Quantifying the Cost of Care for Diabetic Foot Ulcers Treated in a Multidisciplinary Setting
Caitlin W. Hicks, MD, MS, Joseph K. Canner, MHS, Hikmet Karagozlu, MBA, Nestoras Mathioudakis, MD, MHS, Ronald L. Sherman, DPM, MBA, James H. Black, III, MD, Christopher J. Abularrage, MD.
Johns Hopkins Hospital, Baltimore, MD, USA.
OBJECTIVES: Increasing WIfI stage has been previously shown to be associated with prolonged wound healing time, a higher number of surgical procedures, and an increased cost of care in patients with diabetic foot ulcers (DFU) treated in a multidisciplinary setting. However, the profitability of this care model is unknown, especially in the context of institutions operating under a capitated global budget revenue (GBR). We aimed to quantify the hospital costs and margins associated with multidisciplinary DFU care in the setting of the GBR and those treated in a fee-for-service model.
METHODS: All patients presenting to our Multidisciplinary Diabetic Limb Preservation Service (6/2012-06/2016) were enrolled in a prospective database. Inpatient and outpatient costs, variable net margin (VNM, i.e. fee-for-service profit), and net margin (i.e. capitated GBR profit) ($USD) were calculated for each wound episode (initial visit until complete wound healing) overall and according to WIfI classification.
RESULTS: A total of 319 wound episodes in 248 patients were captured. Mean time to wound healing was 143±9 days, and limb salvage at one year was 95±2%. Patients required an average of 2.6±0.2 inpatient admissions and 0.9±0.1 outpatient procedures to achieve complete healing. The mean overall mean cost of care per wound episode was $24,226±2,176, including $41,420±3,318 for inpatient admissions and $11,265±1,038 for outpatient procedures. The mean VNM was $13,452±1,202, including $23,668±1,824 for inpatient admissions and $1,939±309 for outpatient procedures. However, the net margin under capitated GBR was substantially less, equaling only $2,412±375 per wound episode overall, including $5,128±622 for inpatient admissions and a net loss for outpatient procedures ($-3,730±596) (Table).
CONCLUSIONS: The costs associated with multidisciplinary DFU care are substantial, especially with advanced WIfI-staged wounds. While hospitals can operate at a profit overall, the net margins associated with outpatient procedures are prohibitive, and the overall net margins are relatively low given the labor required to achieve good outcomes. This study demonstrates that outpatient reimbursement for DFU care is not sustainable under a capitated GBR. 
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