Society News

“CLINICAL CORRELATION OF SUCCESS AND ACUTE THROMBOTIC COMPLICATIONS OF LOWER EXTREMITY ENDOVENOUS THERMAL ABLATION.” Journal of Vascular Surgery Venous and Lymphatic Disorders, January 2018

A large single center experience with endovenous thermal ablation reveals risk factors for thrombotic complications.

Minimally invasive techniques for treating reflux disease in the saphenous system have greatly improved the quality of life and comfort of those suffering with chronic venous disease and more advanced venous insufficiency.  Painful procedures of the past, sometimes including hospital stays, have largely been replaced by safe and efficacious office procedures (lasting often less than an hour) with minimal subsequent activity restrictions.

Despite these obvious advantages, these therapies do have a very low but definite risk of thrombotic complications, including endovenous heat-induced thrombosis (EHIT) superficial venous thrombosis (SVT) and deep vein thrombosis (DVT).  EHIT includes development of a blood clot at the junction of one of the treated saphenous veins and the femoral or the popliteal vein.

While major DVT and pulmonary embolism are extremely rare, the diagnosis of EHIT may require a period of anticoagulation as well as follow-up visits and studies.  Further, acute SVT can be painful for several weeks following the procedure.  As such, further understanding the risk factors for these complications will allow therapists to better inform patients as to their specific risks for developing them.

As reported in the January 2018 edition of the Journal of Vascular Surgery: Venous and Lymphatic Disorders, researchers from Total Vascular Care and NYU Lutheran Medical Center led by Afsha Aurshina, MBBS, evaluated their large single center experience treating multiple vein types using both radiofrequency (RFA) and endovenous laser (EVLA) ablation techniques.  They retrospectively studied the outcomes of 1811 procedures performed on 808 patients from 2012-2014.  The aim of the study was to define better the success and thrombotic complications of these procedures with respect to technique and vein type.

Overall success (defined as absence of reflux in the targeted vein by post-operative duplex) rates included:

• RFA                                              98.4% (excluding perforating vein)
• EVLA                                            98.1%
• Great saphenous (GSV)                 98.5%
• Lesser saphenous (LSV)                98.2%
• Accessory saphenous (ASV)          97.2%
• Perforator (PV)                             82.4%

With regards to thrombotic complications, the authors reported EHIT rates of:

• Class 1-4                                    5.9%
• Class 2-4                                    1.16%

Acute superficial thrombosis rates included:

• Overall                                                4.6%
• RFA                                                     7.7%
• EVLA                                                  11.4% (no difference in multi-factor analysis)
• GSV                                                   11.8%
• LSV                                                     5.5%
• ASV                                                    6.5%
• PV                                                      2.4%

“Our study demonstrates that there is no significant difference in the success rate of RFA and EVLA in the treatment of venous reflux for GSV, SSV, and ASV,” notes first author Aurshina.  “We found an acceptably low incidence of clinically significant thrombotic complication rates for EHIT and acute superficial thrombosis, with only a 1.16% risk of Class 2-4 EHIT, that may require short term anticoagulation.  We noted risk factors for these complications, after multi-factor analysis, include higher vein diameter and type of vein, with the latter being the most important.”

Large experiences such as these are important to understand the true incidence of these complications and how practitioners might tailor their consent process with their patients.

To download the complete article (link available free from 12/14/2017 through 2/28/2018),

 click:  http://vsweb.org/JVSVL-EVTA
 

For information your patients may be interested in, click:

Regarding Varicose Veins:

https://vascular.org/patient-resources/vascular-conditions/varicose-veins

Regarding Deep Venous Thrombosis:

https://vascular.org/patient-resources/vascular-conditions/deep-vein-thrombosis

“CLINICAL CORRELATION OF SUCCESS AND ACUTE THROMBOTIC COMPLICATIONS OF LOWER EXTREMITY ENDOVENOUS THERMAL ABLATION.” Journal of Vascular Surgery Venous and Lymphatic Disorders, January 2018

A large single center experience with endovenous thermal ablation reveals risk factors for thrombotic complications.

Minimally invasive techniques for treating reflux disease in the saphenous system have greatly improved the quality of life and comfort of those suffering with chronic venous disease and more advanced venous insufficiency.  Painful procedures of the past, sometimes including hospital stays, have largely been replaced by safe and efficacious office procedures (lasting often less than an hour) with minimal subsequent activity restrictions.

Despite these obvious advantages, these therapies do have a very low but definite risk of thrombotic complications, including endovenous heat-induced thrombosis (EHIT) superficial venous thrombosis (SVT) and deep vein thrombosis (DVT).  EHIT includes development of a blood clot at the junction of one of the treated saphenous veins and the femoral or the popliteal vein.

