O Tempora! O Mores!

Bravo to many of my favorite phlebologists for a long overdue but engaging and thorough discussion of unethical vein treatment. I would like to comment on three of their proposed solutions, namely the need for more education, vein center accreditation, and reporting to the state medical board.

The Need for More Education

More education is not the answer. The most fundamental tenet of office phlebology is to ablate superficial reflux only if it is present. You learn this on day one, even if you take a weekend crash course. You also learn why it is wrong to get insurance approval for seven ablations and bill seriatim in exchange for free sclerotherapy. Even after blatant offenders in my community attend national meetings, their hapless patients continue to flood my office just as often as before. We’re talking here about fraud, though none of the panelists used that word.

Vein Center Accreditation

While it is appealing to trust that accreditation or a set of society standards could solve the overtreatment problem, it is important to distinguish that goal from the issue of whether IAC Vein Center (IACVC) accreditation should be a basis for insurance reimbursement. Quasi-government organizations, like JAICO and AAAHC, delight in crafting endless standards of little provenance. They insist you do extensive quality control studies to validate your outcomes, but you will never see them apply a single metric to assess the efficacy of their breathtaking bloat.To comply with their standards is often counterproductive and unnecessarily expensive in time and money for both doctor and patient.

Need an example? Let’s talk about the cornerstone of vein center credentialing—the ultrasound examination to evaluate superficial reflux. I study superficial veins at least a half dozen times a day in patients with class I and II disease. In the course of the ultrasound exam,which seldom requires more than 10 minutes, I walk my patient through the pathology and the options for treatment. I would never relinquish this precious face-to-face exchange.

Yet I would have to, because to be compliant with the standards, an ultrasound with the mandated documentation can take up to an hour per leg. I surely would need to hire an ultrasound tech or send my patient to an outside lab—each of which is a colossal waste of my patient’s time. The burden of doing the ultrasound exam per protocol alone, explains why so few freestanding vein centers are currently certified. What’s more, there is no guarantee that even the best vascular lab will correctly report all the relevant pathology.

Shame on the physician who treats solely on the basis of an ultrasound tech’s report. Most of the frauds in my community do have an ultrasound tech do the exam. Regrettably, that tech is all too often the doctor’s spouse or in-law, or the tech is bonused for reporting positive exams. This may explain why so many of their reports are incorrect, if not deliberately falsified.

Furthermore, the governors of accrediting medical organizations have an irresistible urge to ratchet up their standards every couple years. Guess which standard the IACVC chose to fortify in its very first update of August 2015: the ultrasound examination. IACVC accreditation as a requirement for insurance reimbursement, with the hope that would be a deterrent to fraud, should be quarantined to the State of Massachusetts until it can be documented that IACVC standards enhance vein care in some meaningful way. My prediction is that will never happen.

Reporting to the State Medical Board

Can there ever be a role for reporting miscreants to the State Board? Dr. O’Donnell modeled his case study on a similar scenario reported in the Surgical Ethics Challenges section of the Journal of Vascular Surgery.1 That ethicist observed that physicians function in a moral community, and concluded that the proper response should be to report the offender to the state board. Our round table panelists agree in principle, except for the pesky issue of retaliatory litigation. That poses a dilemma for all righteous practitioners.

My compromise is to allow the patients themselves to file the complaint. After all, they are just as angry as I am, if not more so. I assist them with filling out the complaint forms, and I write a cover letter which is non-discoverable.

Why is it that heavy advertisers appear to be the most common offenders? I suspect that many have to make up in volume what they lack in diagnostic acumen.

Advertising is very expensive here in L.A., and I humbly contend that L.A. is the epicenter of vein advertising and fraud, even accounting for Miami, the con capitol of the universe. Our freeways and the boulevards of West Los Angeles and Hollywood are festooned with dozens of identical huge billboards advertising vein services—owned and operated by a couple of Lap-Band surgeons—and our airwaves are full of ads that lure patients with complaints of restless legs, neuropathy, and all varieties of leg pain to world-famous vein centers.

Many of these ads are broadcast over foreign language stations, which attract older Medicare patients. Unlike private insurance companies, Medicare doesn’t ask fussy questions about whether treatment is indicated. Numerically, L.A. is one of the most diverse and populous cities in the nation, which gives me the luxury of waiting until I have two patients per doctor before I assist with a report. Yes, state medical boards are glacially slow, but after you score your first success, you too will be pumped.

In Conclusion

We should, of course, continue to chip away at the problem. My modest contribution would see a separate code for an abridged ultrasound evaluation of the superficial veins only (in class I and II patients and with reduced reimbursement to be sure). I doubt that the American College of Radiology and/or the IAC would acquiesce, but it would surely make vein center accreditation more palatable to the general phlebology community. More importantly, it would serve to make accreditation a more reasonable condition for insurance reimbursement, and thus a potentially useful tool for reducing fraud.

I also believe anyone given a recommendation for ablation of more than two veins per leg should be obliged to get a second opinion. I agree with the panelists that our vein societies need to get creative and dig into these issues to a far greater extent than they have. The integrity and reputation of our medical profession are at stake.


1. Jones JW, McCullough LB. Discovering overtreatment: Second opinion dilemma. J Vasc Surg 2014;60:1690-2.