What's causing the dramatic increase in EVT in Medicare patients?


ROSEMONT, Illinois, March 18, 2019 – A new report suggests that providers who are not traditionally associated with the treatment of venous disease are driving the rapid increase in endovenous therapies.

In the March edition of the Journal of Vascular Surgery: Venous and Lymphatic Disorders, the researchers note that the ability to treat lower extremity venous reflux by minimally invasive methods and in an outpatient setting has led to a dramatic proliferation in the number of patients undergoing procedures for venous disease. This is likely due to both an increase in patients' demand for treatment and an increased willingness of physicians to provide it.

A compound annual growth rate of 15% has been observed for minimally-invasive procedures to treat superficial venous reflux over the past decade. This is not surprising given endovenous therapy (EVT) carries excellent results and low morbidity.

However, as noted by first author Dr. John Baber, Jr., MBA, “this relatively newfound interest in venous disease may be a result of the comparatively high reimbursement relative to effort for outpatient venous procedures.”

“With reports of fraud and abuse being increasingly highlighted in the lay press, we felt it worthwhile to evaluate the impact of variation in provider specialties and practice settings on utilization and treatment intensity,” Dr. Baber said.

Led by senior author Dr. Andrew Meltzer, researchers analyzed data from the Medicare Provider Utilization and Payment Data Public Use Files from 2012-2014. They compared provider characteristics and patient setting with a Utilization Index (UI), defined as the number of EVT per patient per year.

The data involved 6,599 providers of 40 specialties and subspecialties (or mid-level providers) who performed EVT in 405,232 Medicare beneficiaries. [See chart]. Those providing the services included:

  • Vascular surgeons 22.6%
  • Cardiologists 19.3%
  • General surgeons 13.5%
  • Radiologists 9.3%
  • Other surgeons 7.7%
  • Other 29.7% (non-surgical, non-vascular specialties)

Vascular surgeons had the lowest utilization index (average number of EVT procedures per patient per year) of all providers, 1.32.

Characteristics associated with high utilization (top quartile UI, >1.8) were services provided:

  • By “Other” providers (non-surgeon, non-vascular specialties; odds ratio 3.35)
  • In an outpatient setting (odds ratio 2.62)

In their discussion of these results, Dr. Baber and colleagues state, “Of particular note is the association between increased intensity of EVT utilization and the “other” providers. Nearly one-third of all endovenous ablation procedures in Medicare beneficiaries are performed by providers whose specialty is not traditionally associated with the management of vascular disease.”

“Furthermore, these providers treat venous disease with a greater intensity, with an average UI that is significantly higher than those who specialize in venous disease. In light of the comparatively high reimbursements for endovenous procedures, it would be naïve to attribute this variation to anything other than financial motivations,” Dr. Baber added.

Given that endovenous therapy has become an excellent option for superficial venous disease, it would now make sense that better oversight, updated, evidence-based guidelines and specific criteria for appropriate and ethical use of EVT procedures be established by our leading societies involved in the care of patients with venous disease.

The JVS article is open source through April, 2019 here: https://vsweb.org/JVSVL-EVToveruse