Caveat Emptor / Buyer Beware!

images-4 copy This is a case presentation about a doctor’s deliberate misrepresentation of existing medical facts for excessive financial gains in a field of medicine I have dedicated myself for exactly 30 years: vein conditions, varicose veins included, treatable in an office setting. I assume full responsibility in exposing this case, as it is probably just the tip of the iceberg with many more identical cases happening all over the country ever since the start of American “vein revolution” some 10-15 years ago. (See below.)

The Latin idiom/phrase “caveat emptor” warns buyers to be on the lookout in getting incomplete even false information about the goods or services they intend to buy. Defects in the goods or misrepresentations of services are deliberately hidden/withheld from the buyer for clear financial gains.  In plain English and in a more popular term, this could be considered deliberate cheating  which in medical field is clearly unethical and in total conflict with the Hippocratic oath and of course punishable by law.

PhotoA: Right Leg in clockwise rotation  with calf varicose veins.

Photo 1: Right Leg with calf varicose veins, in clockwise rotation. (Double click to enlarge)

THE patient is a healthy 43 year old non-smoker male. He has been referred to my office (December 2013) by a cousin of his I have successfully rid her varicose veins some time ago. The patient, for years, has on his right leg the same asymptomatic varicose veins (his father had too) and he was interested treating them for basically cosmetic reasons. The examination of the patient was performed in standing position, as it should be in all cases of varicose veins, as the blood (helped by gravity) flows in them downward, making them distend even bulge, even palpable with naked eyes. As one can see, the Right leg (Photos 1&2) displayed only mild to moderate calf varicose veins. The clinical as well as Ultrasound (US) examination revealed reversal of blood flow (medically, reflux) starting behind the knee, at the Junction between the superficial (so called) short  Saphenous vein with the deep Popliteal vein (abr.SPJ). The  gravitational reversed/downhill blood flow pattern was

RT calf  varicosities enlarged

Photo 2: same Right calf (inner and posterior aspect (close-up)
(Double click to enlarge further)

detectable by US up to middle of the calf from where blood “spilled” into multiple visible distended (varicose) venous branches or tributaries of his short saphenous vein. Ultrasound interrogation of the groin disclosed a normal/competent Junction between the superficial ( this time called ) long Saphenous vein with the deep Femoral vein, ( abr.SFJ). No reversal of flow was present along the entire length of the long saphenous being considered totally normal.

The reader has to understand that in normal i.e. physiologic conditions the blood flow in our leg veins, even in a standing position, is always uphill, back towards the heart. This literally anti-gravity uphill flow is enabled by multiple unidirectional valves (like “gates”) we all have in both deep and superficial leg veins; however, varicose veins can occur only along the superficial venous system. Heredity,standing jobs, meager support (skin and subcutaneous fat), gender (female hormones/pregnancies), sedentary life style, obesity may all

contribute in distending the superficial leg veins triggering secondary valvular failure/incompetence that will result in an abnormal reversed gravitational downhill flow or, reflux in medical terminology. The origin of this abnormal pattern of flow usually starts at the site of the two above-mentioned junctions: SFJ in the groin or SPJ behind the knee, causing either long respectively short saphenous varicose veins. (Please note that in some writings “long” or “short” saphenous veins can be used interchangeably used with “great” or “small” saphenous veins.) Detecting these two escape points (as the two junctions are also called), is imperative when choosing and offering a long lasting therapeutic modality. In order to better comprehend this point, please imagine a dripping faucet responsible for a puddle in the yard. Siphoning / suctioning only the water, without fixing the leaking faucet will end up being an exercise in futility as the puddle would surely re-accumulate. In case of varicose vein, the palpable and visibly distended veins are the the puddle equivalents, while the feeding / leaking “faucet” is either in the groin at the SFJ (in case of long saphenous)  or behind the knee at the SPJ (in case of short saphenous vein varicosities). While, in the standing position, the distended veins  –  (as”puddles”)  – are clearly visible even palpable with closed

