December 15th was a normal day at The Vein & Aesthetic Center of Boston. Doctors Elizabeth Foley and Judith Hondo bustled from room to room, caring for patients and doing procedures. Their office staff made sure everything was running smoothly. Little did they know, as they settled into the comfortable, daily groove of a well-established vein care practice, that their thriving business was about to be threatened—threatened by a memo that slipped into the office like a stealth bomb.

The memo was from Blue Cross Blue Shield of Massachusetts (BCBSMA). Ironically, for the gravity of the news that it contained, it was written with the seemingly casual heading, “F.Y.I.”

For your information: Effective on April 15th, 2009, there will be “new privileging requirements” for the treatment of
varicose veins. Specifically, varicosities treated with radio frequency ablation (RFA) and endovenous laser ablation (EVLT). In order to continue to get reimbursed for these procedures, physicians must meet one of the following criteria:
• Board-certified in vascular surgery (VS)
• Board-certified in radiology with interventional training (IR)
• Board-certified in general surgery prior to the establishment of the vascular boards (GS)

In addition, all sites of service must be accredited by the American College of Radiology (ACR) or the Intersocietal Commission for the Accreditation of Vascular Laboratories (ICAVL). Claims for procedures performed at unaccredited sites will be denied, regardless of the performing physician’s privileging status.

BCBSMA: “Quality is the focus of this initiative.”

The memo cites “safety” and “the rapid adoption of these procedures by physicians” as the reason for the new requirements. Dr. Jan Cook, Regional Medical Director for BCBSMA, said, “Over the last five years, an increasing number of people have been receiving this procedure with a wide variety of physicians performing it. We became concerned about the quality of the training. We don’t understand the quality of the training of the physicians that are rendering this service.”

To remedy their lack of understanding, BCBSMA looked to the American Board of Medical Specialties (ABMS) to create new privileging criteria. Says Dr. Cook, “Like other insurers we use the ABMS as our gold standard. In that world, these specialties [VS, IR, GS] are the ones who specialize in venous diseases. We need to ensure that our members have the benefit of seeing professionals who can offer them a wide range of treatment options for symptomatic venous disease.”

VEIN asked Dr. Cook if the company consulted with physicians, vein specialists, or either of the two main vein societies in the U.S., the American Venus Forum (AVF) or the American College of Phlebology (ACP). She responded that BCBSMA “consulted with a variety of people in our network.”

In modern vein care, quality not necessarily tied to specialty

The ABMS is of course a good place to find specialties with the skill set to treat venous disease. But by adhering exclusively to the ABMS, BCBSMA has overlooked the “contemporary world” of vein care, where skilled physicians across many specialties have been providing quality care for years—and have been getting reimbursed for it. Doctors Foley and Hondo, from The Vein & Aesthetic Center of Boston, are a prime example.

Both board-certified in OB/GYN, Dr. Foley and Dr. Hondo dedicated their practice exclusively to vein treatment in 2002. BCBSMA has been reimbursing them for RFA and EVLT since 2004, when the treatments were approved for coverage. In addition to handling thousands of cases and having innumerable hours of experience, both doctors have earned their credentials as registered vascular technicians (RVT) and registered physicians in vascular interpretation (RPVI). Both doctors became board certified Phlebologists in May of 2008, having met the rigorous standards set by the American Board of Phlebology (ABPh). Prior to receiving this memo, the doctors had initiated the process for ICAVL accreditation.

And yet, as of April 15th, after five years of coverage, their practice will be denied payment from BCBSMA, which represents approximately 40% of their patients.

By comparison, an IR, VS or GS who has potentially never performed RFA or EVLT will be eligible for reimbursement—provided their site of treatment is ACR or ICAVL accredited. There is no specific requirement for the study or treatment of superficial venous disease in general surgery, vascular surgery, or interventional radiology fellowships.

