Letters to the Editor

472

Editors note: The following are a selection of responses from the SVS membership sent to Dr. Peter Lawrence based upon his article in a recent issue of Vascular Specialist on the topic of the abuse of peripheral artery disease stenting in Medicare patients.

Despite the unfortunate press, we as a more global medical vascular community are unable to police our own. I have been involved in two specific instances in which inappropriate and overuse of endovascular therapy has been addressed. Unfortunately, these practitioners continue to perform unindicated procedures while hospitals and state medical boards refuse to act.

What is Medicare to do when our own medical regulatory bodies fail to act on behalf of patients and the payor? The two routes of targeting practitioners through Medicare high outliers and legal recourse for poor outcome in unindicated procedures will remain until our societies (this includes SVIR and ACC) decide to collaborate and ensure appropriate practice. Simply stating that SVS has guidelines in place will not solve the problem.

Jason M. Johanning, M.D., Omaha, Neb.

My office of five vascular surgeons actually has an in-office procedure suite. We have converted about 30%-40% of our minimally invasive patient care to this setting. In review of what we have done, we have actually decreased the cost of patient care as there is no facility or hospital add-on charge. Our cost per patient is actually about one-third of what is typically charged by the hospital, and our quality based on our independent QA is the same in our office setting as it is in the hospital. These types of settings can significantly reduce health care costs if done in the proper fashion.

Dennis Fry, M.D., West Des Moines, Iowa

The comments in the article that hospitals confer a greater degree of oversight seems to come right from the AHA. The problem is not office-based procedures but the ethics of fraudulent practices, something that occurs in and among hospitals as well. Hospitals can be as much driven by case volume, even at academic centers, as are the practices of private outpatient procedures.

Paul Gagne, M.D., Darien, Conn.

I cannot help but wonder how our specialty’s lack of identity – and thus lack of appreciation of its responsibility and role in public awareness – has contributed to this scenario. Our inclusion under the umbrella of the American Heart Association, again without any designation of our separate identity, leads only to more confusion about our specialty in the eyes of the public.

The SVS must address its lack of a public identity in a more forceful manner. Unfortunately, it’s biggest hurdle in this may well be the hospital-employed vascular surgeons who cannot fight the administrators marketing theme of “Heart and Vascular,” implying to the public that we are all one, “like the cardiologists do” as many patients state. This is not to fault anyone, but it is to awaken our leadership to the need to establish a separate, independent “awareness” vehicle to better craft our identity as a separate specialty to the entire nation.

It will take time but will be a project which, when done properly, we will never regret. It calls for a board heavily weighted toward the independent vascular surgeons, who try daily, with limited resources, to accomplish this.

Carlo Dall’Olmo, M.D., Flint, Mich.

What the article misrepresents is that this happens only in outpatient labs. The same thing occurs, albeit to a lesser degree, in our hospitals. I am glad to see no vascular surgeons were named. I am also glad they are starting to shine a light on the massive ongoing fraud in EVLT and RF ablation procedures. This is particularly bad in Florida. I wonder if SVS can come up with some response to suggest ways to police this behavior. None of us want more government oversight, but it seems like something needs to be done at the state board level to better regulate these procedures.

Geoffrey L. Risley, M.D., Jacksonville, Fla.

I think most members of SVS have intimate knowledge of a handful of physicians in their communities whose practices would be considered abusive, if not overtly fraudulent. We have struggled locally with the belief that we, as ethical and well-reasoned providers, should have some obligation to report these providers to someone. However, there are no acceptable mechanisms with which to do so, and there is a sense that this would not be accepted well by our colleagues.

We also do not want to be written off as disgruntled competitors. Physicians have never done a good job of policing themselves. Maybe articles like this can be a springboard to discuss ways to reign in the outlier providers in our communities.

Steven Merrell, M.D., Murray, Utah

I agree with Dr. Lawrence 100%. We need the SVS to be a major speaker in this debate. We have to give patients the confidence that they are being cared for by physicians who are not only capable to diagnose the problem but are also able to care for it in the most appropriate fashion. We need to silence the naysayers and the media hogs by developing a method so that surgeons who care for vascular patients in an office-based vascular suite are certified by the Society in the form a Center of Excellence designation. Initial certification would be followed by ongoing proactive reviews on a serial basis. I would ask that the leaders of our society take a step toward developing the concept of this certification body as soon as possible. We need to police ourselves and this may be the way to do it.

Thank you in advance for your attention and ongoing vigilance for the vascular surgical community.

Khash Salartash, M.D., Galloway, N.J.

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