Reducing Wound Care Costs for Health Plans
Chronic wounds are one of the most under-managed drivers of avoidable spend in a health plan’s population. Wound care costs the U.S. an estimated $117 billion each year, driven largely by the roughly 8.8 million Americans living with chronic, non-healing wounds. The path to lower spend comes down to a single idea: reduction. Reduce healing time, reduce reliance on the inpatient setting, and reduce the downstream cost of infection and recurrence. Here is how a value-based, in-home wound care model does all three.
Reduce healing time
Heal rate is the clearest signal of both care quality and plan value, and the industry baseline is poor. Over a 90-day period, only about 51 percent of chronic wounds are healed under the standard model. Much of the gap traces back to inconsistency: many patients go 30 to 48 days between wound treatments when they should be seen weekly, and a large share of clinicians delivering that care are not wound certified.
Esperta closes that gap with 100 percent wound-certified clinicians delivering evidence-based care in the home. The result is 91 percent of wounds healed at 90 days, compared with 51 percent for the industry. Faster healing is not just a clinical win. It shortens the window in which a wound can become infected, recur, or land a member in the hospital.
Reduce inpatient care
The inpatient setting is rarely the right place to treat a wound, yet claims data shows that 80 percent of wound patients with inpatient stays have a primary wound diagnosis. That is expensive. CMS data puts the average case cost per member with one or more chronic wounds at roughly $10,600 annually, and a single complex case can exceed $100,000.
Hospital care also does not solve the underlying problem. Once a member is discharged, care often reverts to a wound clinic or standard home health, both of which carry the same access barriers that caused the admission. Moving care into the home, delivered by certified specialists, reduces dependence on the inpatient setting and the readmissions that follow. Esperta members see a 2.4 percent wound-related hospitalization rate.
Reduce the cost of infection and recurrence
Two clinical failures quietly inflate wound spend: infection and recurrence. In claims from plans without a wound program, roughly 50 percent of diabetic foot ulcers become infected, and of those, about 20 percent lead to amputation. Recurrence compounds it: venous leg ulcers return 60 to 70 percent of the time under fee-for-service care, meaning the plan pays to treat the same wound more than once.
Consistent, protocol-driven care is what breaks the cycle. Esperta’s model contributes to a 3.8 percent infection rate and a 1 percent recurrence rate, against an industry recurrence rate as high as 70 percent. Fewer infections and fewer recurrences mean fewer amputations, fewer admissions, and a more predictable wound spend for the plan.
A model built for population health
For a health plan, the value case is straightforward. Better healing, delivered in the home by wound-certified clinicians, lowers total cost of care while improving the member experience. Esperta members reach a first in-home visit in under 9 days from referral and rate their experience 4.82 out of 5.0. That combination of speed, outcomes, and satisfaction is what turns wound care from an unmanaged cost center into a source of plan savings.
For a closer look at where plans leave value on the table, see 3 ways health plans can maximize potential in wound care and how Esperta is better caring for high-cost members.
Ready to reduce your plan’s wound spend? Learn more about partnering with Esperta on our Health Plans page.