How to succeed in vascular surgery: A guide for the aspiring outlier

Andrew J. Meltzer

Disclaimer: The views expressed here do not reflect those of Mayo Clinic, the Society for Vascular Surgery, Vascular Specialist, or even the author, for that matter. It’s satirical—everybody relax. Our recent paper, “Practice patterns of vascular surgery’s ‘1%’” created a bit of a stir on social media and the medical blogosphere. In the event you’ve been too busy performing indicated and appropriate surgical procedures to keep abreast of every #VascTwitter discussion, permit me to provide an update: 1% of U.S. vascular surgeons account for 15% of Medicare reimbursement to our specialty.

The average vascular surgeon (excuse the oxymoron) receives $271,000 in Medicare payments annually. Meanwhile, the most highly reimbursed 31 surgeons—“1%” of the roughly 3,100 vascular surgeons in the U.S.—receives an average of $3.1 million in annual Medicare reimbursement. This is a staggering statistic. Presumably, at this point you’re all asking the same questions: Who are these elite practitioners of our trade? How do I join this illustrious fraternity? (It does appear to be exclusively male at this point.) How do I increase my Medicare reimbursement to 10 times that of my peers? And so forth.

The devil, of course, is in the details. As one might imagine, you can’t join the 1% just by working harder, practicing medicine in an ethical and appropriate manner as you currently do. The highest-earning members of our specialty have dramatically different practice patterns to the “average vascular surgeon” (again, my apologies). While we, the 99%, toil away in the hospital, the elites spend their days in luxurious outpatient endovascular suites. While we struggle to make ends meet with our inpatient evaluation and management (E&M) and open surgery, the 1% are completely immersed in the treatment of peripheral arterial “disease” with atherectomy. For the uneducated and uninitiated, peripheral arterial “disease” (PA“D”) primarily refers to pre-clinical claudication. Often manifest only as a subjectively weak pedal pulse, this condition requires expeditious intervention to prevent the late sequelae of a normal ankle-brachial index (ABI) measurement.

One percenters

Speaking of atherectomy, this technology essentially defines the 1%. Perhaps you occasionally employ one of these magical devices in your efforts to treat selected patients. You are not alone; the data show that selective atherectomy use is somewhat commonplace among the proletariat. Meanwhile, the 1% utilizes atherectomy in 80% of peripheral interventions! If you are unclear as to why this is the case, it is imperative that you familiarize yourself with the overwhelming body of evidence to support its use. Every single study has confirmed that atherectomy reimburses better than other techniques of comparable or superior effectiveness. An unwavering commitment to this clinically effective-ish technology garnered these 31 surgeons $60 million in atherectomy reimbursement in a single year. Think of that the next time you are in the middle of a distal bypass, harvesting arm vein for rubles!

The 1% are so consumed with the treatment of PA“D” that they barely have time to engage in the Performance and Interpretation of Noninvasive Vascular Studies of Questionable Necessity (PINVSQN). As everyone knows, PINVSQN was heretofore the only means by which properly motivated members of vascular surgery’s working class could ascend to the 1%. We all remember those wonderful Horatio Alger tales from our youth in which an upstart vascular surgeon was able to build a PINVSQN practice so robust that he one day rose to become famous in our field. Alas, those days are gone. Declining reimbursement and increasing regulatory requirements have severely curtailed the billing potential of the noninvasive vascular laboratory. While interpretation of these studies may account for 24% of your total reimbursement from Medicare, the 1% can’t be bothered with such mundane pursuits.


Even venous procedures, which have historically provided easy access to an exciting career in overutilization, are eschewed by the 1%. After all, the typical Medicare beneficiary only has four veins that can be ablated in the name of bilateral lower-extremity edema mitigation. Furthermore, as we have previously reported in the Journal of Vascular Surgery, providers without any formal training in vascular disease dominate the landscape of endovenous ablation overuse. These trail-breaking dermatologists, anesthesiologists, and semi-retired cardiac surgeons are working night and day to limit the global supply of great saphenous vein for future use. Another reason that the 1% remains comparatively disinterested in veins is the fact that veins accrue no plaque and cannot be atherectomized. Or can they?

If you just looked for a Current Procedural Terminology (CPT) code to check the reimbursement for “venous atherectomy,” you are well on your way to joining the 1%. I salute you. Furthermore, if you hope to join this esteemed group, you’ll have to stop performing carotid endarterectomies and repairing juxtarenal aneurysms immediately. The reimbursement for these surgeries is inadequate to justify your time. The 1% obtains just 0.5% of their total Medicare reimbursement from open surgery, having abandoned these more durable procedures for more ephemeral interventions with truncated global periods.

And lastly, while our most recent study did not specifically address this issue, recommending supervised exercise therapy to your claudicants will condemn you and your heirs to lives of poverty and anonymity. Surely by this point you are wondering if your efforts to join the 1% will jeopardize your reputation. In these days of oversight and transparency, is it safe and wise to aspire to such affluence? Absolutely, my ambitious colleague! You have nothing to fear. Our fee-for-service model is as strong as ever, and this “value” craze will disappear, like a previously normal outflow vessel after atherectomy.


The Ivory Tower Academics will criticize your preventative transpedal atherectomy for pre-claudication. You must learn to ignore these anti-capitalists! Fortunately, their collective attention is easily diverted by salacious discussion of surgeon swimwear preferences. Meanwhile, the Appropriateness Politburo is yet another threat to the 1%. These self-righteous surgeons believe their precious “evidence” should guide your practice. Outrageous! Every one percenter knows that the most dangerous aneurysms are 4.9cm—because if you don’t fix it, someone else will.

Perhaps someday the state medical boards and federal government will intercede. There is, of course, good precedent for such supercilious overreach in the name of “fraud detection” and/or “public health.” But there are so many atherectomies to be performed before that day arrives. Good luck, and bon voyage! Your ascension to the 1% begins today.

Andrew J. Meltzer, MD, is chair of vascular surgery at Mayo Clinic Arizona in Phoenix.