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[PainInTheAnes]

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[TheLoneWolf]

Let's assume it's all true, what is the solution?

 

[GravelRider]

Now it makes sense why this one vascular surgeon who is pretty freakin’ rich always says that he wishes all patients were on Medicare.

 

[TheLoneWolf]

Some oversight and real evidence based practices in the CMS reimbursement structure would be a start.

I can’t believe that their entire model for a country of 330 million people boils down to “Wow, look at that rad fancy wire! You do it with xray vision! Here’s 100 gillion billion dollars, you’re like a space wizard Dr. Interventional Procedure, MD!”

It’s like everyone knows the entire Medicare system is a huge joke, but people in government won’t ever touch it

I'm in pain medicine, it's literally the same stuff with a few device makers and a new indication each year to "revolutionize" the system. Just open robbery. Pretty much everything via Medicare doesn't need prior authorization so that's why proceduralists like it.

 

[GravelRider]

Some oversight and real evidence based practices in the CMS reimbursement structure would be a start.

I can’t believe that their entire model for a country of 330 million people boils down to “Wow, look at that rad fancy wire! You do it with xray vision! Here’s 100 gillion billion dollars, you’re like a space wizard Dr. Interventional Procedure, MD!”

It’s like everyone knows the entire Medicare system is a huge joke, but people in government won’t ever touch it

That’s human nature, though. Our entire consumer-based economy essentially thrives on buying the newest and latest technology even if it provides no real advantage over older technology. The first example that comes to mind is all this “smart home” nonsense. You add multiple degrees of complexity, expense, and possible points of failure (and the whole lack of privacy thing) when a good old fashioned light switch did the job perfectly well. How many billions of dollars have been spent “upgrading” light switches to a worse technology that fails more often? Medicine is no different.

 

[Agast]

I'm in pain medicine, it's literally the same stuff with a few device makers and a new indication each year to "revolutionize" the system. Just open robbery. Pretty much everything via Medicare doesn't need prior authorization so that's why proceduralists like it.

That’s also why Medicare is trying really hard to get people to go into Advantage/Replacement plans. The denials save them a ton of money.

 

[GassYous]

No wonder they reimburse us 20$/unit

 

[DirtDocMD]

How can there not be something that triggers an “audit” (within 6-12 months), of proceduralists who are billing 5-10x that of the mean/median practitioners of that specialty?? That should take all of 5 minutes to write software that “red flags” these folks, rather than letting it go on for years before looking into it.

 

[GravelRider]

How can there not be something that triggers an “audit” (within 6-12 months), of proceduralists who are billing 5-10x that of the mean/median practitioners of that specialty?? That should take all of 5 minutes to write software that “red flags” these folks, rather than letting it go on for years before looking into it.

The same could be said of all tax fraud. AI and software could probably catch 99% of all tax fraud, but these agencies are too understaffed to do anything about it.

 

[powermd]

That’s also why Medicare is trying really hard to get people to go into Advantage/Replacement plans. The denials save them a ton of money.

I thought most of the savings were pocketed by the Advantage company with little benefit to MDC.

 

[aneftp]

Some oversight and real evidence based practices in the CMS reimbursement structure would be a start.

I can’t believe that their entire model for a country of 330 million people boils down to “Wow, look at that rad fancy wire! You do it with xray vision! Here’s 100 gillion billion dollars, you’re like a space wizard Dr. Interventional Procedure, MD!”

It’s like everyone knows the entire Medicare system is a huge joke, but people in government won’t ever touch it

Correct. Medicare spending is 20% of the USA annual budget

Defense spending is another 20% of the USA budget.

So they combine for a total of 40% of usa annual spending.

Solve those two riddles. You solve the spending problem with the USA.

But the corporations will kill you first unless one of the newly unemployed 20% of the country will kill you before corporations get to you

Defense and Medicare spending account for such a wide halo economies. It will collapse the USA economy with massive layoffs with any budget cuts. Look at Obama blinking even with a proposed 5% cut in military spending. Image trying to trying to cut Medicare budget by 5%. It’s just really hard. Cms tries to cut Medicare payments but the total Medicare spending keeps going up.

Everyone wants their cut of the pie. We have seen gi docs scope inpatients BEFORE THEY LEAVE THE HOSPITAL. FOR UNRELATED NON GI ADMISSION. Just so they can capture the revenue

Like seriously. The patient already has known anemia of chronic disease. Admitted for copd exerberation 5 earlier. No urgent reason to do an egd. No symptoms besides known anemia. But that just adds to the system.

Anesthesia doesn’t say no either. Cause it’s more revenue for them.

 

[rowsdower88]

The same could be said of all tax fraud. AI and software could probably catch 99% of all tax fraud, but these agencies are too understaffed to do anything about it.

IRS says it collected $38 million from more than 175 high-income tax delinquents

The IRS is showcasing its new capability to audit high-income tax dodgers aggressively as it makes the case for sustained funding and tries to avoid budget cuts sought by Republicans who want to gut the agency

abcnews.go.com

 

[sloh]

How can there not be something that triggers an “audit” (within 6-12 months), of proceduralists who are billing 5-10x that of the mean/median practitioners of that specialty?? That should take all of 5 minutes to write software that “red flags” these folks, rather than letting it go on for years before looking into it.

I think CMS doesn't really do something until there's significant loss of life and/or limb—as in the case OP posted

 

[nimbus]

They Lost Their Legs. Doctors and Health Care Giants Profited.

Medical device makers have bankrolled a cottage industry of doctors and clinics that perform artery-clearing procedures that can lead to amputations.

www.nytimes.com

I wondered why vascular surgery all of a sudden became one of the most coveted specialties for hospitals in the last 3-4 years.

