By Larry Storer

When I recently polled a dozen physician leaders by email about what issues were at the top of their list of the most critical issues facing them in 2018, concerns fell into two categories: political and medical.

Then, face-to-face conversations with some of the physicians attending the 31^st American College of Phlebology in Austin demonstrated how deeply these and other issues affect the way these doctors see the future of venous disorder treatment and medicine in general.

Not surprisingly, those issues causing the most angst were political – things that are difficult to impossible to change. These “external” issues are the leading cause of the professional frustration of these doctors as they prepare for another year.

POLITICAL ISSUES

At the top of the list of “political” concerns is reimbursement. Easy enough to understand, right? Because money is not exchanged at the time of service, physicians are challenged because it is reimbursed by a third party, either Medicare/Medicaid or private. The problem comes when the amount reimbursed and the time that it takes to receive that reimbursement can become a gray area that can squeeze larger practices and mercilessly shut down smaller ones.

“Basically I am feeling the squeeze as reimbursement drops and the costs go up,” said Edward Mackay, MD, RVI, RPVI, who has offices in St. Petersberg and Palm Harbor, Fla. “The margins on some of our main procedures are narrowing. The costs of employees are up, mostly because of health insurance.  As this squeeze occurs, the temptation for some doctors to overprescribe procedures rises.”

Laura Ellis, MD, with offices in Asheville, N.C., and Laguna Beach, Calif., is concerned about insurance. “In both my North Carolina and California practices we are mindful of various insurance company “Policy Statements” on treatment of varicose veins and venous insufficiency, and changes in these statements.

“Extremely problematic right now in North Carolina is the Blue Cross Blue Shield policy change as of Jan. 1, 2017,” she said. “They now allow approval of endovenous ablation of only one vein per leg per lifetime for their policyholders.

As you know, we often have to ablate two or even three veins per leg in certain patients,” Dr. Ellis said. “The expense of treating any diseased veins after the one “allowed” becomes the patient’s responsibility.  This can be quite a hardship for patients who already have high premiums and deductibles.”

Deborah Manjoney, MD, who practices in Wisconsin, said that certainly reimbursement was at the top of the list, in part because it may affect some physicians’ choice of the “best practice” in treating veins.

“Did you know that Medtronic has been able to ‘set’ reimbursement for VenaSeal Closure System at $2,100 from CMS going forward in 2018? They are positioning to have a higher reimbursement than laser and radiofrequency closures.  Will that influence physician decision?”

James White, MD, FACS, said that the biggest problem he faces in his Tennessee practice now is the major increase in deductible amounts since the Affordable Care Act.

“My Medicare population has increased on an annual basis as the private insurance vein procedures have decreased. Also, the complexity of the procedures have increased due to older patients with longstanding venous stasis who present for care in place of young working adults with C3 disease. Patients present with symptomatic varicose veins and C3 disease.

“We go through the hoops to get the EVA procedure pre-determined. But many times, older patients directly tell me: ‘I cannot afford the deductible and out of pocket fees, so I will not have the procedures completed.’

“Varicose venous stasis is an insidious disease, but not urgent. Each year, benefits decrease and deductibles increase, effectively limiting the number of patients who need treatment to prevent end-stage venous stasis disease.”

Just under reimbursement in the list of pressing “political” concerns was ethics. Or, more to the point, a lack of them.

Mel Rosenbatt, MD, FACPh, whose surgical practice is in Connecticut, was specific about where he is seeing the most unethical procedures: “Unethical treatment of a normal great saphenous vein.”

Another physician with a lot to say about the lack of ethics by some vein doctors is Jose I Almeida, MD, FACS, RVT, whose vein practice is in Florida.

“In my home state of Florida, unnecessary laser ablations have risen to especially high levels,” he said. “Patients show up to my office in droves for second opinions after having encountered unnecessary procedures by doctors who run the gamut of backgrounds.

“Because doctors are reimbursed on the same fee schedule regardless of their experience, qualifications, knowledge and expertise, some doctors have entered the field with poor training and an even poorer sense of ethics.”

“This has inadvertently led to doctors themselves cashing in, favoring volume over value, and offering patients unnecessary treatments and procedures for their own financial gain.

“Unscrupulous doctors respond by gaming the system – embellishing records to suggest that the procedure is medically necessary in order to justify insurance coverage.”

Dr. Mackay said that competition is up from people who are not well trained. “We have techs doing the procedures for these poorly trained doctors – not PAs, NPs, but RVTs or ultrasound techs.

“It’s very hard to compete with practices that essentially treat venous disease as just another profit center with no real interest in the disease.”

Manu Aggarwal, MD, MHSA, whose two offices in Ohio have been Intersocietal Accreditation Commission certified since 2007, agrees, but is unsure of how to police physician ranks.

