As part of VEIN Magazine’s ongoing coverage of conversations around a proposed American Venous Forum/American College of Phlebology (AVF/ACP) Merger, doctors Jose Almeida, Steve Elias and Robert Kistner got together (over conference call) to explore the idea further. Here’s an excerpt of that conversation.
Steve Elias: We’re talking about the conceptual idea of having one major vein organization in the United States. I particularly want to say it from that perspective, not as bringing two existing organizations together. Say it’s 1985 and we’re sitting around at a vascular meeting thinking we’d like to have a vein organization. What are the components that each of you would say are necessary to create a vein society? What elements would be important? Bob, you may have gone through this when you started AVF.
Robert Kistner: In the beginning, the concern was how many people are interested enough in veins to even write a paper, much less to get enough people together to have a forum, much less to require that people have any certain background in venous disease. The original thought was the first thing to do is to develop a forum, and that’s what we called it—the American Venous Forum. We were looking for ways to share information from the literature and gather the people who had a background and interest in this.
The main source of members came out of the Society for Vascular Surgery (SVS) and the Society of Clinical Vascular Surgery (SCVS) that existed at that time. We thought, “Well, is it even possible to get enough papers together to have an annual meeting to talk about this?” The thought was to start by sharing knowledge, so we called it a forum for transfer of information.Those thoughts have stuck.
The Forum included elements of research and education and clinical practice, along with a means to present those to one another. The Forum did not have the purpose of trying to organize movements and guidelines and that sort of thing at that time. It was a way to get together to share information and try to develop a mass of data for more scientific analysis from the knowledge we had.
"Vein docs from all walks of life start opening vein clinics;" as Dr. Russell Samson said in an editorial of the Vascular Specialist, “Vein clinics and vein specialists are being established faster than Starbucks."
Jose Almeida: Fast forward 30 years, and the endovenous revolution is upon us. The unregulated office environment has opened wide up. Devices are now catheter-based, and non-surgeons can learn things in a weekend course. You lose all the control of formal training and the “surgical line” is now blurred. What once was board certification by the American Board of Medical Specialties (ABMS), and a formal residency from the Accreditation Council for Graduate Medical Education (ACGME), now all gets circumvented. Vein docs from all walks of life start opening vein clinics; as Dr. Russell Samson said in an editorial of the Vascular Specialist, “Vein clinics and vein specialists are being established faster than Starbucks.”
Get a book or go to a weekend course, then advertise yourself as a vein specialist and you now have a vein clinic. Unfortunately, everything has become commoditized, to the point where all vein centers are the same. Patients go online, look for generic vein specialists, ensure the doctor is on their insurance plan, and they assume they’re getting expert vein care.
There are untrained, unqualified doctors out there saying they’re board certified in venous disease, which is a bogus certification. It’s dishonest information to unwitting patients. This, I’m sure, was not the original intent of the AVF founding fathers.
Going back to the original question regarding one venous society for the United States, what should that really look like? I think people have to be properly trained and certified. I don’t like the idea of the AVF merging with the ACP—I believe they’re two different organizations with two different agendas.
Steve: People treating vein disease are from different backgrounds. Imagine there is no society, there’s no AVF, no ACP. If we need a society that’s going to put all these people under one umbrella, what are the things this society needs in order to ensure good patient care, good exchange of educational ideas, and political clout to encourage research.
Jose: I think the starting point is to recognize that you have about 5,000 vein centers in the U.S. They come from all walks of life. There should be some stratifications. For example, lack of formal training should prohibit one from doing deep venous interventions, especially in the office.
Robert: I think the first thing you need is to develop some kind of an organization.
Without the societies, I don’t think we would have gotten here. We wouldn’t have gotten here with the universities or just by talking on the corner. You need some form of an organization. What you need within the organization is a group of experts with the ability to convey information to each other in order to develop a plan and an analysis of what the population is and what the knowledge base is. Organize the knowledge base into a mass that’s understandable, and can be not only amassed, but then can be converted into practices and new developments.
Steve: Can that organization only accommodate people who really know about treating superficial disease, or maybe people who only know about treating deep disease, or people who don’t even treat disease but are vascular medicine people who know a lot about venous disease? Can the organization be created such that members join different sections and identify themselves i.e “I’m a member of this particular section. I don’t really propose to have expertise in this other aspect of venous disease?"
Robert: This is not just a simple problem. Certain people have expertise in one approach, and other people have expertise in other approaches. Medicine and surgery are two different approaches. Bring in radiology and bring in all kinds of different things; there’s room for medical, there’s room for surgical, and there’s room for specialty treatments. Those wouldn’t all be the same person.
Jose: We need clear lines of demarcation. We’re all Fellows of the American College of Surgeons. If you visit FACS, there are codes of professional conduct. They give nice guidelines on proper behavior.