While major DVT and pulmonary embolism are extremely rare, the diagnosis of EHIT may require a period of anticoagulation as well as follow-up visits and studies.  Further, acute SVT can be painful for several weeks following the procedure.  As such, further understanding the risk factors for these complications will allow therapists to better inform patients as to their specific risks for developing them.

As reported in the January 2018 edition of the Journal of Vascular Surgery: Venous and Lymphatic Disorders, researchers from Total Vascular Care and NYU Lutheran Medical Center led by Afsha Aurshina, MBBS, evaluated their large single center experience treating multiple vein types using both radiofrequency (RFA) and endovenous laser (EVLA) ablation techniques.  They retrospectively studied the outcomes of 1811 procedures performed on 808 patients from 2012-2014.  The aim of the study was to define better the success and thrombotic complications of these procedures with respect to technique and vein type.

Overall success (defined as absence of reflux in the targeted vein by post-operative duplex) rates included:

• RFA                                              98.4% (excluding perforating vein)
• EVLA                                            98.1%
• Great saphenous (GSV)                 98.5%
• Lesser saphenous (LSV)                98.2%
• Accessory saphenous (ASV)          97.2%
• Perforator (PV)                             82.4%

With regards to thrombotic complications, the authors reported EHIT rates of:

• Class 1-4                                    5.9%
• Class 2-4                                    1.16%

Acute superficial thrombosis rates included:

• Overall                                                4.6%
• RFA                                                     7.7%
• EVLA                                                  11.4% (no difference in multi-factor analysis)
• GSV                                                   11.8%
• LSV                                                     5.5%
• ASV                                                    6.5%
• PV                                                      2.4%

“Our study demonstrates that there is no significant difference in the success rate of RFA and EVLA in the treatment of venous reflux for GSV, SSV, and ASV,” notes first author Aurshina.  “We found an acceptably low incidence of clinically significant thrombotic complication rates for EHIT and acute superficial thrombosis, with only a 1.16% risk of Class 2-4 EHIT, that may require short term anticoagulation.  We noted risk factors for these complications, after multi-factor analysis, include higher vein diameter and type of vein, with the latter being the most important.”

Large experiences such as these are important to understand the true incidence of these complications and how practitioners might tailor their consent process with their patients.

To download the complete article (link available free from 12/14/2017 through 2/28/2018),

 click:  http://vsweb.org/JVSVL-EVTA
 

For information your patients may be interested in, click:

Regarding Varicose Veins:

https://vascular.org/patient-resources/vascular-conditions/varicose-veins

Regarding Deep Venous Thrombosis:

https://vascular.org/patient-resources/vascular-conditions/deep-vein-thrombosis

“CLINICAL CORRELATION OF SUCCESS AND ACUTE THROMBOTIC COMPLICATIONS OF LOWER EXTREMITY ENDOVENOUS THERMAL ABLATION.” Journal of Vascular Surgery Venous and Lymphatic Disorders, January 2018

A large single center experience with endovenous thermal ablation reveals risk factors for thrombotic complications.

Minimally invasive techniques for treating reflux disease in the saphenous system have greatly improved the quality of life and comfort of those suffering with chronic venous disease and more advanced venous insufficiency.  Painful procedures of the past, sometimes including hospital stays, have largely been replaced by safe and efficacious office procedures (lasting often less than an hour) with minimal subsequent activity restrictions.

Despite these obvious advantages, these therapies do have a very low but definite risk of thrombotic complications, including endovenous heat-induced thrombosis (EHIT) superficial venous thrombosis (SVT) and deep vein thrombosis (DVT).  EHIT includes development of a blood clot at the junction of one of the treated saphenous veins and the femoral or the popliteal vein.

While major DVT and pulmonary embolism are extremely rare, the diagnosis of EHIT may require a period of anticoagulation as well as follow-up visits and studies.  Further, acute SVT can be painful for several weeks following the procedure.  As such, further understanding the risk factors for these complications will allow therapists to better inform patients as to their specific risks for developing them.

As reported in the January 2018 edition of the Journal of Vascular Surgery: Venous and Lymphatic Disorders, researchers from Total Vascular Care and NYU Lutheran Medical Center led by Afsha Aurshina, MBBS, evaluated their large single center experience treating multiple vein types using both radiofrequency (RFA) and endovenous laser (EVLA) ablation techniques.  They retrospectively studied the outcomes of 1811 procedures performed on 808 patients from 2012-2014.  The aim of the study was to define better the success and thrombotic complications of these procedures with respect to technique and vein type.