The normal and abnormal venous circulation

The normal and abnormal venous circulation

eyes (!!),  the two above-mentioned junctions – (as faucets) – are NOT!!  Even a thorough clinical examination could be inaccurate and misleading, therefore, a non-invasive  ultrasound (US) test/interrogation of the groin or behind the knee area, becomes imperative in order to detect and localized the leaking junction(s). This will enable to individually tailor the procedure for each case, and also assure the longest lasting results possible. Indeed, we can fix the existing varicose condition but NOT the tendency to possibly create new recurrent veins. Missing to diagnose a junction or NOT treating it properly will surely assure varicose vein recurrences. This is the case with injection sclerotherapy and with both thermal ablation methods that shy away from the true junctions since a blood clot in that area could dislodge and find its way, through the deep veins, to the lungs with dire consequences ( pulmonary emboli).  The US examination preferably should be done by the practitioner, or at least in his/her presences as he/her will be responsible for offered procedure’s performance and outcome.  (Additional information)

Left leg ( four sides in clockwise rotation) No varicose veins present!

Photo 3. Left leg ( four sides in clockwise rotation) No varicose veins present!

LEFT leg (Photo 3) displayed NO varicose veins at all and the ultrasound interrogation of SFJ in the groin as well as SPJ behind the knee disclosed a normal/competent junctions over both: i.e. normal uphill flow i.e. reversed flow (reflux) was non-existent. Both legs displayed minimal and scattered spider veins.  

Exhibit A: Fees for endovascular ablation

Exhibit A: Fees for endovascular ablation

After the examination I have informed the patient I can help him and described him that I intend to do the same procedure I have performed in the last 20 plus years for more than 3500 times: a tamed, minimally invasive surgical approach (well described on this website), performed in simple local anesthesia and in an office setting that will not incapacitate him. Indeed, he was told he will be able to drive away from my office and immediately resume normal daily activities, sporting activities included, except swimming and the light dressing covered by a surgical stocking should not interfere with his quality of life. I also informed him, based on my vast experience, that I am expecting no complications worthy of mentioning. In addition I also informed him that any  necessary post-operative follow-up examinations certainly are  included in the quoted fee of $2300. The patient agreed and was relieved as my fees were  reasonable, as the reader will se below…

Exhibit B: Fees for sclerotherapy

Exhibit B: Fees for sclerotherapy

Please note that  together with Prof. Dr. Albert Yellin from the Department of Surgery USC, I have authored  and published several publications on the tamed, minimally invasive surgical approach for varicose vein that were all a first in the American surgical literature. (see bibliography 1-4

At this stage the patient disclosed me that basically he came to me for a second opinion. Indeed he was seen in August of 2013 by a local  “vein doctor” and showed me the documents he had on himself regarding  the intentions and fees for the two  options given to him, one for endovenous heat ablation totaling, a whopping $9,300 (Exhibit A), and one for injection sclerotherapy totaling $4.950 (Exhibit B). Since he was in my office, and upon my request, he signed an information release document that was immediately faxed demanding release of pertinent medical information. We promptly received by return fax, the ultrasound examination  (Exibit C)…  good enough to conclude that something smells fishy…terrible fishy to say the least. I am not here to argue about fee issues. This is a free market country and for some doctors – especially those in  cosmetic specialties – skies  could be the limit! Nor do I intend to start a public debate what is or what should be the best treatment option for varicose veins: foam ultrasound guided injection sclerotherapy, endovenous thermal ablation by radio-frequency current (VENUS) or by laser (EVLT),  or the tamed minimally invasive local anesthesia in-office surgery, of course I certainly prefer. I am here however, to shed light about a deliberate fraudulent practice I believe is happening all over the country when using the high tech treatment options for the varicose veins. The issue , the main issue in this case, is the deliberate and purposely misleading incorrect diagnosis for the sake of the all mighty dollar…

Exhibit D - the ultrasound examination with the 3 outlined paragraphs.

Exhibit C – the ultrasound
examination with the 3 outlined paragraphs.

