By John Kingsley, MD, FACS, RVT

As practicing phlebologists, we have enjoyed great success in medicine over the past several years.  Our patients are happy as we have provided a much needed service to the American population, relieving pain and restoring quality of life.  In fact, more productive patients are affected positively by modern vein treatments than by other vascular methods including arterial.  We as physicians have appreciated our virtual re-birth in medicine, practicing primarily in office-based vein centers where we are less affected by the developing adversarial hospital/doctor relationships.  We have again enjoyed being physicians, making decisions for our patients, and performing the art and science of medicine which we love. 

In the past couple of years, our specialty has come under increasing scrutiny due to the increase in number of procedures being performed and the cost of those procedures.  Private insurers and the federal government are slowly reducing the reimbursement rates for each vein specialty procedure we perform.  We can anticipate further reductions, with the latest threat being a review of the relative practice value assigned to the vein procedures.  Although we fight hard to preserve these much needed services, we find that we must carefully examine not only our reimbursement but also our costs if we are to continue to enjoy this specialty.  More importantly, if the reimbursement drops further, and our costs escalate, this specialty will rapidly disappear, for the procedures will no longer be cost effective for our patients or for the providing physician.

If we are good business doctors, our expenses can be held to a minimum while we provide the very best quality for our patients.  Our profit margin in our office-based vein centers is directly proportional to our costs.  We can drive hard bargains with our vendors who wish to support us in a win- win situation.  We have been successful and have enjoyed tremendous relationships with the vein support businesses over the past few years.  These businesses have supported our individual practices, and have also supported our Societies. 

LAWSUITS!  The Achilles Heel

Lawsuits are the Achilles Heel that now threatens our practices and the very continued existence of the vein specialty.  These are not lawsuits against physicians individually, but are lawsuits among the vein support industry claiming procedure patent infringements.  Initially the Diomed Holdings Inc. company sued all competitors over patent infringements.  Diomed was successful in their suits, but failed as a business, partially at least due to the tremendous burden of legal fees to bring about the lawsuits.  This unpleasant situation seemed to be the end of the legal wrangling, until earlier this year when the VNUS company brought more similar patent infringement lawsuits. 

VNUS sued all competitors and Total Vein Systems (TVS).  AngioDynamics and Vascular Solutions Inc. settled their lawsuits with VNUS, making cash payments and agreeing to royalties paid to VNUS for each laser fiber, procedure pack and other supplies sold to physicians by these companies.  The understood suggestion was that these companies must raise their prices to physicians in order to level the playing field with VNUS for physician business.  TVS notified doctors that they refused to settle the lawsuit in a way that would increase costs, and is in an expensive battle with VNUS at the present time.

The obvious result of the business-against-business lawsuits is that you and I, as practicing phlebologists, will ultimately pay the price.  Already this has happened if you are purchasing supplies and equipment from AngioDynamics and Vascular Solutions.

These companies must raise their prices to physicians in order to maintain their own profitability.  Our costs escalate while our reimbursement declines, a situation not compatible with survival. 

If these battles continue, and if VNUS presses on in their lawsuits to demand royalties or bury competition, then my prediction is that the vein industry as it is today will disappear.  Office-based vein centers will close; only hospitals will be able to afford the high costs of the supplies, including the VNUS catheter; and ultimately the patients and the insurers will pay the ultimate price for “modern health care.” 

Access will be severely restricted for our patients, and there will be a reverse toward outdated, but more affordable, methods of treatment – even for our patients with stasis ulcers.  The number of physicians practicing phlebology will decline as the specialty retracts; and the American College of Phlebology will reduce in numbers and will no longer be the successful Society as exists today.  The total effect on the vein specialty will be devastating.

We as physicians have been casual observers of the vein business lawsuits, believing that we were not going to be affected.  We also have a serious antipathy toward procedure patents, believing that these are not in the best interest of our patients and have never held up in court challenges. 

Procedure patents stymie growth and invention and advancements in modern health care, and prevent physicians from offering the very best to our patients.  Yet that is exactly what is occurring in the vein specialty.  Apparently the equipment used for procedures can be challenged, and now has been upheld in court for Diomed. 

VNUS has taken Diomed’s legal success and is now threatening the very foundation of the vein specialty.  In many ways, VNUS may be destroying their own business as the physicians in the trenches are so adversely affected by lawsuit effects.

We need to be aware and we need to be proactive.  We should not support those companies that threaten our very existence by the continued lawsuits and by the physician price gouging to assure their own profitability.  We should support fully those companies that wish to maintain a win-win relationship with physicians, allowing us to provide modern care for our patients at a reasonable cost.  We should support those who compete in the market by offering the best products and the best procedures.  If a product or procedure is the best, physicians will adapt and will use that product for patient care.  We as physicians have competition all around our personal practice locations.  We do not sue our competition, we simply work to out-compete them.  That makes us better and makes us try harder.  Our patients ultimately receive the benefit.

Doctors literally hate lawsuits, in any fashion or form.  Nothing ruins our day and week and year more than a legal summons.  We very much dislike lawsuits among businesses that ultimately affect our own practices, escalate our costs and can threaten our very survival. 

A successful vein industry business is one that supports our work and which is a collegial partner with physicians.  I personally like the VNUS ClosureFast procedure, and I like the CoolTouch laser procedure, and I would like to be able to offer all of these procedures to my patients.  I would also like to keep my costs tolerable so that this very special medical practice can continue indefinitely. 

The lawsuit Achilles Heel will hopefully be resolved in a successful manner for everyone, so that physicians and industry can continue our remarkable specialty. 

Our patients will be most appreciative. VTN

John Kingsley, MD, FACS, RVT, is founder and president of the Alabama Vascular & Vein Center in Birmingham, Ala., and the new Atlanta Vascular & Vein Center. Dr. Kingsley is a Board Certified Phlebologist, having recently completed the requirements and examination to become a Diplomate of the American Board of Phlebology.  He is also a Board Certified Vascular Surgeon and General Surgeon, having completed those requirements as well and having maintained the Diplomate requirements in surgery for many years. He is a frequent U.S. and international speaker to vein and vascular societies, and is a formal consultant to the Tokyo Vein Clinic.  He has received numerous awards in his specialties, including being designated an Emeritus Fellow of the Australasian College of Phlebology.  He and his colleagues in Birmingham are reported to enjoy the largest single center experience with endovenous laser ablation procedures in the world.  He continues to see patients each day while directing the growth and performance of his specialty centers (alabamavascular.comatlantavascular.com). and