Overall success (defined as absence of reflux in the targeted vein by post-operative duplex) rates included:

• RFA                                              98.4% (excluding perforating vein)
• EVLA                                            98.1%
• Great saphenous (GSV)                 98.5%
• Lesser saphenous (LSV)                98.2%
• Accessory saphenous (ASV)          97.2%
• Perforator (PV)                             82.4%

With regards to thrombotic complications, the authors reported EHIT rates of:

• Class 1-4                                    5.9%
• Class 2-4                                    1.16%

Acute superficial thrombosis rates included:

• Overall                                                4.6%
• RFA                                                     7.7%
• EVLA                                                  11.4% (no difference in multi-factor analysis)
• GSV                                                   11.8%
• LSV                                                     5.5%
• ASV                                                    6.5%
• PV                                                      2.4%

“Our study demonstrates that there is no significant difference in the success rate of RFA and EVLA in the treatment of venous reflux for GSV, SSV, and ASV,” notes first author Aurshina.  “We found an acceptably low incidence of clinically significant thrombotic complication rates for EHIT and acute superficial thrombosis, with only a 1.16% risk of Class 2-4 EHIT, that may require short term anticoagulation.  We noted risk factors for these complications, after multi-factor analysis, include higher vein diameter and type of vein, with the latter being the most important.”

Large experiences such as these are important to understand the true incidence of these complications and how practitioners might tailor their consent process with their patients.

To download the complete article (link available free from 12/14/2017 through 2/28/2018),

 click:  http://vsweb.org/JVSVL-EVTA
 

For information your patients may be interested in, click:

Regarding Varicose Veins:

https://vascular.org/patient-resources/vascular-conditions/varicose-veins

Regarding Deep Venous Thrombosis:

https://vascular.org/patient-resources/vascular-conditions/deep-vein-thrombosis

Registration is now open for the Vascular Research Initiatives Conference, to be held Thursday, May 9, in San Francisco. Abstracts for VRIC are due Wednesday, Jan. 10. Learn more about VRIC, and submit your abstracts here. 

Registration is now open for the Vascular Research Initiatives Conference, to be held Thursday, May 9, in San Francisco. Abstracts for VRIC are due Wednesday, Jan. 10. Learn more about VRIC, and submit your abstracts here. 

Registration is now open for the Vascular Research Initiatives Conference, to be held Thursday, May 9, in San Francisco. Abstracts for VRIC are due Wednesday, Jan. 10. Learn more about VRIC, and submit your abstracts here. 

Have you put off paying your 2018 SVS membership dues? Don’t wait too much longer! Access to the Journal of Vascular Surgery suite of publications expires on Jan. 15 for those who have not yet paid their 2018 dues. Renew today.

Have you put off paying your 2018 SVS membership dues? Don’t wait too much longer! Access to the Journal of Vascular Surgery suite of publications expires on Jan. 15 for those who have not yet paid their 2018 dues. Renew today.

Have you put off paying your 2018 SVS membership dues? Don’t wait too much longer! Access to the Journal of Vascular Surgery suite of publications expires on Jan. 15 for those who have not yet paid their 2018 dues. Renew today.

Abstracts are due Wednesday, Jan. 17, for the 2018 Vascular Annual Meeting, set for June 20-23 in Boston. Guidelines, submission policies and general information on VAM are available online. VAM plenaries are June 21-23 and exhibits are June 21-22. Registration and housing will open in early March.

Abstracts are due Wednesday, Jan. 17, for the 2018 Vascular Annual Meeting, set for June 20-23 in Boston. Guidelines, submission policies and general information on VAM are available online. VAM plenaries are June 21-23 and exhibits are June 21-22. Registration and housing will open in early March.

Abstracts are due Wednesday, Jan. 17, for the 2018 Vascular Annual Meeting, set for June 20-23 in Boston. Guidelines, submission policies and general information on VAM are available online. VAM plenaries are June 21-23 and exhibits are June 21-22. Registration and housing will open in early March.

SVS members, please encourage medical or pre-med students interested in vascular surgery to apply for scholarship to attend the 2018 Vascular Annual Meeting.

VAM will be held June 20 to 23, 2018, in Boston. (Plenaries are June 21-23 and exhibits are open June 21-22.)  The Society for Vascular Surgery offers travel awards, including complimentary VAM registration, to be used toward the cost of travel, housing and meals.

Two awards are available, the General Surgery Resident/Medical Student Travel Scholarship and the Diversity Medical Student Travel Scholarship. Recipients become part of the hugely popular scholarship program, designed to let residents and students explore their interest in vascular surgery.

