Venous Insufficiency: Will Obamacare Turn Back the Clock on Endovenous Ablation?

Of the estimated 35 million adults in the United States who suffer from superficial venous insufficiency, or venous reflux disease, the majority have symptoms and signs that cause significant pain and disability.

Until 2000, the only treatments available for patients with significant saphenous veins insufficiency were compression hose, high ligation or ligation and stripping. The latter two treatments were often considered too invasive for patients with symptoms other than hemorrhaging veins or non-healing leg or ankle venous ulcers. The landscape of venous insufficiency treatment was transformed dramatically by the introduction of endovenous thermal ablation in 2000. The radiofrequency catheter system was first approved by the FDA in 1999, and the first LASER system for endovenous ablation received FDA approval in 2001.

In the past decade, our understanding of venous insufficiency has been greatly enhanced as endovenous ablation has been applied to patients with advanced staged of venous insufficiency with excellent results. Superficial veins other than the great saphenous vein — such as the small saphenous vein, intersaphenous vein and anterior accessory saphenous vein as well as other perforating veins — are now treatable with endovenous ablation. Modern ultrasound evaluation of the lower extremity venous system by experienced vascular technologists can accurately identify which veins are insufficient and the severity thereof. Ultrasound directed ablation of the abnormal veins under local anesthesia has yielded far superior results than vein ligation or vein ligation and stripping. The net result has been relief for millions of patients worldwide and for hundreds of thousands of patients in the United States. Ulcers are being healed in record time, stasis dermatitis changes are being reversed and leg swelling and pain is receding in thousands of patients once thought to be untreatable.

So what does the future hold for patients with venous insufficiency in the United States? How will President Obama’s proposed health care bill affect the treatment of patients with venous disease? If the Canadian health care program, which has been touted as one which should be emulated, is our window into Obamacare, the prospects for patients with venous insufficiency may not be so good. Like most other physicians in Southwest Florida, I often see patients from other states and countries. In the past month, I have seen a handful of Canadians who have had severe venous insufficiency. The first, a 65-year-old active woman, had terrible leg pain and was confirmed to have severe great saphenous insufficiency. The next Canadian patient, 84 years old and active, presented with a two-year history of severe stasis dermatitis and two months of multiple ulcerations and severe pain. Both patients had been treated with compression hose and had seen their Canadian primary care physicians for evaluations. The only treatment for these patients covered under the Canadian health plan was either ligation or ligation and stripping of the great saphenous vein. This has been confirmed on the Canadian health care website. Both patients came to the conclusion to have their veins treated with endovenous ablation rather than stripping, at their own expense. Both have been treated successfully and have recovered from their endovenous ablations, performed under local anesthesia. No risk of general anesthesia, no incisions, no fasting, no more venous insufficiency or venous hypertension. The first patient returned for her threeweek follow-up appointment without leg pain for the first time in years. The second patient’s leg ulcers are drying up and the dermatitis is healing.

If cost containment in venous disease treatment entails offering only antiquated and invasive treatments which most patients will likely opt not to have unless they develop ulcerations or bleeding, then a parallel, private delivery system of medical care will be spawned. This offloading of patient care responsibility to these private clinics with modern technology, and the financial burden to the patient, will serve to create two very different classes of medical care. This will possibly discourage patients from seeking earlier medical attention and result in disease progression and delay of treatment until complications occur and are severe enough to force patients into consenting for less advanced, more invasive treatments. The Canadians will likely still come south for their treatments; the question is whether Americans will be happy footing the whole bill for the minimally invasive treatments currently covered by most payers.

MD News February/March 2010



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