We have a serious problem with mistaken identity as wound care practitioners, and I don’t know what we are doing to do about it. I’ve told you that Medicare is holding me accountable for all the wound center patients with CHF and diabetes that get re-hospitalized each year because I provide the plurality of their Evaluation and Management (E&M) visits, and thus Medicare thinks I am their primary care doctor.
Medicare is not the only payer that is confused. The private payers are confused, too. How do I know that? They send me very nice letters on a regular basis. Do you get any letters like the one below, which are “Care Considerations?” I get a lot of these telling me that the patients I am seeing in the wound center are not on the right combination of medications for their blood pressure or diabetes, or that certain blood tests or screening tests have not been ordered. I usually write a note on the letter saying, “I am not the PCP, I am the Wound Care doctor,” and fax it back, but there’s really no point. Until there is a sub-specialty for wound care, or until Medicare implements the system it has talked about that would allow us to define our “relationship” to the patient, there’s really nothing I can do about being mistaken for the PCP.
What’s the big deal about mistaken identity? Well, it can get you kicked off the panel of a private insurance company for failing to meet the quality standards that the payer has set for a specialty that you don’t even practice.
Below is a heavily redacted letter sent to me by a wound care practitioner who is an internist. She was trying to understand the “quality measure” data described in the letter. She participated in the Merit Based Incentive Payment System (MIPS) through the US Wound Registry (USWR) through which she had successfully reported a suite of both standard MIPS measures and wound care quality measures. It turns out she had the same problem of mistaken identity with this private payer that I had with Medicare. They payer had identified the patients for whom she provided the plurality of Evaluation and Management (E&M) services over the year. Then to evaluate the quality of her practice as an Internal Medicine Physician, this Blue Cross Preferred Provider Organization (PPO) had set up its own quality reporting system that was completely separate from MIPS and which did not require her to actively submit any data. Their quality measures included cancer screening for cervical, colorectal and breast cancer, diabetes management (e.g. monitoring renal function and A1C), medication monitoring (e.g. adherence to statin therapy, diuretics), appropriate imaging for low back pain, prescribing disease modifying agents for rheumatoid arthritis, and NOT prescribing antibiotics when treating acute bronchitis.
A letter accompanied the report, congratulating the Wound Care practitioner for having achieved a “Blue Ribbon” in quality related performance recognition, “compared to peers in the same Working Specialty.” When she and I explored the links provided in the report, it was clear that if she had NOT met the PPO’s performance criteria, she could have been taken off the list of approved providers for this PPO. If that happened, she would no longer be “in network” for the beneficiaries of this PPO when they were referred for wound care services.
To summarize:
- My colleague practices only Wound Care
- She is Board Certified in Internal Medicine
- She is a preferred provider in a private payer’s PPO
- The PPO believes that she practices Internal Medicine since, in the absence of a recognized wound care sub-specialty, there is no way to indicate to the PPO that she is a wound care practitioner
- The payer identified the wound care practitioner as being the primary care physician responsible for group of patients for whom she provided the plurality of services during the year (because patients with wounds are seen more often in the wound center than by their PCP).
- The PPO created its own “quality measures” that have nothing to do with the data she submitted to Medicare to satisfy the requirements of the Merit Based Incentive Payment System (MIPS)
- The “quality measures” that this private PPO developed and by which this wound care practitioner were assessed, focused on whether certain types of cancer screening were performed, EVEN THOUGH THIS PHYSICIAN WAS NOT THE PRACTITIONER WHO ORDERED THE CANCER SCREENING, and whether the patient was on certain medications EVEN THOUGH THIS PRACTITIONER WAS NOT THE INDIVIDUAL WHO PRESCRIBED THE MEDICATION.
What did we learn?
Whether this wound care practitioner remained on the panel of a PPO was based on quality measures that had nothing to do with wound care using data contributed by other doctors.
How long do you think anyone can continue to practice wound care if quality is going to be determined by the performance of others, and wound care practitioners are held responsible for the cost of all the patient’s underlying medical conditions?
Dr. Fife is a world renowned wound care physician dedicated to improving patient outcomes through quality driven care. Please visit my blog at CarolineFifeMD.com and my Youtube channel at https://www.youtube.com/c/carolinefifemd/videos
The opinions, comments, and content expressed or implied in my statements are solely my own and do not necessarily reflect the position or views of Intellicure or any of the boards on which I serve.