The patient was examined correctly, standing, in both setups, as it indeed should be as varicose veins become obvious when blood, under gravitational “down-flow” (reflux), makes them bulge/protrude from the surface of skin. As mentioned just above, varicose veins can be clinically diagnosed even with closed eyes, by simple leg palpation in this position, and only in this position! I have no idea who in the BH office did the ultrasound test  (in my setup I do it) but the BH doctor signed to it electronically and he would also be performing one of the proposed therapeutic procedures, thus responsibility is his. The patient complained of ONLY of right leg (calf) varicose veins (Photo 1&2). Reading the BH executed ultrasound report, it seems that we both agree with the clinical as well as ultrasound examination which concluded that the right superficial long saphenous vein is normal and that its corresponding junction, the SFJ is competent thus normal too. We both also agreed that  the right calf varicose veins belong only to the territory of superficial short saphenous vein and that, as expected, its corresponding junction, the SPJ, was found incompetent or leaking. Photo A depicts the four sides (front, inner, posterior, lateral aspects) of the right leg in clockwise rotation showing existing  calf varicose veins. Photo depicts the same right calf varicosities  in close up photography. The left leg  (Photo 3) is the leg I have the problem with as the two superficial long and short saphenous veins were wrongly diagnosed  ( in the BH office) as faulty, with both SFJ and SPJ leaking that my clinical as well as ultrasound examination revealed as completely NORMAL. Please read the Exhibit C paragraph 1:  “ Severe valvular incompetence is identified from the sapheno-femoral junction (SFJ) and through the saphenous vein to the level of the knee” and later in the same paragraph “ Severe valvular incompetence is identified in the short saphenous vein” Moreover, Exhibit C paragraph 2 reads: “Multiple tortuous varicosities of the left GSV (Greater Saphenous Vein …” finding that were NOT visible during my examination. But let the pictures speak for themselves. Please look well, Photo C, displays the four positions of the disputed LT leg, photographed again in clockwise rotation, and NO varicose veins could be detected. (Please double click on the Photos and Exhibits to enlarge them). While still on Exhibit C paragraph 3, one can clearly read: “This patient DOES meet the qualifications for venous ablation of the left  (?) great saphenous vein and both right and LEFT (?) small saphenous veins. (Procedure code 36475, need Autho(rization) for 3 times) (?). Wow!!! And indeed in the fee chart given to the patient (Exhibit A),  $2200 is multiplied by 3 for a total of $6.600 out which $4400 are fraudulent fees. I permit myself to also comment on the follow up visits as well. The general rule myself follow and abide by,  is that for the first 60 days, the follow up “fees” are included in the original fee. And while I do agree that after any form of thermal endovenous ablation, RF current or laser, the possibility of an unwanted deep vein thrombosis/clot is there, ultrasound follow up of the deep vein is indeed needed, yet the quoted six times are, maybe, just a little too …  generous. Indeed, a blood clot in the deep venous system once discovered, will need anticoagulant treatment to prevent the dreaded pulmonary emboli that could be fatal. All these potentially severe complication for  basically a cosmetic procedure, most varicose veins  basically are!! Therefore, endovenous ablation will never be my preferred treatment modality, not to speak about many other annoying complications,  none seen with the minimally invasive surgical approach I prefer. The fees for sclerotherapy (Exhibit B)  takes in consideration again 3 treatable varicose systems, out of which two on the disputed left leg do not exist.

Discussion. Varicose  veins (VV) are the most common manifestation of lower extremity vascular pathology in general and venous pathology in particular. Due to condition’s high prevalence/penetration, (mainly in the cosmetically driven female population), the demand  for consultation and treatment is significant. Traditionally, the treatment  was in surgical hands. Unfortunately, the over 100 year old classic stripping surgery had to be performed in general anesthesia, hospital setting and was dreaded by patients because of excessive operative trauma, lengthy convalescence, frequent unaesthetic skin scarring  and occasional nerve damage as well. As time passed, newer and much less traumatic procedures were slowly introduced. Two innovations revolutionized varicose veins surgery and both by Swiss colleagues. The dermatologist Robert Muller introduced in the mid sixties the hook removal of varicose branches via millimetric skin openings cutting down on trauma and also much improving the cosmetic appearance and the vascular surgeon, Andreas Oesch who finally tamed the traumatic stripping of the main saphenous vein trunks by introducing the invaginated PIN (peel-out) stripping. Personally, I have adopted these minimally invasive approaches and together uniquely performed them in an office setting (not hospital) and only plain local (not general) anesthesia. So far in twenty years this tamed procedure  was used  by me 3500 times with utmost patient satisfaction.

