A Case of Mistaken Identity

I don’t want to sound like a doomsday lunatic, since there are enough of those running for President. Besides, I’m not qualified to run for President since I can do simple MATH. I’ve pointed out that in 2016, I looked at my “Quality and Resource Use Report” (QRUR) and thought, “This could be the end of wound care as a field.” I base that observation on actual data. I work as a physician in a Hospital-Based Outpatient Wound Center two days a week, which is less than half time. My primary board certification is in Family Practice. In 2016, Medicare determined that 17 of my patients with chronic conditions were hospitalized as were 12 diabetic patients, 1 COPD patient, and 8 heart failure patients. If I had hit 20 in any of those categories I could have had a claw back of money under PQRS. Note that although I worked less than half-time as a physician, my hospitalization rate was more than 50% of the threshold in two categories and was nearly half the threshold in a third.  It’s safe to say if I had worked full-time in 2016, more than 20 patients would have been hospitalized in at least 2 if not 3 of the categories that comprise hospitalization rates per 1,000 beneficiaries for ambulatory care-sensitive conditions. Additionally, I was right at the halfway mark for “All Cause” hospital re-admissions.

The numbers below make perfect sense if you know the prevalence rate of serious co-morbid conditions in my patients (60% with diabetes, 54% with ischemic heart disease, 24% with CHF, etc.). I recently blogged about this. The problem is not so much that patients with chronic wounds are very sick and get hospitalized frequently (often not because of their wounds) – although that’s unfortunate for the patients. The problem, at least from the perspective of the Wound Care Practitioner, is that Medicare THINKS we are their primary doctor. Unless you board certified as a surgeon or a podiatrist, Medicare assumes you are the primary doctor because you probably provide the plurality of the Evaluation and Management (E&M) services in any given year. The issue for me is not so much that the patients were hospitalized, but that Medicare holds me accountable for the fact that they got hospitalized, and there is no mechanism for me to explain to Medicare that I’m just their Wound Care doctor.

Why is this a problem? Because these patients need a lot of expensive care – not just for wound care, but for all their complicated problems. And the wound care practitioner “owns” it all.

A few weeks ago I was leaving the hospital and found myself behind a Bentley belonging to a cardiologist. I  know it was a cardiologist because he has vanity plates that say “HRT-[blank].”

I see a lot of his CHF patients at the wound center because they have lymphedema and copiously draining, non-healing ulcers on their chronically swollen legs. He’s not going to get a claw back of his Medicare Part B payments for the CHF patients we share if they get re-hospitalized this year. Why? Because Medicare is going to claw back my Part B payments instead. Think about that.