My Brother's Keeper – The Newest Medical Paradigm Protection Status
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By Michael Miller DO, FACOS, FAPWCA, WCC


Most of us are familiar with Genesis 4:9, in which, after Cain murders Abel, God questions him about his brother. His famous reply is “Am I my brother’s keeper?” Cain’s response (framed as a question) has led scholars to consider the consequences of assuming responsibility for the actions of another over whom you may or may not have a modicum of control.

With the recent Supreme Court decision regarding what has been mockingly called Obamacare, a new paradigm in health care has commenced. In our present medical model, reimbursement is based on choosing the correct codes to define your care, regardless of outcomes. This new exemplar is a radical departure in which reimbursement for care will be shared among multiple entities. The Accountable Care Organization (ACO) is based on the concept of shared risk. In simplest terms, what has already begun is that in a given region, a large medical conglomerate has received the nod to create its own multi-focal care entity. It then must identify partners to provide pieces of the care spectrum that it does not offer, such as a long-term care partner, a long-term acute care partner, a home health care partner, and the like.

This means that the initial delegated entity must carefully vet its potential partners to ensure that their choice provides the highest-quality, most cost-effective care with excellent outcomes. Moreover, each potential addition to this chain of care must itself be sure that the other members of the team they are considering joining represent excellence in their own areas of care. If all aspects of the machinery work as intended, then patient outcomes, cost savings, and subsequent reimbursement to all members of this ACO are optimized. Of course, as is true with every chain, the weakest link becomes the focal point after a failure.

What is a hapless wound care specialist to do in the face of an omnipresent care entity that can choose its “mating partners” on the basis of any criteria it wishes? My own investigations have led me to the following conclusions, which, like the ACO concept itself, have little to no evidence support, but seem to make as much sense as the ACO concept itself.

  1. There is safety in numbers. As a former staunch solo practitioner, I recognized the attractiveness of having partners, associates, and colleagues whose skill sets are similar to my own. It is easier to contract with a group than multiple individuals. Plus, misery loves company.
  2. You must track your outcomes. Insurance companies are doing it, and with the coming of mandatory EHR use ($44,000 only seems like a lot of money), the data will be out there for all the world to see regardless of your desire to control its release. You already know who in your area could not do wound care without antiquated solutions and methods. These are the “dabblers” who will never be considered for ACO membership (unless nepotism becomes a stronger instinct than greed).
  3. The only way to make certification meaningful is by having the skills to back it up. I previously blogged regarding the ease by which certification may be obtained. If you do great wound care, your referring caregivers will continue to recommend you based on their patients’ outcomes, not how many letters appear after your name. The ability to pass a factoid-based quiz (in which memorization replaces the logical thought processes needed on a case-based exam and in real life) merely qualifies you for the wound care version of Trivial Pursuit.
  4. Most importantly, you must become your brother’s keeper. It is imperative that you identify and stratify all the benefits and detriments of each of your potential partners. No one entity holds the mandate of excellence in all specialties. Places I would confidently go to have a joint replacement or an organ transplant may have other areas of care (including wound care) that border on the Neanderthal. If the risk is shared, then the most risky partners are those that define the outcome. Although not all partners will participate in the care of each and every patient, one bad apple will spoil the whole bunch, and the bad taste it leaves will persist until either the apple putrefies or the ACO does…taking you with it.

The good news is that like the search for the elusive Higgs boson, hard work, careful evaluation of all available information, intelligent and compatible colleagues, and a heck of a lot of pure dumb luck will result in finding that which others have sought; namely, a successful, reproducible outcome as a member of an ACO.

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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