More or less the same time I started using the minimally invasive surgical approach in early nineties, non-surgical novel and also minimally invasive methods of treatment were introduced as well: ultrasound guided foam sclerotherapy and thermal endovenous ablation procedures (first CLOSURE by RF current followed by laser or EVLT ) for which surgical skills were basically not needed. Moreover, as manufactures of the hardware managed to convince insurance carriers, Medicare included, to honor quite excessive reimbursement fees, the floodgates opened for basically all non-surgical specialties feeling the drop/pinch in their insurance reimbursable incomes in their respective specialties. Indeed, attracted by prospects of higher and even reimbursable fees, many, many of these diverse specialists jumped on the opportunity and became, over the night – well, over a weekend course, – “vein specialist”. Yes, the “vein revolution” , already mentioned above, was started and it still goes on…

In 2009, it was the last time I was targeted and enticed by VNUS Co. (the hardware manufacturer for CLOSURE by RF current – radio-frequency – thermal endovenous ablation), to join the “club”, which of course, I did not do. (My patients treated with the minimally invasive surgical approach were satisfied, so was I and as they say, “if ain’t broke don’t fix it”. Moreover, I was a “fee for service” physician thus never depending on insurance reimbursement. My fees were and are reasonable and whatever the insurance reimbursed, the patient got it.)

Exhibit D depicts Medicare reimbursement fees, procedural codes, and approximated intra-operative times. When seeing the document in 2009, first, I could not believe my eyes: for a life threatening Abdominal Aortic Aneurism (AAA) an extremely difficult procedure needing extraordinary technical skills  and for which the operating time was correctly estimated for 3:30 hours, the Medicare’s doctor reimbursement fee was $1.858. For a similarly technically challenging cleanup of the carotid artery, a stroke and life preventing procedure (Carotid Endarterectomy), the fee was $1.608 and time allocated 2.4 hours.  Yet, for the endovascular  – by CLOSURE – ablation, (CPT code 36457) needed for a condition that is in most cases a cosmetic nuisance,  the reimbursement fee is the highest on the entire list: $2.493 !! while the allocated time to complete the procedure: a measly one hour!!!! So, for  3:30 grueling hours spent on one of the most technically challenging and risky procedures existing in the surgery to the a human being

Medicare payment fees, CPT codes and times (Double click to enlarge)

Exhibit D: Medicare payment fees, CPT codes and times
(Double click to enlarge)

the surgeon, who trained for six years in general surgery and additional 1-2 years in a vascular surgery fellowship, is paid LESS  than a dermatologist, family practitioner, radiologist, etc. who spent a weekend in a workshop learning the thermal ablation technique, (workshop usually organized by the hardware manufacturer), yet he will be reimbursed BETTER that the vascular surgeon. INCREDIBLE!!! Please note that the Medicare fee charts guide most insurance companies, meaning that they usually follow Medicare’s fee fluctuations and copy it. As previously already mentioned, considering that in the last 15-20 years overall  physician’s reimbursement dropped significantly for most specialties, anything new that does not need special skills yet is better reimbursed became very attractive indeed. Personally, I have nothing against all this provided that the standard of care is maintained: procedure being patient appropriate, should be well performed, does not have potential severe complications, assures good results and that the  patient is not fooled or taken advantage of, as in this case almost was. I have to “commend” the hardware companies as they did a “great” job: first by assuring exaggeratedly high reimbursement fees and by advertised these high income opportunities to all medical specialties: dermatologists, gynecologist, internists, radiologist, family practitioners, cardiologists etc. etc. and of course surgeons as well, who all bought into the gold rush… By the way, from the same Exhibit D one can read that Vein Stripping surgery -procedural CPT code 37722 – is being reimbursed for a measly $465! No wander surgeons, mostly depending on insurance reimbursement, embarked on the bandwagon too!  Unfortunately, greed joined into the fray as well. Indeed, greed driven physicians, like in this case, are easily able to talk into a naïve, cosmetically motivated patient to undergo thermal ablation by stressing that is a simple procedure of 45 minutes, performed in an office setting and not like the dreaded stripping surgery that needs hospital setting (the minimally invasive surgical alternative is not even mentioned existing), and  stressing that if the patient has insurance it will not cost him/her much… regardless if the procedure is or not warranted… Click here to see the full VNUS physician recruiting pages guaranteeing $655,653.60 in additional revenues per year for coming on board with them…)

