Several years ago, I left my hospital-based IR practice to run vein centers for a large regional organization. Having learned about this opportunity through the SIR Annual Scientific Meeting, I was excited by the benefits it would unlock: a work–life balance, no call weekends and the support of a large group when dealing with the never-ending struggle with insurance company credentialing and contracting.
As with some of my former colleagues, I hoped that joining a large group would help lower the likelihood of plan exclusion or of ending up in a financial disadvantage in contracts and would increase referral opportunities. However, I soon learned that even with this added clout behind me, several plans remained out of reach as insurers claimed their panel for IR was full—whatever that means.
Like many aspects of the credentialing, contracting and referring process, this struck me as unnecessarily difficult and exclusionary. If, as a provider, I am willing to accept the payer’s fee schedule, why limit the number of providers if not to simply control and limit patient access?
A specialty that is intentionally suppressed from view and has no industry mechanism to be recognized for excellence in patient care will have obvious difficulties demonstrating its value.
After setting out on my own, I quickly realized how fortunate I had been in my former practice, with the constant flow of hospital-based referrals. Though I developed good relationships with local practitioners, I soon found this was not enough to gain access to their patients. Many of these potential referral groups had coalesced into even larger restricted networks in order to add further benefits from economies of scale for credentialing, contracting and referrals. Referrals contained within their networks of providers were strongly encouraged and incentivized.
Much like the restrictive nature of exclusivity contracts, these provider network integration arrangements limit member providers in certain specialties based on organizational needs. “Desirable” specialty providers often overlap in services provided—there were typically several vascular surgery groups, cardiology groups and various endovascular providers in addition to the exclusively contracted diagnostic and interventional radiology group. Network organizations that were affiliated with entities that owned hospitals and surgical centers also provided special membership status to other network organization members and a back door to access for those practices that could fill beds and operating rooms. It became clear that this system was not interested in allowing membership to an independent IR outpatient vein center practice.
Following the path of least resistance, I pursued inclusion in restricted networks that didn’t already have vascular practice partners. This approach initially seemed promising: the network appeared genuine in their review of all potential members while seeking practices with proven service excellence. However, they did not have the internal resources to establish their own criteria for specialty distinction and instead relied on insurance industry metrics for practice assessment.
This led to an alarming discovery: vascular and interventional radiology, recognized by the American Board of Medical Specialties (ABMS) as a primary specialty, was excluded from designation for excellence in vascular care. The only specialty included for this category was vascular surgery. The metrics reviewed were only relevant to a primarily inpatient vascular surgery practice. Other specialists had their own categories, and only IR was entirely excluded from this process. This only added to my growing realization that IR is often the object of suppression and discrimination.
As practitioners know, many potential referring practices no longer rely on referral pads or business cards. They simply go online to their organization’s menu of preferred providers and select the specialist via an electronic referral. I was shocked to learn that, in my state, provider information for those practicing VIR is suppressed from these provider directories. Unless an individual provider finds someone in the insurer’s IT department to toggle a switch from “suppressed” to “unsuppressed” or, more often, takes the time to file an appeal through the insurer’s escalation department, their personal practice information will not be published.
If you are excluded from these listings, how will patients or fellow providers know that your practice even exists, other than by word of mouth? A specialty that is intentionally suppressed from view and has no industry mechanism to be recognized for excellence in patient care will have obvious difficulties demonstrating its value. Ultimately there is only one result: decreased patient and provider access to VIR services.
After several months of on and off again discussions with a restricted network leadership group, I sent a retrospective evaluation of outcomes data for 38 thousand patients my center had seen throughout 2017. This type of data demonstrated my organization’s commitment to cost-effective care with optimized outcomes and opened the door to preferred provided status. We also sought areas where we could function as a spoke and hub referral design, demonstrating our value to hospital administrators. These areas ranged from wound and lymphedema care referrals to arterial screening studies. The end result was a success: patients will now be referred to those with a proven record of optimizing care, thus increasing access to quality VIR care.
Suppressing services and being denied access to referrals and patients is an ongoing challenge facing many practicing IRs, but it is one that can be overcome. The key is to be prepared, persistent and armed with excellent patient care—and continued dedication to promoting the value and rights of IRs within a complicated and sometimes unfair system.