This could be an opportunity to delineate the proper training requirements for specific interventions. For example, the training requirements would be different for spider vein intervention, saphenous vein intervention and deep vein intervention. We could monitor this internally within this new organization. Recognize that there are boundaries, and boundaries are important, especially if we’re going to allow people from other backgrounds to do surgery.
Robert: I can completely agree with that. In a way, what we need is a Flexner Report in venous disease.
Steve: Do you feel the aspect of having better control of quality of care and identifying outliers will be better served if there is an organization with one voice, rather than two or three separate organizations that are not unified and looking at the global picture?
Robert: Absolutely, as long as the “one voice” is high-minded in a professional sense. It gives us an opportunity to outline limitations and boundaries. Given certain backgrounds, you would be appropriate to do certain things and not other things. Probably no one person is going to do it all.
Jose: The American College of Surgeons publishes a bulletin to its members, and those who have been investigated for professional misconduct have their names posted in the bulletin. I think this is valuable and helps enforce the code of conduct internally. Perhaps this “Joint Venous Council” could do the same.
"Have principles from the societies—from the ACP, from the AVF and from the SVS. These organizations need to get together and create these principles."
Robert: I agree with that but let me add, within the organization, you also need to find pathways for new people to come in and they have to be defined. You would probably define them along the lines of educational background. I think that’s where the ACP, to my knowledge, did build pathways for new people to come into the field.
Jose: When I was chair of the membership committee, we created pathways for primary care in the spirit of making the AVF more inclusive.
Robert: What pathways did the AVF create for primary care people?
Jose: In a nutshell, if you’re formally trained and have a specialty board—any surgical board, interventional radiology, or interventional cardiology—you’re offered AVF membership. If you’re primary care, you have to have ABMS board certification in your primary specialty, i.e. internal medicine, family practice, emergency medicine.
We ask for a letter demonstrating genuine commitment to venous disorders; the contents include caseload and recommendations from peers. If you took that American Board Venous Lymphatic Medicine (ABVLM) exam and passed it, that’s a genuine commitment. However, we do not recognize the ABVLM as board certification. Another alternative, 100 CME credits dedicated to a venous meeting, shows true commitment.
Robert: When we started out the AVF, the admission requirements were written papers and a bunch of things. You must have re-addressed that in depth, Jose.
Jose: Originally, the American Venous Forum had a 300-member cap. A decision was made at the Pacific Venous Forum to start becoming more inclusive and expand the society. Then, a new set of membership criteria were needed, and I just happened to fall into the chair of the membership committee at that same time.
Robert: I don’t know if you agree, but I think a lot of people in the ACP who are serious practitioners developed a base knowledgeable of venous disease but didn’t get onboard training with exposure to venous practice. What needs to be added back in to the ACP program is for doctors to have some approved experience in whatever role you wish to play in treating venous disease; that would have to be worked out.
Jose: When we talk about this bigger society, or a merger, do we re-vet? Do we re-look at everybody? I think we would need to. We can’t just merge. We would need to re-vet everybody.
Robert: Merge is the wrong word. The two societies are ill-prepared for a true merger at this point, but probably well-prepared to cooperate in a joint venture to improve the present condition.
Steve: Perhaps the concept of reorganization with different sets of criteria is in order. If the new organization has different categories (or tiers) of membership, you can identify people based on their qualifications. There are some ACP members who probably fulfill a significant number of criteria that AVF might want and probably would have no issue getting to be members of the AVF, either.
If someone could be identified and categorized in this new organization, the lines would be clearly defined, and at the same time you would keep all of the “vein specialists” under one umbrella, which allows the people in charge to have some control and some influence over everyone.
"What we need right now is a code of conduct."
Robert: I have a suggestion. Suppose you have a would be member who doesn’t fit the criteria for this new organization. Provide a pathway where you could set it straight. Provide him or her with some kind of an approved experience that would cross those barriers. You’ve got to do some kind of a vetting process.
Steve: Right, at first the goal of the new organization would be to try to appropriately include as many people. Bob, I think you bring up a very good point. If they don’t fit the criteria, here is your pathway. If you’d like to be in it, here’s what you need to do.
Jose: Here’s the American College of Surgeons’ website, their code of conduct. “Some hospitals permit arrangements through which a staff member can achieve surgical privileges under the tutelage of a qualified surgeon, without serving in a formal, organized, accredited residency training program.” They go on to say, “This is an undesirable situation because it frequently results in an inadequately trained physician who may aspire to be a surgeon.” How do you train people?
Robert: One of the challenges of a new organization would be to establish that. As I see it, you could say, okay fine. You could come in and do three months of training, and then you can do sclerotherapy, and then phlebectomies, whatever, but you could build it with a whole range of specifications required for the new entry.
For somebody that’s been practicing, some reasonable shortcuts may be admissible. Have principles from the societies—from the ACP, from the AVF and from the SVS. These organizations need to get together and create these principles.
