by Dr. Stephen Daugherty
A month back Dr. Santangelo sent out a query on the American Vein & Lymphatic Society’s Member’s Digest regarding why some providers are having difficulties with payers regarding board certification and holding hospital privileges. Dr. Daugherty was kind enough to send a rather extensive reply which we re-publish with his permission. As an aside, if you are not a member of the AVLS I strongly encourage you to join and be part of the solutions we try to bring to phlebology and lymphatic disease.
Dr. Santangelo,
The answers to your question are complex and this response cannot be comprehensive. Payors have many different reasons for denying payment or for limiting participation in their networks. Some may be with good, but ill-informed intent while others may be more questionable. There is a trend toward development of narrow networks driven by payor desire to contract with what they perceive to be the least expensive physicians even though they lack the sophistication to differentiate between the value of the lowest contract fee-for-service rate and the long-term cost of care (or lack thereof). Some of us will be excluded from payor contracts because the payors do not understand how to value high quality care or to differentiate it from the cheapest payment for an episode of care. Others will be excluded because of statistical patterns interpreted as overutilization, patient satisfaction issues, or high complication rates. The real reasons for payor decisions regarding network participation may be very opaque.
Some payors require network physicians to be board certified or board eligible in an American Board of Medical Specialties (ABMS) member board and/or to maintain hospital privileges. This is based partially upon the old idea that medical staff membership provides some assurance of quality. We suggest maintaining board certification in an ABMS member board even though the expense and time involved in maintaining certification may seem unreasonable. Many physicians meet the hospital privileges requirement by medical staff membership in the “Associate” or “Community physician” category. Others have agreements with hospitalist groups to evaluate and admit patients to a specific hospital which may be accepted by some payors.
The AVLS (formerly the ACPh) was the driving force behind development of the ABVLM and the Registered Phlebology Sonographer (RPhS) credentials and the Intersocietal Accreditation Commission–Vein Center Division (IAC-VC) in an effort o improve venous and lymphatic acre and to provide mechanisms for physicians to demonstrate their knowledge to colleagues, the medical community, payors, and regulators. We have supported these projects and likely will support facility accreditation under development by the Outpatient Endovascular Interventional Society (OEIS) and the AAAASF.
The ABVLM was created in 2007 and ow has about 850 diplomates from multiple specialties who have proven knowledge, education, and experience in venous and lymphatic diseases (VLD). Acceptance of a new specialty board by the ABMS averages about 15 years and we anticipate it will involve a subspecialty board within one or to existing ABMS boards. The ABMS has a very thoughtful 10 page document for diplomates to provide to payors in order to educate them about the UNIQUE value of the ABVLM. We encourage diplomates to work to educate their payors about the ABVLM.
It is noteworthy that the IAC-VC recently amended its standards to allow ABVLM certification as one of the credential pathways for physicians to be members of the medical staff of accredited vein center. This reflects a growing recognition that the ABVLM is the only certification process that requires diplomates to demonstrate the knowledge and experience specifically in the areas of venous and lymphatic diseases.
The ABVLM is the only reliable credential that the physician has the knowledge necessary to treat venous and lymphatic disorders. The AVLS is reviewing means to increase the strength of this message to payors and we already do this as we interact on medical policy issues with payors.
The AVLS developed the Patient Reported Outcome (PRO) registry in order to collect data to improve venous and lymphatic care and to measure outcomes. Participation in the registry and analysis of the data, we believe, will help us to demonstrate the value of venous and lymphatic care which some payors doubt.
In summary, we must provide value to patients and payors and we must convince them that historic requirements of medical staff privileges or unrelated board certification do not measure quality of care in 2020 and beyond. We continue working to provide better surrogate measures to predict quality of care and to measure quality of care actually delivered. We, as a society and as individual physicians, must build respect and relationships with payors. This process is complicated, but it already is yielding results in the medical policy arena, and our efforts must continue.
Best wishes to all of you and many thanks for the great things about the world in which we live and our opportunities to make lives better for those we encounter. Happy Thanksgiving.
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Stephen Daugherty, MD, FACS, FAVLS, RVT, RPhS
VeinCare Centers of Tennessee
Clarksville, TN
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