It is worth mentioning that there is no division between medical specialties on this issue. To the contrary, concerned physicians and societies are uniting en masse to address it. Significantly, one of the doctors heading a special task force on the issue, Dr. Julie Stoughton, is a general surgeon who operates an ACR accredited facility in Massachusetts. Another key committee member, Dr. Robert Min, is a prominent interventional radiologist and past president of the ACP. In addition to the ACP, societies that have pledged their support include the Society of Interventional Radiology (SIR), the Society of Vascular Surgery (SVS), the American Venous Forum (AVF), the Society for Vascular Ultrasound, (SVU) and the American Society of Dermatologic Surgery (ASDS).

Quality of care: A defensible argument?
Nobody will argue that the patient comes first: high quality care is—or should be—of paramount importance to physicians and insurers alike. However, looking at the facts, it is difficult to give BCBSMA the benefit of the doubt when they say that patient care is the focus of this initiative.

Dr. Nick Morrison, President of the ACP, calls the BCBSMA reasoning “disingenuous and indefensible… it’s a blatant attempt to restrict access to patients under the guise of providing them with high quality care.”

In addition to missing the mark by excluding many highly skilled vein care specialists from their privileging criteria, technological advancements and low rates of serious complication also argue against their claim that this directive is quality-driven.

EVLT and RFA are minimally invasive, ultrasound-guided procedures most commonly performed on an outpatient basis, using local anesthesia. The most common risk of complication is deep vein thrombosis (DVT). The occurrence of DVT in RFA/EVLT treatments is around 1%. In the majority of cases, these procedures have replaced the older practice of vein stripping. Vein stripping is commonly performed in operating rooms under general anesthesia. In addition to the higher risks associated with general anesthesia, DVT occurrence in vein stripping is closer to 5%. And in simple terms of patient comfort and recovery, there is no comparison: EVLT/RFA patients can usually resume normal activities within hours or days, whereas vein stripping recovery can take weeks, with substantial discomfort.

Varicose veins have been estimated to occur in 15-20% of people. An aging population and enduring obesity epidemic will likely keep those percentages on the rise. It is easy to see how patient access to safe, affordable treatment has driven rapid growth in the field of vein care, particularly over the last five years.

It is also easy to deduce that this phenomenon has caused a rapid and substantial increase in claims to insurance carriers. BCBSMA does not mention this in their memo.

Why all vein specialists should be concerned
The memo that has Massachusetts on edge could be the snowstorm before an avalanche. Asked if this is a matter of national concern, Dr. Morrison of the ACP responded, “for now it’s Massachusetts, but there is a well-founded intuition that if they go ahead with this, similar policies will be adopted nationwide. That would have terrible consequences for patients in terms of accessibility, and for the venous disease industry across the board, from physicians to equipment manufacturers. It is critically important that we stop this or get them to be more reasonable. Everybody except the insurance companies will suffer.”

At the time of this writing, a special ACPappointed committee is attempting to talk with BCBSMA. First and foremost, the committee hopes to delay the implementation of the directive and to open discussions. One critical topic is the importance of continued patient access to treatment. Another is rethinking privileging criteria to include a broader range of specialists. Physicians who can prove their competency should have the opportunity to do so, and to be considered for continued payment privileges.

Dr. Cook of BCBSMA says the insurer is “always open to talking with network physicians,” and that they are “having ongoing conversations with [the ABPh] and their members on this topic.”

Nonetheless, she said the program is still set to go live on April 15th.

Back at The Vein & Aesthetic Center of Boston, things are on hold. A large investment in new ultrasound equipment has been shelved, and the ICAVL accreditation process has been frozen. Says Dr. Foley, “My initial reaction [to the memo] was that this issue would be easily rectified. I thought we’d just call and explain that they’d forgotten to include phlebology in their privileging criteria. I never thought it would turn into the nightmare it’s become.”

For more information, please contact the American College of Phlebology at (510) 346-6800.
Sarah Spataro is a freelance writer in Los Angeles, California. She
can be reached at [email protected].