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.

Recommended for You

  • April 29th, 2022

    By Emily Greenstein, APRN, CNP, CWON, FACCWS

    After attending the Spring Symposium for Advanced Wound Care and hearing many great lectures, I got to thinking, “What are the pillars of chronic wound care?” We have all heard of the concept “look at the whole patient and not the hole...

  • January 21st, 2021

    By Lauren Lazarevski, RN, BSN, CWOCN

    Could metallic micronutrients be the missing link for your patient with a chronic wound? When we consider the nutrition required to optimize wound healing, protein supplementation is usually the star of the show. However, there are...

  • January 12th, 2022

    by Heidi Cross, MSN, RN, FNP-BC, CWON

    The following is a wrap up of the 2019 pressure injury guidelines of the National Pressure Injury Advisory Panel (NPIAP)1 related to nutrition, of which there are 15. For guidelines #1 to #10, see my last few blogs (Parts...

Important Notice: The contents of the website such as text, graphics, images, and other materials contained on the website ("Content") are for informational purposes only. The Content is not intended to be a substitute for professional medical advice, diagnosis, or treatment. The content is not intended to substitute manufacturer instructions. Always seek the advice of your physician or other qualified health provider with any questions you may have regarding a medical condition or product usage. Refer to the Legal Notice for express terms of use.