by James A. Heinz, MAHA
From 2003–2006, James Heinz was involved with phlebology and minimally invasive techniques on the medical device side as a Certified Clinical Trainer and Sr. Territory Manager with VNUS® Medical Technologies (Covidien). In 2006, he helped open several Center for Venous Disease (CVD) offices and continues to help manage them as the founder of CVD. Along the way, CVD offices and medical directors have adopted and embraced the Total Vein Care philosophy. Here VEIN Magazine asks James to discuss his experience and why he feels that Total Vein Care has made the difference for so many patients and doctors.
VM: What inspired you to follow the Total Vein Care philosophy?
JH: I feel this philosophy is the correct approach and requires a skill set that is focused on becoming an expert in phlebology. This expertise includes all aspects of phlebology—including ultrasound—and requires an investment in education, technology, and time.
Having visited hundreds of vein centers and having opened our own across the Southwest, we started to look at a “best practice” model focused on patient care and clinical outcomes. Total Vein Care encompasses all aspects of vein care from diagnostic ultrasound, ablative techniques (GSV, SSV, and perforators), micro-ambulatory phlebectomy, visual sclerotherapy, ultrasound-guided sclerotherapy, surface laser or RF wavelength treatments, and wound care. Without the proper training and proper investment, Total Vein Care cannot be accomplished in the office setting.
VM: Why do you feel the Total Vein Care philosophy is so important?
JH: Take a look at those doctors around you who do not provide Total Vein Care to gauge the satisfaction of the patient. Nearly 30% of CVD’s revenue is derived from patients coming from other practices. These are the practices that do not provide Total Vein Care convenient, onsite diagnostics or have an informed and caring medical staff. There are probably many reasons they do not provide these services. At the top of the list would be lack of expertise or experience, low comfort level, lack of investment, or possibly the wrong assumptions related to “ablative only” thought processes. We know that in most cases, an ablative procedure above the knee is not going to provide the outcome that meets with the patient’s expectations. Managing these expectations can be a challenge when you are providing Total Vein Care; but we look at this as the first mission of our practices as it relates to the expected outcome and the management of patient expectations. With Total Vein Care, your own outcomes will speak for themselves.
VM: What are the benefits of adopting this philosophy into one’s own practice?
JH: When you accept the Total Vein Care philosophy, it raises the bar for everyone practicing phlebology. Once you accept that this is the right thing to do, training and investment is needed for yourself and your staff to support it. We hear from patients all the time that had a right GSV done and down the road the patient still has pain, swelling, flaking skin, and varicose veins. The patient simply doesn’t understand the disconnect with their former doctor and a medical director who is driven by the Total Vein Care mentality. Not only is the skill set different many times, but the technology may be different as well.
The expectations from the patient may be higher than we would like. This may be created by the treating physician who is offering the services or the medical device companies that sell the technology (laser or RF). But sometimes the time spent in explaining what they received as part of their treatment plan versus what they needed is a very long process, and trust has to be regained between the physician and the patient. Many of these patients either don’t go back to their former doctor or the treating physician writes these patients off as “problem patients” because they are not satisfied. The real truth is that they needed more treatment to get the issues resolved. I will admit as well that some patients will never be happy despite your best efforts.
VM: As a physician practicing phlebology, how do you know if this philosophy is right for you?
JH: Total Vein Care may or may not be in the treating physician’s toolbox, and as a doctor, you’re the only one who can determine this. The good news is that there are many people out there to help you. For instance, at CVD, we require diplomate status with ABPh. Understanding that this is not an accepted board by the AMA, we put this in place to raise the educational level of our doctors. That was the motivation.
As the founder, I wanted the best trained doctors in our markets, and this is not specialty specific. Our doctors are double and triple board certified, and they still comment on what they learned from going through the ABPh process. There is little doubt that our doctors have a greater understanding of phlebology due to ABPh diplomate status and advanced ultrasound credentials such as RVT or RPVI status.
Another overwhelming consideration of not providing Total Vein Care is increased cost. When we don’t approach the patient’s problems or concerns and do it right the first time, many red flags are raised for everyone treating veins. As agreed upon by most experts, venous disease is progressive. Treating this disease in an incomplete fashion only delays treatment at a higher cost. Yes, I believe that this hurts the entire industry and is a true concern of many insurance medical directors. This has led to credentialing conversations, accreditations discussions, and restrictions on who can treat veins now and in the future.
The insurance companies don’t like the cost associated with vein care and certainly don’t want to pay a second doctor to continue treatment, especially when it is on the same limb. I don’t think this is unreasonable either. From a patient perspective, you’ve presented to them that you treat veins. This might be a part-time situation or full-time passion, but the patients came to you because they believed you could help them. When the insurance companies find out that you cannot due to patient complaints, you’ll no longer be able to treat veins. This trend is coming to a city near you.
VM: How does this philosophy fit in with the current insurance policies?
JH: One of the more bizarre insurance twists out there is the lack of medical policy to treat perforator veins under most private pay plans. Treating perforators is not optional and is a huge part of CVD’s practice. Think about the logic: The Food and Drug Administration has approved the VNUS RFS™ device to treat perforators (based on the 510k and data requested) which is the only FDA-approved device on the market for the treatment of refluxing perforators. Despite this, insurance companies will deny this technology and approve foam sclerotherapy (not FDA approved) to be used on a communicating vein that connects to the deep system. This is something to really think about. I truly believe that adverse effects are grossly under reported in the US and abroad.
As a veteran member of the American College of Phlebology Reimbursement Committee, these decisions and others are cause for great concern. In some situations, the insurance policy is dictating treatment—or lack of—instead of patient symptoms and doctor choice. Total Vein Care, while a noble goal, can be derailed by some things you simply cannot control. But I think most doctors would agree that learning to do the best job you can do is the new standard of care.
VM: What are some other considerations to think about when contemplating this philosophy?
JH: Something important to consider related to Total Vein Care is your own reputation. Most of today’s more successful practices are very active in promoting patient education, marketing, and branding their services through advertising. While a solid doctor-to-doctor referral base and patient word of mouth is more advantageous and less costly, there is a cost associated with everything you do. There are no doubt happy patients with great outcomes who will praise your work, comment on your office staff, and reflect positively on your practice and revenue stream.
To summarize, Total Vein Care makes dollars and sense. If you need additional training, there are many ways to improve your skill set before you make the investment needed. The American College of Phlebology, American Venous Forum, Society for Interventional Radiology, American Board of Phlebology, doctor luminaries, and other organizations and individuals are available to help you. CVD offers training opportunities as well. Don’t forget to tap into the resources provided by your device companies too, as they created the market and exist to grow the specialty or they will not survive.
The specialty of phlebology is enhanced with every positive outcome and satisfied patient. I believe Total Vein Care is the philosophy that leads to better patient satisfaction and a more successful phlebology practice.
