Acute Care Hospitals and Wound Care – The Black Holes of the ACO Empire Protection Status
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by Michael Miller DO, FACOS, FAPWCA, WCC

And so it goes, the more things change, the more they stay the same. The Accountable Care Organization (ACO), proposed to be the salvation of the health of America, appears to be turning into the Death Star.

Like that old Purina Cat Chow commercial, the starts and stops of this haphazard, incongruent miasma of unintelligible (and unread, at least by several members that voted for it) rules, regulations and witty repartee seem to change by the hour…chow, chow, chow.

But lest you accuse me of honi soit qui mal y pense, I offer as always, a humble yet rambling perspective of what is poised to usurp a “not too bad” health care system. As a “dyed in the wool” non-hospital affiliated, wound care specialist, I am amazed at why any self-respecting doctor would perpetually poke themselves in the eye with a Dakin’s soaked sharp stick by willingly working for a hospital. Allowing hospitals to be in charge of the money for an ACO makes as much sense as putting Edward Snowden in charge of the NSA, or having a new LPN run the wound care at a nursing home.

Let’s look at the unquestionable facts. Hospitals are monuments to cost inefficiency, bureaucracy and self-aggrandizing. They are subject to archaic rules, decisions made more on politics than patient care and have a sense of self preservation so strong that they not only will throw you under the bus for daring to question their data but hold you down so the bus can run over you again. As a non-hospital affiliated wound care doc, I marvel at the naiveté of my hospital affiliated colleagues to droningly work in a draconian environment. Decisions are made regarding product selection and utilization by committees with individuals who neither understand nor care about what wound products and technologies are used and how. They cite rules and regulations based on information found in the Hospital Care for Idiots coffee table book. Of course, seducing a once-respected clinical doc to wear the administrative 'Dark Helmet' always plays well. And having the dabbler’s guide to recipe-based wound care lovingly produced by a “Best Practices” wound management company only provides the arsenic icing for the cake.

Wound people who work specifically in the hospital seem to have little to no understanding of what happens outside their pseudo-sterile walls when the patient ultimately survives their orders to return home. Patients subject to home health care dressings done twice a day, seven days a week; peanut butter and jelly sandwich wound dressings, consisting of enzymes with growth factors and a healthy dose of the topical antimicrobial du jour from dabblers with no comprehension of how HHC is paid for, are randomly issued with no responsible entity's signature. Actually, they rarely have comprehension of how their own inpatient care is paid for since a cost center could include an EKG, sandpaper and one of those basins used to collect anal seepage.

Any patient arriving that has a non-God-given hole gets a vigorous swabbing, a “low hanging fruit” diagnosis and an order for a decubitus antibiotic that always seems to be ahead of the order for the pressure relieving device but behind the one for social services to confirm the payer. And if the patient cannot remember what their dressing regimen is or the dressing is ripped off in the ER for initial evaluation and replaced with Betadine soaked gauze (to sterilize the wound and prevent infection of course!), the presentation of the contact information from the “outside” wound caregiver is blithely ignored with all the sincerity one can muster as the family is told, that because “they are not on staff, we can’t take orders from them.” Of course, information regarding dressings, treatments, and the rarely-needed report on the status and progress of the wound prior to admission can be easily overlooked since the odds are that the treatment would not be continued even if they got that information.

Even more laughable are the orders sent from the depths of these intellectually stygian edifices under the guise of best practices. How can so many “certified” wound care specialists do things so unwoundly? Dare I refer you to my eloquent diatribe “The Magic of Instant Open-Heart Surgery, and the Wound Care Certification Status Quo.” I reiterate that certification is no longer a milestone but a simple and offensively easily achievable means to increase one's pay without really having to “put up or shut up.” And these are the gatekeepers for moneys left over?

And so, the hospital becomes the primary point of origination of all funding and thus gets to select and divvy out the money to partners who they identify as paranoid about being ignored and thus left out of any profit potential. Does this sound to anyone else as good an idea as letting Chewbacca field 911 calls? The ACO concept as currently written will fail, at least in the wound care arena for the following reasons:

  • Patients are in the hospitals for too short of a time to really establish a treatment plan since hospital plans are based on manpower, monies and technologies not usually available outside their walls.
  • There is not a lot of overlap of personnel working in multiple venues and thus knowledge transfer between hospital-based wound care, outpatient wound care, home health wound care and LTC wound care is either nonexistent or incomprehensible. A change in the name of the collagen used in one location could conceivably delay initiation of care in another venue for decades.
  • The atmosphere between any one of these entities and any other of them is based on adversity, not collegiality and this will worsen when ACOs make everyone responsible for the dollars they use to provide care. That’s why I believe pressure ulcers develop during ambulance rides between the nursing home and the hospital.
  • It benefits hospital to lie. With the sanctions put on them for creation of bedsores and the realization that, in the grand scheme of things, long term care facilities are considered the bidets of wound care knowledge, expertise and cost effective care, the hospital will always believe it has a cesspool to empty its garbage into. Lets face it…would you believe a 5-hospital system with an esteemed head or a 30 bed facility who just hired their third DON in six months? The home health care agencies are being seduced into believing that their survival depends on their accepting a 500 pound lymphedematous, malnourished, craniotomy patient with a leaking bolt in the hopes that the next referral will be Tony Danza with halitosis.
  • Hospitals will use the ACO concept to reinforce the incestuous behavior that has put them into the current situation in which they have poorly managed their wound care costs. Something is awry anytime the decision as to which NPWT pump to use in a hospital is based on a cadre of nurses seduced by free lunches, or copious infusions of pseudo-science Kool-Aid, all in the name of ensuring that a friendly rep stays friendly at the cost of a better, more efficacious competitor. Of course, our current Sith overlords have conjured a Deus Ex Machina by creating the competitive bidding system assuring that no one will get paid what they’re worth thus simplifying matters by eliminating everyone.
  • As far as the ACO concept improving accessibility to care, I am not sure how that will happen. You might have the same buildings, but they will be staffed by fewer personnel (look at the St. Vincent layoff of over 865 employees in Indiana alone) with fewer high tech toys since the costs will not be covered since there will be little profit that remains after the hospital has created economic pan-delerium (kudos to comedian Jeff Foxworthy). What demon possesses those who believe that the 'Age of the ACO' heralds better care coordination, when in this pre-ACO world, the right hand isn’t even sure the left hand exists, let alone functions?

    To those of you who persist in working outside the hospitals and thus may be subject to the whims of a selection process akin to picking the most eloquent of the Real Housewives cast, I offer my strongest support for you to hunker down, and offer the same high quality, diagnosis-based, evidence-supported, cost-effective care you can. In the end, the hospitals will recognize that they may control the money, at least initially, but since their having patients means that the vast majority of monies will also be eaten up by them, the crumbs they reluctantly have to share with their…partners will eventually force them all to reassess their relationship with each other and most importantly their patients. To those deluded hospital administrators, docs and care coordinators who blithely and willingly persist in the belief that sharing costs is politico-speak for sharing care and not spreading the blame, I offer a final statement in the spirit of George Lucas…

    May the farce be with you!

    Until we ramble next time.

    About The Author
    Michael Miller DO, FACOS, FAPWCA, WCC is the Founder and Medical Director of The Wound Healing Centers of Indiana and IndyLymphedema, as well as a clinical consultant, teacher, inventor, and published author.

    The views and opinions expressed in this blog are solely those of the author, and do not represent the views of WoundSource, Kestrel Health Information, Inc., its affiliates, or subsidiary companies.

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