The patient in this case informed me that the BH “specialist” told him that he has indeed visible varicose veins on the right leg – the patient was aware and consulted him for – but he told him too that he has them on the left leg as well, below the skin, therefore non visible to the naked eye…but they need medical attention. This is how a single procedure, fully indicated for the right leg, swell, (with two unneeded ones for the left leg), into three procedures… although the two additional proposed ones, had no medical nor cosmetic reasons: they simply did not exist (see for yourself Photo 3).  There is only one single explanation for the two additional suggested procedures – for the non-existing left leg veins – namely financial gains, or plain English, greed. The patient believed the doctor blindly, especially as both have the same ethnic background and speak the same mother tongue and psychologically, few consumers/buyers will suspect a “tribesman” to be dishonest! I was told that the BH doctor advertises in the ethnic newspaper, a good source for generating additional naive patients and fraudulent income.

Once the patient is convinced that the procedures are needed and agrees to their performance, the following needed step is to convince insurance carriers to pay the bill. To get insurance carrier approval for the procedure is not easy but if a good supportive ultrasound examination test exist, it makes it easier. In our case the ultrasound test, was – as we have seen- falsified to justify the claim.  It was shamelessly and daringly put on paper as no insurance company would come to the doctors office (audit) and examine the patient and check the accuracy of the ultrasound test. Doctors could argue about interpretation and meaning of any test, but one can’t fool anybody when the obvious naked eye evidence, which should be there and visible to ALL, is simply missing… (see Photo 3)  This patient never had and does not have varicose veins on the left leg of any kind: neither long not short saphenous. THEY WERE SIMPLY INVENTED TO JUSTIFY FINANCIAL GAINS. PERIOD. The best analogy I could come up with is to convince a hernia patient, having a legitimate and visible / painful ONE SIDED inguinal hernia, that he has one on the OTHER SIDE  as well, not yet painful and not yet visible as it is still under the… skin.  I am aware of cases in which unnecessary ultrasound tests were/are performed routinely for simple spider veins; cases in which long saphenous veins were closed i.e. ablated, while the patient is told that without the (well reimbursed) procedure the spider veins will never go away. Apparently, greed overrides ethics, morals and shame.

Unfortunately, I take issue with a second misconduct regarding this case, namely the malpractice one. A normal long saphenous vein is an excellent vascular conduit used in bypassing coronary artery occlusion as well as obstructive arterial disease of the legs. Ablating, closing, destroying or removing a normal saphenous vein for financial gains in my humble opinion is medically criminal and in total contradiction with our Hippocratic Oath. This patient was lucky as he escaped the trap put in front of him…

Bibliography:

1. Goren, G., Yellin, A.E. Surgery for truncal varicose veins: the ambulatory stab avulsion phlebectomy. Am J Surg 1991; 162:166-74

2. Goren, G., Yellin, A.E. Invaginated axial saphenectomy by a semirigid stripper: PIN stripping. J Vasc Surg 1994; 20:970-77

3. Goren, G., Yellin A.E. Invaginated axial stripping and stab avulsion phlebectomy: a definite outpatient procedure for varicose veins. Amb. Surg 1994; 1: 27-35

4. Goren, G., Yellin, A.E. Minimally invasive surgery for primary varicose veins: limited invaginated axial stripping and tributary (hook) stab avulsion. Ann Vasc Surg 1995; 9:401-14 (also translated to French and Spanish)

 

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