The stuff in this article is crazy. Sounds like some of these vascular guys were making 10k per atherectomy, which can be done w simple moderate sedation or maybe just local in some cases.

“From 2017 to 2021, about half of Medicare’s atherectomy payments — $1.4 billion — have gone to 200 high-volume providers, the Times analysis found.
Many of the doctors who do the most vascular procedures receive payments — for consulting, speeches and other services — from the device industry that profits from their work.
For example, the top provider of Medicare-financed atherectomies in Louisiana, Dr. David Allie, received $2.8 million from drug and device makers between 2013, when the federal government began collecting such data, and 2022.”

If you ask me, the real problem here is Medicare, CMS, and the people who run it. These companies wouldn’t have a patient base if it weren’t for bought and paid for CMS people approving the treatments and offering a gold mine worth of reimbursement for it. Forget insurance companies, device companies, and all the people who are just parasites on the system. The SYSTEM is the problem with stuff like this.

Mustapha is actually a cardiologist, not a vascular surgeon, doing peripheral vascular interventions. Could be some element of turf war in the background. I don’t see how this is much different than “fem-pop-chop-chop-chop.” Limb salvage procedures often fail. They might have lost their legs regardless.

 

[nimbus]

This paper was cited in the NYTimes article. It’s easy to see how the incentives drive practice. Medicare pays $12444 in the office setting and $635 in the hospital. I’m sure they did this thinking it would offset high hospital facility fees. The simple solution is for Medicare to reimburse equally regardless of setting (hospital vs outpt) or procedure (angioplasty vs atherectony). I don’t see anything showing that atherectomy has worse overall outcomes than angioplasty but it does make the doctors richer.

Use of Atherectomy during Index Peripheral Vascular Interventions

There are minimal data to support the routine use of atherectomy over angioplasty and/or stenting for the endovascular treatment of peripheral artery disease.We sought to describe physician practice patterns and examine physician-level factors associated ...

www.ncbi.nlm.nih.gov

“In 2019, the national average Medicare physician payment rate for atherectomy was $635 for in-hospital cases compared to $12,444 for office-based cases (8). In contrast, the 2019 national average Medicare physician payment rate for angioplasty was $466 for in-hospital cases compared to $3,628 for office-based cases (8). This may explain our finding that physicians with high utilization of ASC and OBLs have a nearly 8-fold higher use of atherectomy compared to physicians with predominantly hospital-based practices. The high use of PVI in office-based compared to hospital settings is consistent with previously published data (25). Moving forward, efforts for cost containment around new technologies should include early and ongoing refinement of reimbursement policies to prevent similar patterns from happening in the future (26).”

 

[Beeftenderloin]

Mustapha is actually a cardiologist, not a vascular surgeon, doing peripheral vascular interventions. Could be some element of turf war in the background. I don’t see how this is much different than “fem-pop-chop-chop-chop.” Limb salvage procedures often fail. They might have lost their legs regardless.

Where I did fellowship and where I work currently we had/have cardiologists routinely doing peripheral and even large central vascular interventions, right up to stenting big red (with vascular on standby for stuff like that). Some amount of peripheral vascular training is starting to become more common in a lot of interventional cardiology super-fellowships.

You gotta hand it to the cardiologists. In stead of ceding territory to mid-levels like most specialties, they’re out there taking ground from heart surgeons (TAVR, TMVR, mitra/tri-clip), vascular surgeons (PV right up to AAAs), and radiologists (cardiac MR/CT, etc.).

 

[PainDrain]

Where I work there is an interventional cardiologist who does all sorts of vascular procedures; stents, EVARs, carotid stents. I have seen several of his patients who did not do well, not sure how he gets away with it. Most of the vascular surgeons don’t want to clean up his messes but sometimes they have no alternative.

 

[BLADEMDA]

That's how the Hospital or ASC can pay us our stipends. We get $20 per unit from CMS but they get huge sums of money from CMS so we get some of that money as well via stipends.

 

[coffeebythelake]

That's how the Hospital or ASC can pay us our stipends. We get $20 per unit from CMS but they get huge sums of money from CMS so we get some of that money as well via stipends.

Facility fees? Stuff like $ per unit is small talk

 

[Harpoon1]

Everyone wants their cut of the pie. We have seen gi docs scope inpatients BEFORE THEY LEAVE THE HOSPITAL. FOR UNRELATED NON GI ADMISSION. Just so they can capture the revenue

Every day occurence. If someone ever cared to tackle real fraud in healthcare they should start with the gi docs.

 

[aneftp]

Every day occurence. If someone ever cared to tackle real fraud in healthcare they should start with the gi docs.

Unfortunately gi doc scooping for another $200 Medicare egd is peanuts.

So much pork can be cut out. Starting with half the administrators. But like I said before hand. It’s a halo economy. You cannot cut out the pork without people losing their good paying jobs.

They pick on healthcare “providers” but we all know our income barley touches the problem.

 

[psychbender]

Unfortunately gi doc scooping for another $200 Medicare egd is peanuts.

So much pork can be cut out. Starting with half the administrators. But like I said before hand. It’s a halo economy. You cannot cut out the pork without people losing their good paying jobs.

They pick on healthcare “providers” but we all know our income barley touches the problem.

Precisely. Payments to physicians and providers makes up only about 10% of healthcare expenditures.

Regarding the GI example, the blame cannot be placed squarely on the GIs. Some internist or intensivist (or, at least as likely, some NP or PA playing hospitalist) consulted GI at some point, resulting in that needless scope. Maybe we shouldn't consult for dumb **** that won't change outcomes.

 

[pastafan]

The other major question is never addressed. All of these vascular procedures have 100% failure rate if the patient continues to smoke. Why are we paying for a procedure that is guaranteed to fail?