Wound Care in Crisis – Big Brother, Where Are You When We Really Need You?
by Michael Miller DO, FACOS, FAPWCA, WCC
As much as I detest bureaucratic oversight and mandates from those above who have no idea what they are doing in their own day to day lest my own, I am coming to the conclusion that a big hammer is needed and fortunately, it seems to be coming. At first, when I heard the whisper that there would be a single amount paid for each wound care case, I shuddered because I was concerned that it would make me look harder at how I spend my patients' money. Diabetic foot ulcer debridements weekly to every other week... going to advanced biologics after the basics have not produced the desired results... tough decisions when economics is the ultimate gatekeeper.
But the last few weeks and several encountered legal cases as an expert have given me pause to rethink my position on oversight.
Like the orthopedic surgeon who used 10 Apligraf applications on a patient with simple venous ulcers in the OR and then sent to the PT department where she underwent weekly lymphedema therapy... for simple venous ulcers. She wisely escaped her deluded captors when they felt the 11th and 12th applications would turn the tide. I healed her in six weeks using four-layer compression, a silver dressing for two weeks and then a simple Telfa island dressing.
Or the two patients I assumed management of in the nursing home with straightforward venous ulcers and chronic venous insufficiency that had been treated the year before by an ID doctor (more about him in a minute) with weeks of oral and topical antibiotics and single layer Kerlix gauze compression for three months before the staff CWOCN treater changed the care to daily Dakin's and used tubigrip also daily for a five month period. Need I add that our care assumption resulted in complete resolution of the leg edema in three weeks and the wounds decreased by 50% in two weeks. The family blithely and blindly took her to the ID doctor (whom I have named the Man of La MRSA) recently who... changed her to Levaquin three times a week and topical gentamycin to the legs daily to treat recalcitrant infection. His diagnosis based on...a swab. A second patient received the same care a week later despite the nursing staff pleading with the family to not do so and proof that the patient had improved.
Our Ethical and Collegial Responsibility as Health Care Providers to Confront Harmful Care
If you knew a colleague was impaired due to illness, or substance abuse, would you not ethically do all you could to help them and make sure that their patients were not injured? Does the danger of confronting them outweigh the ethical dilemma of letting them continue to harm patients in the name of profit? Why then do we tolerate unethical, dangerous care due to the misguided tenet that it is not right to criticize another physician in front of patients? How many of you have seen patients ruthlessly savaged by profit-driven, wound management company zombies who have been seduced into enduring hours in oxygen coffins, marinated in Dakin's solution, slathered in topical antibiotics, who's response to the question "What did doctor tell you she was treating?" are answered with a blank stare, a spastic shoulder shrug and the all too often heard response, "they never said."
What of the patient with the diabetic foot ulcer whose plastic surgeon finally admitted failure after six weeks of full weight bearing, dry gauze dressings so that he could place a skin graft which promptly developed a large hole in the middle because he never had her offload. And the pitting edema with discoloration at the ankle above never once crossed his mind when the graft failed to take fully due to persistent drainage from the poorly covered wound below. His staff told the patient he was angry with her for not letting him try to get that new wound to heal.
To those purveyors of politically correct collegiality, I say "Balderdash." I have the opportunity to speak to the investment communities on a regular basis and the hottest topics are what is the new product coming in wound care and what is happening in the wound care world. I always warn them at the start of the call that what they will hear from me will be diametrically opposed to what they have already heard. I can tell you that at the end of each and every call, they assure me that not only were my opinions markedly different than what they had heard, but that what they heard from me made more sense. More often than not, the others they call admit that they do not do wound care full-time but work in a center a few days (I choked at that) a week.
Wound Care Outcomes: Quality of Care Versus Quantity of Wound Care Centers
The real question is whether it is more cost-effective and assures better care and outcomes to have very few high quality wound care centers or many, many mediocre ones? If I knew that a given center could reach the 60% competency level, I would consider allowing them to survive, but the rampant inconsistency of treatments, the random, hodgepodge of treatment utilizations, the overuse of high reimbursing dressings and technologies and the horrendous outcomes from these has led me to accept the impending CMS physician payment publications. I know that the vast majority of management company, hospital-affiliated wound care centers will be at the highest levels of reimbursement thanks to their abuse of debridements (never to 100% bleeding and rarely limited to diabetic neuropathic ulcers as a weekly cost center). Their coding is based more on where the dart lands on the board and less on what was the diagnosis they were treating. Of course, leaving out outcomes data is like a candle without the cupcake below. Seeing the average time to heal a venous ulcer with the range also seen and then juxtaposed against the costs to heal it should provide enough information to make even the most loyal hospital employee doctor consider other options rather than blithely referring to his own chamber of horrors.
With the coming of the Accountable care organizations and their delusion of improving care comes the concept that they will either recognize poor outcomes and cost-ineffectiveness and avoid association, or they will become victims of their own ignorance and nepotism. Without full-time, dedicated wound care specialists manning their beds, wound care centers are destined to become little more than depositories of second rate dabblers—a situation only slightly less bad than what passes for wound care now in far to many "Centers of Excellence." I applaud those of you attending the many excellent conferences that are held in so many locations. The opportunity to juxtapose your knowledge and skill set with those of others allows you to see where you stack up. I implore you to look at the posters and talk to the presenters and pose them the questions you fear may make you sound ignorant. You are not alone, even the best wound care doers have people they contact for insight, a new thought or fresh pair of brains. Help is always an e-mail, a phone call or a text away.
Of course, Big Brother has no problem stepping in when we fail to recognize help is needed. And help he will but in his own imitable style.
Until we ramble again.
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.