“First and foremost in my mind is the negligent and fraudulent care of patients with venous and lymphatic disease,” she said. “How can we police this and utilize our accrediting bodies?”

Jeff Miller, MD, who operates his vein treatment centers in five Southeast Michigan locations, said unethical care should be at the top of the list. “The bad players are going to adversely affect those with morals.”

Lowell Kabnick, who is an associate professor at NYU and has a practice in New Jersey, said he is concerned about the differences between LCDs and ethics.

Another ethical issue facing phlebologists in 2018 was listed by a number of physicians who also selected ethics as a separate item: Non-providers providing care.

The late Dr. John Kingsley called them “weekend wonders”: Physicians who take a weekend course and then hold themselves out as a qualified vein specialist. Additionally, new technological developments have made some procedures easy to perform. Add to this a bad economy and doctors with an even worse sense of ethics and these weak practitioners are popping up everywhere.

Dr. Almeida said the endovenous revolution began around the year 2000 when venous procedures traditionally done by surgeons in the operating room under general anesthesia, moved to the office under local anesthesia. When catheter-based vein ablation started to take a foothold and really disrupted traditional surgical practice – things went from the hospital to the office.

“The problem is that there is little or no oversight in the office – i.e., to perform a procedure in a hospital one needs to get privileges from a credentialing committee. But to do the same procedure in an office, you are your own credentialing committee,” he said.

That’s allowing different doctors from all different specialties looking for new sources of revenue to enter the venous space with often no training except for a weekend course.

There is no oversight when you are your own credentialing committee. Another problem that physicians see as only getting worse in the future is social media.

Doctors from other specialties who have become mentor-taught in a weekend course can look just as qualified as any of these distinguished doctors when they do a little creative writing on their website.

“So online, we look the same,” Dr. Almeida said. “Someone like me who is a double-board certified, fellowship-trained vascular surgeon doing venous surgery for 20 years might look the same online as a doctor who started yesterday and embellished their online credentials. To make matters worse, I often see content from my website copied verbatim on someone else’s.”

One can now buy Google Adwords and boost search engine optimization (SEO) to come up first in a Google search – basically, untrained doctors are “purchasing credibility.” So when a patient looks online for varicose veins or vein doctor or spider veins, the doctors with the highest SEO come up first and then that’s where the patient is naturally going to click and begin their search and often fall into the wrong hands.

Government regulations was also mentioned by several physicians as a problem sure to get worse in 2018.

“This is becoming unbelievable,” Dr. Almeida said. “I spent six hours last night, and still need another four hours next week of training on a new EMR system at the University of Miami Hospital.”

Another aspect of government interference is over-treatment.

“This is huge,” Dr. Mackay said. “We are spending time finding out about the last mammogram or checking their blood pressure or smoking history or whether they have their flu shot. It goes on and on. I don’t treat hypertension or order mammograms.  They have doctors for that.  it’s a waste of time.  Let us concentrate on what they are seeing us for.

MEDICAL ISSUES

It was apparent there was generally less frustration when the physicians began to discuss medical issues that they believe they will face in 2018. Finally, something they believed they could do something about.

Managing overhead issues was at the top of about four lists: the cost of finding, training and retaining employees; the rising cost of health insurance; the cost of locating and retaining new patients, and marketing; and the rising cost of technology and its short shelf life.

The misdiagnosis of complex vein problems was next on the list of medical issues in 2018. Specific references to venous aneurysms, a spectrum of congenital anomalies of the inferior Vena Cava; pelvic congestion and pelvic venous disease; and May-Thurner syndrome, also known as the iliac vein compression syndrome.

In various ways, three physicians noted that while venous insufficiency is the most common vascular disorder today, it remains the most prevalent but underdiagnosed and misdiagnosed disorder.

Literature estimates that more than 30 million Americans suffer from symptomatic venous insufficiency, but fewer than 2 million actually seek treatment. Venous vascular disease is five times as prevalent as peripheral arterial disease and 2.5 times as prevalent as coronary artery disease.

And finally, two people thought that more emphasis should be placed on men with venous disease.

APPROACHING MEDICAL ISSUES

Dr. Rosenblatt praised a recent Society of Interventional Radiology (SIR) Foundation Research Consensus Panel  (RCP) on pelvic venous disease and prioritization of research in this area.

The SIR Clinical Research and Registries Division supports one-day RCP meetings twice a year to discuss critical research areas and determine how the priority topic can be further developed.

After the SIR Foundation leadership selects a current critical topic in IR, such as pelvic venous disorders, the lead investigator coordinates a panel of multi-disciplinary subject matter experts. Each panelist presents on a specific subtopic and discusses future research needs.

Then the RCP panel determines two to three top clinical research priority topics that may be developed into a clinical research trial or research project, and the principal investigator is encouraged to write an article on the research and solution for the organization’s peer-reviewed journal. VTN