We are all well aware of the decreasing reimbursements affecting the practice of medicine each day during this recession. Endovenous procedures are no exception. Gone are the days of unbridled spending without a serious look at the bottom line.

Private insurance reimbursements for endovenous laser ablation of the greater or lesser saphenous vein is roughly $2,300 per laser ablation procedure; with additional procedures [perforators] the procedure package may increase to $2,900. In regard to Medicare, the average reimbursement is roughly $1,400 per case, without the additional procedures. Note, these figures will vary from state to state and from carrier to carrier with expectations for continued decrease in reimbursements by Medicare and private insurance providers to follow in the future.

So what can mature vein practices do to manage the bottom line? In a series, I will share my experiences with cost saving techniques utilized in my vein practice. These techniques are designed for mature vein practices — ones that have already invested in education, equipment and marketing strategies with a successful plan.

Before the 1980s; almost all medical surgical equipment was able to be reused following strict sterilization protocols. With the advent of HIV — almost overnight single-use equipment was advocated in medicine. Everything from suture trays to laparoscopic trochars were regarded as single-use only. Due to financial demands, hospitals and clinics around the world more recently have safely embraced reusable technology. Appropriate cleaning and sterilization techniques have been tested and approved.

When our practice was in early stages of development, our only source for laser equipment, fibers and sheathes revolved around Diomed, our parent company. After all, they were the ones who sold us our first laser with certification and protocols.
As you can imagine, when AngioDynamics acquired all the assets of Diomed (after filing Chapter 11), they also acquired all the debt from Diomed: Litigation fees, merger and acquisition costs, attorney fees, back taxes, and many other costs – including royalty fees – the pricing scale for the “Diomed” laser kits increased accordingly being passed on by AngioDynamics.

Personal offers for single use endovenous laser kits from AngioDynamics to my practice over the last year have ranged from $250 to $350 per kit. Endovenous laser kits included:

1.    600 micrometer insulated laser fiber
2.    Marked 45-50 cm 4 Fr introducer sheath
3.    0.35 “j” guidewire
4.    16g venous access needle

And all items are listed as single use. The recession took hold and we started looking for ways to help our bottom line.
We have been able to reduce our laser kit cost to a fraction of the offered commercial kits (See Table, page 1) by separate purchase of kit items from an independent vein surgery supply source in Houston – Total Vein Systems.

Total Vein Systems (TVS) offers components of the commercial laser kits at reasonable rates – no frills. Thus, we have changed our basic kit components to unmarked 45 cm 4 Fr introducer sheaths and reusable laser fibers.

The reusable laser fibers from TVS can be cleansed, sterilized and used up to 5 times before discarding. The introducer needle and “j” guidewire have remained constant in our practice, single-use per patient.

With appropriate processing protocols, the Federal Drug Administration (FDA) cleared for market Five Times Fiber is a 600-micron laser fiber that can be used with laser systems having transmissions between 532 and 2100 nanometer (nm). The fiber is manufactured with a universal SMA 905 connector. The Five Times Fiber comes with video instructions that are easy to follow for re-sterilization of the reusable fiber, “clip and snip.”

The “j” guidewire, access needle and sheath are considered single-use and these items are treated as such. During the endovenous laser ablation, only 1cm of laser fiber is actually in contact with the patient as the majority of the fiber is protected in the sheath. As noted with 810-980 nm laser wavelengths, carbon deposits are frequent on the distal fiber end. Only the distal tip of the fiber requires special preparation prior to re-sterilization.

The Process
The process is simple. After patient use, the fiber is unscrewed from the laser. A rubber cap is provided to cover the SMA 905 connector to ensure that no particles have access to the fiber core interface.

The remaining portion of the fiber is then cleaned with enzymatic solutions and soft cotton wipes to remove any blood or gross carbon particles — especially from the distal working tip. The entire fiber maybe immersed in fluids for cleaning.
Specific care is necessary for the proximal end of the fiber SMA 905 connector. Compressed canned air can be used to clear the SMA 905 connector ensuring a dry, particle-free presentation end.

Once the fiber has been cleaned, dried and inspected, the distal working tip is reviewed. Using a micro sheath stripper, the insulation is stripped from the distal end of the glass fiber.

The glass fiber is then cleaved in a simple process using a white ceramic scoring tile. The glass is etched in a transverse straight line. With a slight pull, the glass fiber is broken along the cleavage plane. The distal and proximal ends of the fiber must then be reviewed with magnification loops.

The protective rubber boot is removed and the ends of the fiber are pointed toward a light source. Any pits, carbon deposits or core defects noted on either end should alert the physician not to reuse that particular fiber. After inspection, the fiber is coiled and the protection rubber boot is placed to cover the SMA 905 connector.

The date is marked on the date tag and the fiber is placed into a self sealing sterilization pouch. Steam sterilization is then completed using wrapped cycles on a standard autoclave. Attempting to use a fiber more than the recommended five times may result in suboptimal energy delivery to the patient due to undetected stress fractures of the fiber.

Carbon deposits on the face of the fiber connection can overheat the connector; smoke and overheating may result in damage to the laser optics. If you stay within the manufacture recommended five-time guidelines you will have no problems with reusable fibers and laser damage.

Over the last 10 months, we have used more than 50 of the Five-Times-Fibers without a single problem. In other words, 250 cases.

When we first started using reusable fibers, our former fiber representative sent a detailed letter warning us that we should reconsider using “knock off” fibers that could lead to the destruction of laser diodes or the fiber recognition system.

The fact of the matter is that laser fibers in other applications (other than medical) are used with diode lasers multiple times without damage or degradation to the diode laser. Damage occurs when laser energy is reflected and not transmitted along the glass fiber. Carbon deposits or core defects could allow reflected laser energy to damage the laser/fiber interface.

As long as the cleaning and sterilization protocols are followed, there is no danger of laser damage. The recognition system is a device created by certain laser companies to insure control over what type fibers can be used with certain systems — namely their laser systems. Nothing more.

The more control a company has in regard to laser fiber use; the more they are able to manage the cost of the disposable materials used in the procedure and their bottom line — not yours.

As pointed out by our AngioDynamics laser representative, if you want to be a “clip and snip physician,” you should understand it is a no frills way to proceed with vein practice management.

There will be no sales rep, with no local marketing budget, no practice support, no physician locator service and no extra ways to actually help build your vein practice.

If you have a mature vein practice without need for sales reps, instruction, marketing or website landing pages, your overhead procedure cost can be reduced just by the incorporation of reusable laser fibers.

Over the past year my clinic, Advanced Surgical Concepts, has saved approximately $50,000 just by using the Five Times Fiber reusable laser fibers and laser supplies offered by Total Vein Systems.

More bottom line savings tips to follow.