Steve: From the higher level, conceptually, we all feel a new organization should try to create categories and try to include people of various skill levels so that they can be elevated to better skill levels, and become what we all think of as a true vein specialist. Can we accomplish that? We don’t know. How do we accomplish that?
Robert: In 2008, I was appointed to a sub-committee of the AVF by Joanne Lohr that contained three other members, Peter Gloviczki, Lowell Kabnick and Mike Dalsing. It was titled the intersocietal relations committee. We submitted our report that included quotations from each of us which supported the idea of developing and increasing relationships of the AVF certainly with ACP and with other organizations, including SIR, Vascular Medicine, Internal Medicine, Hematology and so forth.
It went on and on. This was approved by all involved. The more we got into it, the more the discussion spread out in the way we’re trying to go now, into where do you draw the lines?
Steve: The concept of a “super” organization or a mother organization, or a consortium, is probably a good compromise at this point. It would allow all the people who have an interest in vein disease to have a voice and help direct some ideas and guidelines to the various groups from above. Like you said, it needs to include SIR, ACP, AVF and others that have an interest in venous disease.
Robert: Envision that. If you wanted to go out for national research funds, it’s far more powerful. If you wanted to
go out for awareness, it’s far more powerful to have the support of up to 8,000 members of AVF, ACP, SVS, etc. than from one or two of the above. This applies to all of the main initiatives including research, education awareness, as well as the development of practices.
Jose: What we need right now is a code of conduct.
"It’s all about money. If we can show the industry how we can help them, insurance companies save money."
Steve: One of the first statements out of this mother organization, the consortium, could be that a code of conduct is necessary because we all feel that it’s getting out of hand. I just gave a talk at the New York Venous Symposium about the difference between unethical care and fringe vein care.
The statement is going to go into deep disease as well as the treatment of deep disease comes out of the hospital setting and moves to freestanding ambulatory, or vein centers or vascular centers. Just like how superficial vein treatment got out of control, the control of the deep vein treatment will be the same. People are going to be throwing in stints in somebody who has a 40% stenosis.
Robert: I think we can do some house cleaning in our specialty through societal requirements. Raise the standards in general. Of course you can’t correct all the bad actors, but you can probably influence some of them. You can help the misinformed. You can give them a way to add to their knowledge and practice codes, and a lot of them will appreciate the help. Going forward, you can build on that.
One critical way is to develop a list of bad practices that do not meet the standards of good practice and should not be recognized by insurance and government payors.
Jose: After establishing codes of professional conduct, the second objective of this “Joint Venous Council” could be to partner with insurance companies. If insurance companies give us access to claims, we could monitor venous doctors internally. We would also be in a better position to establish true medical necessity guidelines based on evidence. As we are all aware, current policies are capricious and are not based on best evidence or societal guidelines. This needs to change.
Steve: Jose, you know it’s all about money. If we can show the industry how we can help them, insurance companies save money.
What we need to put in play is this: if we help to identify the bad actors, and we have our code of conduct, and we’re saving you “X” number of dollars with what we’ve done, you’ve got to reward those people by not lowering your reimbursement rates for procedures every year. For those people we feel are doing it right, you need to give them a little bit more. The reason why is because they’re really saving you money in the long run because they’re just doing the appropriate care on the appropriate patients.
Jose: Then the incentives are aligned appropriately. Right now, the incentives are misaligned. I agree. That’d be great. We have a code of conduct. We want to do the right thing for patients and in doing, this I think we’re going to save them money.
We can’t do it as a small voice, it has to be a big voice. In summary, I don’t believe we need the AVF to merge with the ACP. What we need is a creation of a Joint Venous Council comprised of larger venous stakeholders— American Venous Forum, Society for Vascular Surgery, American College of Surgeons, Society of Interventional Radiology, American College of Phlebology and the Society for Cardiac Angiography and Interventions.
The objectives of the Joint Venous Council (JVC):
- Establish a code of professional conduct that members can refer to. The American College of Surgeons has an excellent template to work from
- Align ourselves with third party payers to establish better medical necessity processes. If the JVC had access to claims, we could audit and police ourselves internally. We need to link reimbursement to behavior. This is where the IAC falls short. By the way, the SVS registry (the VQI) is a robust system where the auditing process its claims-based. Currently, they audit Medicare claims only; perhaps the future could help us do the same with commercial carriers
- Venous Curriculum – there are members of the AVF and ACP who have begun putting together a venous curriculum for training purposes. We could help program directors with residents, plus something to help train non-surgeons
Steve: Jose as you have pointed out (in fact as early as 2007) the idea of a cooperative, super organization with the suggested name Joint Venous Council was discussed in a supplement to the Journal of Vascular Surgery. The idea is not new, but I believe the forces in play and the evolution of vein care warrants this idea even more in 2016. Let’s hope all involved can come together and develop this to fruition.