Advocating for Varicose Vein Coverage

On August 8th, Dr. Boyle traveled to Wilsonville, Oregon, advocating for more equitable Varicose Vein Coverage by the state of Oregon. Currently most insurance companies and Medicare provide coverage for patients with symptomatic varicose veins that are impacting their activities of daily living and quality of life.  The Oregon Health Plan, which provides medicaid health insurance to those in Oregon only covers the most advanced stages of venous insufficiency (those with end stage venous ulcers).  This means many OHP patients must wait until the end stages of the disease to qualify for treatment.  A public hearing was held August 8, 2019 by the Oregon Health Evidence Review Commission (HERC) considering pubic comment on this subject.   What follows is a summary of Dr. Boyle’s public comments advocating for varicose vein coverage for OHP members who suffer from symptomatic venous insufficiency.

Comments for Health Evidence Review Commission (HERC) on Lack of Treatment Coverage for Varicose Veins (for patients with Oregon Health Plan).  August 8, 2019.

My name is Ed Boyle and I am a surgeon from Bend, Oregon. In my practice, I specialize entirely in the care of patients with venous disease.  Many of our patients present with venous insufficiency, or what in laymen’s terms are called Varicose Veins.  Most of our patients have one or more of the following symptoms from their varicose veins:  pain, swelling (which can be severe), skin breakdown (known as stasis dermatitis), blood clotting in the veins (known as superficial thrombophlebitis, bleeding from the veins or venous stasis ulcers.  In Oregon, unlike in surrounding states like California and Washington, Medicaid recipients are not covered for common varicose veins procedures.  I witnessed first-hand on a regular basis how this negatively impacts their quality of life, their health and how this adds to overall healthcare costs for the state of Oregon.

My goals for traveling to present at this meeting are two fold:  1) Advocate for patients with the Oregon Health Plan (OHP) with inadequate coverage of chronic venous insufficiency that impacts their quality of life and can lead to death and disability.  2)  As a taxpayer and citizen of Oregon, advocate for a maximally value healthcare approach for the state of Oregon in the care of patients with chronic venous insufficient.

It is important to recognize:  Varicose veins (known medically as chronic venous insufficiency) are a progressive problem that can be slowed with proper treatment.  We categorize patients in 6 classes ranging from: C0 (no visible veins); C1 (spider veins); C2 varicose veins only; C3 Varicose veins with leg swelling; C4 with skin changes of stasis dermatitis; C5 those with prior healed vein ulcers and; C6 being those with active venous ulcers.

Right now, OHP only covers patients with the most end stage manifestations of this process (those with C6).  Once it gets to this stage, patients likely have had multiple trips to the emergency room, wound care clinics or even hospitalizations for difficult to treat wounds and infections.  This is because patients with earlier stages of the process, like C3, C4 and C5, can have significant disability that impacts their ability to work and can lead to very expensive hospital costs if left untreated.  Thus there is a need to allow coverage for treatment earlier in the process (C2,C3, C4, C5) to prevent the disability and costs of waiting until this is an end stage problem (C6).

We are here today to advocate for coverage for earlier stages of this disease.  From an published peer reviewed clinical evidence and value healthcare perspective, nearly all insurance payers, both private and public, have looked at the evidence and cover symptomatic varicose vein patients as part of a comprehensive vein treatment policy that directs treatment to those with symptoms that do not respond to conservative therapy.  In the United States, this includes Medicare (for example Noridian), most of the state Medicaid programs including Washington and California and nearly all private health plans.  OHP is an outlier in not covering treatment as these entities do.  Because of this policy in Oregon, many patients suffer, and ultimately the costs are higher.

It is worthy of note that the vein care policies that nearly all public and private payers have adopted are quite similar.  Coverage is provided for those with significant symptoms of pain, burning, swelling, recurrent clotting, skin ulceration that does not heal, severe skin irritation or bleeding.  Nearly all require a period of 3 months of “conservative therapy” that includes exercise, weight loss, leg elevation and compression hose.  All of this is easily documented and easily coded with existing ICD-10 codes.  None cover treatment of veins for those with no or mild symptoms.

In older days, these cases were done in hospitals with major surgery that included a general anesthetic (known as vein stripping).  Now they can be done in the office setting under a local anesthetic (known as endovenous ablation with radiofrequency, laser ablation or the medical adhesive Venaseal).  Patients walk in, get the treatment and walk out.  They can generally drive themselves home since there is no sedation.  They can generally go to work the next day.  Symptoms often improve significantly in the first week:  Swelling goes down; ache and heaviness are reduced; itching and skin irritation gets better; and wounds start to heal.

There is a large body of literature that support the earlier treatment of symptomatic varicose veins (C2, C3, C4, C5) before they become end stage (C6).  This is summarized in clinical practice guidelines I have included.  There is no question that there is ample high quality peer reviewed evidence to support these treatment guidelines. This is the reason nearly all insurance payers (Public and Private) cover varicose vein treatment in this fashion.

My suggestion to the HERC is as follows:  The HERC and ultimately the OHP should adopt a varicose vein coverage policy that is equivalent to the policies used by Medicare or the Medicaid policies of the surrounding states of California or Washington (I have included them in my presentation materials).  These will allow treatment for those with documented symptoms of pain, burning, swelling, clotting, bleeding or skin breakdown who have tried and failed conservative therapy.  By adopting this policy, the citizens of Oregon with OHP, as well as their families, co-workers and employers, will be better served.  Furthermore, the state of Oregon will save money by not waiting until the end stages of the process when wounds and infections can lead to costs that can exceed hundreds of thousands if not millions of dollars for patients who require hospital admissions and care.  In this way, this is truly a value healthcare policy decision that puts the best possible outcomes for the least amount of money at the forefront of the policy decision.

Thank you very much for considering my input.

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