The Key to Getting Better is to Get Worse First: How the Medical Payment System Fails in Treating Wound Patients Protection Status

by Michael Miller DO, FACOS, FAPWCA

Ramblings of An Itinerant Wound Care Guy pt. 1

I want to thank the WoundSource folks for inviting me to vent my spleen as a blogger. By way of introduction, I have been a full-time wound care doctor since 1997. My practice takes place in acute care and long-term care facilities, two free-standing (non-hospital affiliated) clinics, and I make about 25 house calls per month on behalf of many home health care agencies, all in the great State of Indiana.

The name of the blog reflects what I hope to achieve; to identify those controversial, irrational, or just plain unusual things that affect what I do and how I do it as I travel from patient to patient and situation to situation. While it is not my intention to alienate any particular group at any given time, I am smart enough to recognize that when you take on an issue, someone is not going to like what you think. It is always easier to ask for forgiveness than to ask for permission and so, with that in mind, I offer the first of what I hope will be a thought provoking, or, at the very least, a confounding topic.

Each workweek is filled with the opportunity to achieve great satisfaction, both personally and professionally, but the monotony of this is all too often broken by the inherent insanity of our current medical payment system…hence the title of this edition of the blog “The Key to Getting Better is to Get Worse First.”

I will not waste any bytes rehashing the benefits of our current payment system(s) (perhaps a topic to consider at some other time say, when under general anesthesia), but I will admit that I do like the color Red. For better or worse, we live (and practice our craft) under rules and regulations that seem designed to inhibit creativity, punish compassion, and assure that successful care outcomes occur only after running a gauntlet lined with creatures named UR, RUGS, MDS and of course, CMS.

Case in point: My patient, a delightful 77 year old female, was seen at home because her home health care nurse was concerned about her failure to improve. With the new diagnosis of Chronic Venous Insufficiency with VLU made, evidence-based treatment was ordered and instituted expertly by the agency nurses. Despite excellent care and a motivated family, she did not improve as expected. The general consensus was to take her to the next intensive level of care, namely an inpatient stay at a rehabilitation facility (you may comfortably substitute the words “long-term care facility with a good therapy department”).

So, the obvious decision being made, I embarked on a saga of frustration worthy of Sisyphus. Of course, when the next course of action in medicine is obvious, you can be assured that it will be impossible, unobtainable, or unreimbursed.

A quick check of the guidelines for do-gooders revealed that according to CMS, patients cannot go into a long-term care facility without a three-day hospital stay (or as it was put to me, three midnights) before they can take advantage of their 100 compensated days. There are many other terms that go along with this, such as replenishable, co-pay, and lifetime, but these are better left untouched for the time being.

The solution seems so simple. Having so obviously failed home care, the patient is admitted to the hospital for the mandatory three-day stay, and “abra-cadabra,” problem solved, except that to meet the criteria for admission, they actually have to be sick.

This dilemma has two, and only two options for resolution: The first, and rarely successful, is that the patient actually has something wrong (maybe the good fortune to have another potentially life threatening condition resolved with a three-day stay) and meets admission criteria. The second and more likely, is that they are too healthy to warrant admission even as they commence spinning down the toilet of care.

The conundrum: failing care at home and requiring a more intense and higher level of care to get better, but needing to demonstrate more significant morbidities and more serious illnesses to get through the gate and closer to the ultimate goal.

In essence, you cannot get better, even if you get worse, until you get much worse. Then, you can finally get better.

Of course, this elegant scenario does not take into consideration the simple facts:

  • Hospitals are veritable culture plates of the most horrific, infectious denizens
  • The high likelihood of leaving less nourished than upon arrival
  • Risk of bedsore development
  • Numerous other counterproductive occurrences

When the patient finally is received at the ultimate destination, the long-term rehab facility, the original goals pale in comparison to the plethora of new and exciting co-morbidities that now inhabit their once barren medical record.

Let’s review: a patient is not sick but needs care; the patient requires more care than can be given at home; the next higher level of care is considered but not possible; the patient is allowed (in fact forced) to worsen; when the patient’s condition is worse, they are allowed into highest level of care; the patient survives the care and enters long term rehab (the original level of care desired). Is this success?

Of course, after contacting my three State Representatives, the best response received was that CMS was considering allowing for a three-day observation stay to count towards the criteria for going into long-term care. You of course noted the word “considering.”

Despite the absurd waste of money, the amount of man hours used to get the patient to some form of resolution, and dare we consider the illogical, unethical, horrific treatment of a patient who simply needed a little more help to get better, this scenario is the norm. To get better, you need to get a lot worse.

The resolution is simple: enact the three-day observation “gatekeeper” criteria. Or, do away with the mandatory, unquestionably cost-ineffective and detrimental hospital stay, allow for a direct home-to-facility, 10 to 14-day, long-term care placement. After which, an evaluation can determine whether the patient will benefit from additional short-term care at that level, or if they will, in fact, never improve. If the latter is decided, the patient could be returned to their home for palliation or placed in more definitive long-term care status.

In either case, the patients directly get the care they need, at a point where they can most benefit from it. The needed care is received and compensated without adding undue and costly risks, and with a minimum of bureaucratic gesticulation - a novel concept. Dare I suggest that those of you, who have experienced this, write to your own representatives and make sure they know it exists? Interestingly, there are a fair number who are not aware. Until next time, when we ramble together…

About The Author
Michael Miller DO, FACOS, FAPWCA 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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Wow, Amen!!!! Looking forward to reading more of "my" thoughts soon.

