered by military and civilian health care providers, including contractors, through its clinical quality management program. The National Defense Authorization Act for Fiscal Year 2020 included a provision for GAO to review aspects of DOD's clinical quality management program, including its processes for reviewing the quality and safety of providers' care. This report describes DHA's processes for preventing and responding to quality and safety concerns about individual health care providers at MTFs. In future work, GAO will examine the implementation of these processes at MTFs. GAO reviewed documentation that contains policy and guidance for these processes, including DHA's August 2019 procedure manual for managing clinical quality management in the Military Health System. GAO also interviewed officials from DHA and each of the military services. We provided a draft of this report to DOD for review and comment. DOD concurred with our report and provided technical comments, which we incorporated as appropriate. For more information, contact Sharon M. Silas at(202)512-7114 or Silass@gao.gov.
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    In Crime News
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    A Seattle man pleaded guilty today to one count of wire fraud for carrying out a scheme to defraud several COVID-19 relief programs.
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    In Crime News
    The Civil Rights Division of the U.S. Department of Justice and its Servicemembers and Veterans Initiative would like to wish a happy Veterans Day to our soldiers, both past and present. We owe you our thanks, but more than that, we owe you our freedom. As the head of the Civil Rights Division, I am entrusted with enforcing laws that protect the rights of the brave men and women of our nation’s armed forces, and the veterans who have served in the past. Enforcement of these very important federal civil rights laws helps ensure that these men and women can continue to safeguard our freedom. 
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  • Combating Wildlife Trafficking: Agencies Work to Address Human Rights Abuse Allegations in Overseas Conservation Programs
    In U.S GAO News
    U.S. agencies primarily use Leahy vetting as the enforcement mechanism to prevent U.S. funding for combating wildlife trafficking from supporting human rights abuses. Statutory provisions commonly referred to as "Leahy Laws" prohibit the U.S. government from using certain funds to assist units of foreign security forces where there is credible information they have committed a gross violation of human rights. The Department of State (State) and the U.S. Agency for International Development (USAID) generally consider park rangers to be foreign security forces that are authorized to search, detain, arrest, or use force against people, and thus subject to Leahy vetting, according to agency officials. State or USAID may provide funding to the Department of the Interior's Fish and Wildlife Service (FWS) that it then uses to support park ranger activities. In those instances, FWS submits the candidates' applications to State for Leahy vetting. According to a State official, Leahy approval of a security force unit is good for 1 year, and State must vet individuals again if their unit continues to receive support from State or USAID funding sources. Both U.S. agencies and implementing partners took a variety of steps in response to recent allegations of human rights abuses by overseas park rangers. For example, a State official in the Central Africa region told GAO that while the Democratic Republic of the Congo embassy's vetting program has very strict control mechanisms, the International Narcotics and Law Enforcement Affairs Bureau requested quarterly reports to facilitate a review of all assistance to park rangers to ensure that any reported activities were vetted according to Leahy Laws. USAID officials told GAO that in addition to continuing Leahy vetting, the agency's response included strengthening human rights training and conducting a site visit to a park in the DRC where human rights abuses had allegedly occurred. According to officials, the visit involved speaking with beneficiaries to further understand the allegations and efforts to assess root causes, mitigate impacts, and stop future occurrences, including making referrals to appropriate law enforcement authorities if warranted. FWS officials also stated that they take seriously allegations that U.S implementing partners have supported park rangers who have committed human rights abuses. Since June 2019, the Department of the Interior has approved no new awards to the World Wildlife Fund (WWF)—one of the implementing partners which has supported park rangers alleged to have committed human rights abuses. Moreover, the International Affairs program within FWS has put all new funding on hold since September 2019, pending a departmental review. Agencies are also implementing various changes in response to congressional directives on safeguarding human rights. For example, State officials told GAO that they have added language to all notices for countering wildlife trafficking awards that requires implementing partners to include social safeguards plans in their projects. The plans will articulate an understanding of how their work could negatively affect local communities. USAID officials stated that USAID has included provisions in new agreements with FWS that require adherence to the congressional directives. FWS officials also confirmed that they are cooperating with USAID in these efforts. Implementing partners—WWF, the Wildlife Conservation Society (WCS), and African Parks (AP)—have all conducted investigations to address allegations of human rights abuses by park rangers, according to officials from these organizations. They have also developed grievance mechanisms to report human rights abuses. For example, WWF has received 50 complaints in roughly the past year related to its project work, according to WWF representatives. WWF has responded to complaints of human rights abuses through this mechanism by reporting the allegations to relevant authorities and meeting with community representatives. U.S. agencies provide training and equipment for park rangers overseas to combat wildlife trafficking. From fiscal years 2014 through 2020, the U.S. government provided approximately $554 million to undertake a range of activities through federal agencies and in cooperation with implementing partner organizations in the field. Multiple non-governmental organization and media reports, however, have alleged that organizations that have received U.S. funds have supported park rangers engaged in combating wildfire trafficking who have committed human rights violations since the mid-2000s. GAO was asked to review human rights protection mechanisms related to U.S. efforts to combat wildlife trafficking. This report examines 1) what enforcement mechanisms agencies have to prevent U.S. funded efforts to combat wildlife trafficking from supporting human rights abuses and how they implement them, and 2) how agencies and implementing partners address allegations of human rights abuses. GAO spoke with agency officials and implementing partner representatives locally in person and overseas by phone, and collected and analyzed information related to program implementation. For more information, contact Kimberly Gianopoulos at (202) 512-8612 or gianopoulosk@gao.gov.
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  • Department of Justice Awards Over $35 Million to Provide Housing to Victims of Human Trafficking
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  • Man Who Worked At Local Research Institute For 10 Years Pleads Guilty To Conspiring To Steal Trade Secrets, Sell Them In China
    In Crime News
    A former Dublin, Ohio, man pleaded guilty in U.S. District Court today to conspiring to steal exosome-related trade secrets concerning the research, identification and treatment of a range of pediatric medical conditions. Yu Zhou, 50, also pleaded guilty to conspiring to commit wire fraud.
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    A federal grand jury has returned a 147-count superseding indictment against 40 defendants across South Carolina in the largest federal racketeering conspiracy in South Carolina history.
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    The Department of Justice announced today that it is requiring Intuit Inc. and Credit Karma Inc. (Credit Karma) to divest Credit Karma’s tax business, Credit Karma Tax, to Square Inc. in order for Intuit, the creator of TurboTax, to proceed with its $7.1 billion acquisition of Credit Karma.  The department said that without this divestiture, the proposed transaction would substantially lessen competition for digital do-it-yourself (DDIY) tax preparation products, which are software programs used by American taxpayers to prepare and file their federal and state returns.
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  • Wisconsin-Based Nonprofit To Pay $1.9 Million To Settle Allegations Of False Claims And Kickbacks On Federal Contracts For Blind Workers
    In Crime News
    Industries for the Blind and Visually Impaired Inc. (IBI) has agreed to pay the United States $1,938,684.09 to resolve allegations that IBI violated the False Claims Act and the Anti-Kickback Act in connection with certain federal contracts set aside to employ blind workers, the Justice Department announced today. 
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