Branching Out: Ask These 5 Questions Before Launching a Vein Care Service Line

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Some hospital systems are considering offering integrated vein care centers. One of the challenges they face is uncertainty about reimbursement.

Plenty of need

As the U.S. population continues trending older and toward more comorbidities, the number of patients with venous diseases is growing. More than 25 million people have varicose veins. While some are looking for a cosmetic fix, the condition can be part of the etiology of more serious venous disease (Circulation 2014;130:582-7).

“The difference is pain, aching and possible full disability,” says Peter Gloviczki, MD, a vascular surgeon at the Mayo Clinic in Rochester, N.Y., and a member of the team that developed the system’s vein care program. Venous disease, he notes, is “a large bag of possible venous problems,” ranging from the acute—such as venous thromboembolism and deep vein thrombosis—to chronic conditions.

The recurring nature of venous conditions also suggests that there may be plenty of patients to direct to vein care programs. Painful varicose veins, venous insufficiency and chronic ulcers often bring patients back for ongoing treatment. Researchers who analyzed a sample of claims data from 2007 to 2011 found that chronic venous ulcers cost $14.9 billion per year, not including out-of-pocket payments or other indirect costs (J Med Econ 2014;17[5]:347-56). In North America and Europe, spending on varicose vein treatments was nearly $208 million in 2016, and costs are expected to increase by 6.9 percent in the coming years, according to Grand View Research, a market research and consulting firm based in San Francisco. Up to one-half of acute venous disease patients develop post-thrombotic syndrome, bringing them back for care (Thromb Haemost 2010;104[4]:681-92).

The growing prevalence of both chronic and acute venous disease and patients’ ongoing needs should be considered as healthcare teams weigh decisions about launching specialized vein care programs, says Gloviczki.

Bringing specialized vein care centers into a healthcare system typically means more opportunities for collaboration among specialists. Systems with integrated vein care can leverage the skills of their vascular teams to support other departments’ efforts, such as to improve wound care and healing in dermatology, to improve blood flow to extremities in orthopedics and to open and maintain ports for hemodialysis and chemotherapy in oncology. On the surface at least, venous disease is a tempting area to expand into because it is replete with new opportunities for healthcare systems to offer new services to patients in their communities while enriching their hospitals’ revenue streams.

Sources: *Circulation 2014;130:582-7. †Thromb Haemost 2010;104[4]:681-92. ŧJ Med Econ 2014;17[5]:347-56. §Grand View Research, San Francisco.
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Uncertain reimbursement

Before rushing forward with a specialized vein care line, there are hurdles to be analyzed, says Gloviczki. Care in this arena can be complex and reimbursement can be difficult. Currently, there is no national coverage decision, leaving healthcare systems to navigate local coverage determinations, where care covered in one community might not be reimbursed elsewhere.

In 2016, the Centers for Medicare & Medicaid Services convened a Medicare Evidence Development & Coverage Advisory Committee (MEDCAC) to examine the state of the science on lower extremity venous disease. The MEDCAC concluded that the evidence for lower extremity chronic venous disease treatments needed strengthening across the board: the studies were too small and too few to earn much confidence, according to the committee. Where the issue is cosmetic—patients complaining of “ugly” veins but no pain—there isn’t enough evidence to justify medical treatment, the MEDCAC says, and interventions should not be covered. Rather, patients should be pointed toward exercise assessment, education, nutrition and arterial testing. For cases marked by pain, clotting or open, slow-healing wounds, the MEDCAC nudged its opinion on intervention up to “low-to-intermediate level of confidence.”

With conclusions like these from CMS’s advisory committee, it’s unlikely that CMS will issue a national coverage decision for all forms of vein care, Gloviczki predicts. Still, he and colleagues from the American Venous Forum and the Society for Vascular Surgery reached out to the committee, expressing confidence in the evidence for improving patient outcomes with venous interventions. To date, Gloviczki says, neither CMS nor the MEDCAC has responded. In the meantime, to avoid reimbursement dilemmas, healthcare systems might be wise to limit interventions to patients with symptomatic acute and chronic venous disease.

Start with a mission & a plan

Just as Gloviczki and his team proceeded with caution when launching the Mayo Clinic’s vein care program, Raghu Kolluri, MD, system medical director of vascular medicine and medical director of the vascular core laboratories at the OhioHealth Heart and Vascular in Columbus, recommends a methodical approach to any service line expansion, including for vein care. First, both physicians emphasize, it’s crucial to start with a solid mission and a business plan that together address the following questions:

1-Do you really know the community & what patients need? Some forms of venous disease are more prevalent than others in certain geographic areas, based on factors such as the population’s age, sex, obesity, activity level and so on. Carefully consider what patient population will be best served in the local area, says Kolluri. Knowing the local population also can inform decisions about viable partnerships.

2-Have you thought strategically about reimbursement? Since not all venous disease cases will be reimbursed, concentrate on offering services that will be deemed medically necessary. Kolluri says his program has never had problems getting reimbursed, perhaps because it has focused on medical, rather than purely cosmetic, venous disease.

Vein care center collaborations and specialty care also should be a priority, since these partnerships can ease reimbursement concerns. Kolluri’s team built partnerships with other specialties, particularly podiatry and dermatology, and made wound care a top priority. “The more comprehensive you are, the more patients you’ll get and the fewer problems there are in getting preapproval,” he says.

3-What will your expenses be & how will you bill for them? In addition to the costs of staff and training, make a point of considering your space and equipment needs. They might differ depending on whether you’re providing inpatient or outpatient care, and both will affect income and expenses. For example, an inpatient program will need to consider beds for longer stays, whereas more space can be devoted to operating rooms, imaging or recovery if the vein care program is largely outpatient. “Billing is different for outpatient as opposed to inpatient care,” Kolluri says, noting that OhioHealth’s care line is a combination approach.

4-What is your blueprint for multispecialty collaboration? Collaboration with other specialties also increases the number of patients who can effectively be helped by a vein care service line. A collaboration, however, is only as strong as the plan you make for it. Kolluri describes the partnership between vein care and other specialties as a marriage, most successful when everyone communicates well. At its best, multispecialty collaboration enhances patients’ experiences. The team will require specialized training, but a more interconnected, integrated team means better care and a stronger vein care center in the long term.

5-Have you laid the foundation for achieving accreditation? Don’t forget that aspects of the vein care center will be regulated through accreditation, so do your homework, says Gloviczki. The Intersocietal Accreditation Commission’s latest guidelines, released June 1, outline standards for care teams, space, equipment and continuous quality improvement. These guidelines can be useful in developing the blueprint for the central team and considering how other care team members and their training will fit with and balance needs across specialties.