"Evidence based" wound care is "beaurucratic speak" for government regulated distribution of healthcare. Something that is frequently lost sight of is providing delivery of care using every tool available in the medical armament to acheive the best outcome. While most of the care delivery system is held hostage to a regulatory environment that mandates a patient's condition must meet certain criteria prior to the application of an intervention - the concept of "time is tissue" is often put aside. We should always try to put ourselves in the place of the patient, and ask how would we prefer to be treated. On the basis of some regulation or on the basis of a well planned, organized and logical approach managed by a physician who has the patient's best interest at heart?

I am a board certified WOC nurse. In our neck of the woods which is suburban Harrisburg, Pennsylvania, there is not one physician or podiatrist who practices evidence based wound care. Oh yes, there are plenty of physicians and podiatrists who call themselves "experts" in wound care but in general, wound care is still a free-for-all so that these docs can keep their revenue flowing. Wound care centers seem to be full of docs who use CRNPs and PAs that are trained by their respective employer physicians and the wound care they order is definitely NOT evidenced based….but the physicians can bill the NP and PA services to the insurance companies without question. Sometimes the closest thing ordered for a patient who needs moist wound healing products is the "product of the day" that came with the big expensive lunch brought by a sales rep. If the patient is lucky the product will work for them. But nine times out of ten, the product of the day is not appropriate because it is not utilized based on the actual assessment of the wound. I have worked in acute and long term care, and at two wound centers where I just see this over and over again....but patients keep coming back, often times unnecessarily, because "the doctor said so" even though there is no improvement in their wound status. At one wound care center I worked, the CRNP told me the goal was to maintain the wound base until the patient could qualify for hyperbaric oxygen treatment because "that's where the money is." I now work in home care and believe me, we discourage as many patients as possible from going to the wound care centers because their clinical outcomes are much better when the care is provided by properly trained nurses in the home. Our nurses have excellent clinical outcomes and our patients don't develop MRSA infections like we have seen in the wound centers, which by the way, when reported to the state or JCAHO no one seems to care....very sad. Several wound care centers in our area are directed by plastic surgeons who make it quite clear that seeing wound patients is simply a means to supplement their income in between the “tummy tucks and boob jobs” that many people have stopped getting done because of the bad economy.

The home care agency I work for is quite large and the nurses only want what is best for each patient to properly heal. Since our agency has developed such a good reputation with positive clinical outcomes for patients, this has increased the number of referrals for wound care assessment and treatment recommendations. I am proud of the agency nurses for what they have done and I will continue to hope that eventually wound care will only be provided by physicians and other practitioners who utilize strict evidence based standards of care that promote positive clinical outcomes.

Don’t get me wrong. I understand that health care is a business, everyone needs to be paid and facilities/agencies need to make money to stay in business. However, I believe that it is certainly possible to provide appropriate patient care, achieve positive clinical outcomes and still make budget.

I am a board certified wound care nurse, was working for a large national home care agency. Going out doing home visits with Dr Miller and see increased outcomes and decrease in cost of dressings. This did not make the owner happy and has made so rash decisions and unethical ones. The patients, are the ones I feel pain for. The patients continue to suffer from improper wound care, by nurses that are just looking for how many visits they can do in a day and increase their paychecks. The agency continues to skyrocket in hospital admissions, canceled visits and quick, improper dressing changes.
It is the expert teaching of Dr Miller, that has helped open my eyes to alot of things and added to my already stronge knowledge base.

Although I currently work in the wound care industry, I would like to respond as a licensed nursing home administrator. I could not agree more with Dr. Miller - his statements are accurate for a significant number of skilled nursing facility admissions, or even more appropriately a large number of admissions that are denied due to lack of available funds within the family to pay for care and lack of access to short term, emergency state funds.
The system to provide for people who need the next level of care, but not acute care is not broken, it simply doesn't exist. But as anyone interested in this website knows, there has never been an "reform" to CMS since it's inception, merely politically manipulated regulatory updates. I consistently urge my congressional representatives at the state and federal level to eliminate the three day stay.
Thanks for the energy you are giving to the blog in addition to all you already do - my hunch is it will be quite popular.

I have worked for one of the biggest agencies in the Nation and have found it was less than about the money and more about the money. It is sad to say, patient care was only 2nd and healing wounds way below that. Working with Dr Miller, we saw a big increase in outcomes, decrease in dressing costs and increase in patient satisfaction.
This hard work, was not important to the agency I worked for and caused problems for Dr Miller and myself. Being one of the few agencies, with a Certified Wound Care Nurse, was not important to the agency and was believed any nurse was a wound nurse.
A Certified Wound Care Nurse, goes through a lot of training, education and hands on experience. The expertise and testing is not easy, as with any certification. The test is not on dressing selection, but looking at the whole patient. Need to be aware of interventions, as well as, what is being put on the wound. The knowledge I have, is related to years of doing wounds and working with different experts. Always remember anything medical is a "practice." It is learning what works one time, may not work another.
It is not just passing a test, makes a good wound care nurse, it is also knowing your limits, continuing your education and not thinking you are the only one that knows about wound care.

Wound care is one aspect of the health care system that badly needs a revision. Too bad, though, that it is often overlooked.

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