The SVS Foundation seeks applicants for its Student Research Fellowship awards, designed to stimulate laboratory and clinical vascular research by undergraduate college students and medical students attending universities in the United States and Canada.

Urge students you know with an interest in research to apply today.

SVS members, please encourage medical or pre-med students interested in vascular surgery to apply for scholarship to attend the 2018 Vascular Annual Meeting.

VAM will be held June 20 to 23, 2018, in Boston. (Plenaries are June 21-23 and exhibits are open June 21-22.)  The Society for Vascular Surgery offers travel awards, including complimentary VAM registration, to be used toward the cost of travel, housing and meals.

Two awards are available, the General Surgery Resident/Medical Student Travel Scholarship and the Diversity Medical Student Travel Scholarship. Recipients become part of the hugely popular scholarship program, designed to let residents and students explore their interest in vascular surgery.

The SVS Foundation seeks applicants for its Student Research Fellowship awards, designed to stimulate laboratory and clinical vascular research by undergraduate college students and medical students attending universities in the United States and Canada.

Urge students you know with an interest in research to apply today.

SVS members, please encourage medical or pre-med students interested in vascular surgery to apply for scholarship to attend the 2018 Vascular Annual Meeting.

VAM will be held June 20 to 23, 2018, in Boston. (Plenaries are June 21-23 and exhibits are open June 21-22.)  The Society for Vascular Surgery offers travel awards, including complimentary VAM registration, to be used toward the cost of travel, housing and meals.

Two awards are available, the General Surgery Resident/Medical Student Travel Scholarship and the Diversity Medical Student Travel Scholarship. Recipients become part of the hugely popular scholarship program, designed to let residents and students explore their interest in vascular surgery.

The SVS Foundation seeks applicants for its Student Research Fellowship awards, designed to stimulate laboratory and clinical vascular research by undergraduate college students and medical students attending universities in the United States and Canada.

Urge students you know with an interest in research to apply today.

Make a tribute gift to honor someone whose life has been touched by GI research or celebrate a special occasion such as a birthday while supporting the AGA Research Awards Program through the AGA Research Foundation. A tribute gift will make your loved one feel special because it honors their passion, and also provides us with needed support in furthering basic digestive disease research.

•  Giving a gift to the AGA Research Foundation in memory of a loved one. A memorial gift is a meaningful way to celebrate the legacy of a family member, friend, or colleague.
•  Telling your friends and family members to donate to the AGA Research Foundation in YOUR honor.

Your next step

An honorary gift is a wonderful way to acknowledge someone’s vision for the future. To learn more about ways to recognize your honoree, visit our website at www.gastro.org/contribute or contact Harmony Excellent at 301-272-1602 or [email protected].

[email protected]

Make a tribute gift to honor someone whose life has been touched by GI research or celebrate a special occasion such as a birthday while supporting the AGA Research Awards Program through the AGA Research Foundation. A tribute gift will make your loved one feel special because it honors their passion, and also provides us with needed support in furthering basic digestive disease research.

•  Giving a gift to the AGA Research Foundation in memory of a loved one. A memorial gift is a meaningful way to celebrate the legacy of a family member, friend, or colleague.
•  Telling your friends and family members to donate to the AGA Research Foundation in YOUR honor.

Your next step

An honorary gift is a wonderful way to acknowledge someone’s vision for the future. To learn more about ways to recognize your honoree, visit our website at www.gastro.org/contribute or contact Harmony Excellent at 301-272-1602 or [email protected].

[email protected]

Make a tribute gift to honor someone whose life has been touched by GI research or celebrate a special occasion such as a birthday while supporting the AGA Research Awards Program through the AGA Research Foundation. A tribute gift will make your loved one feel special because it honors their passion, and also provides us with needed support in furthering basic digestive disease research.

•  Giving a gift to the AGA Research Foundation in memory of a loved one. A memorial gift is a meaningful way to celebrate the legacy of a family member, friend, or colleague.
•  Telling your friends and family members to donate to the AGA Research Foundation in YOUR honor.

Your next step

An honorary gift is a wonderful way to acknowledge someone’s vision for the future. To learn more about ways to recognize your honoree, visit our website at www.gastro.org/contribute or contact Harmony Excellent at 301-272-1602 or [email protected].

[email protected]

Beginning in February 2018, The New Gastroenterologist (TNG) – a supplement to GI & Hepatology News that addresses issues pertinent to trainees and early-career GIs – will switch to a primarily digital format. We are excited about this change and confident that it will allow for a more effective and widespread dissemination of content that is valuable to both AGA members and our readership more broadly.

AGA Institute

[email protected]

Beginning in February 2018, The New Gastroenterologist (TNG) – a supplement to GI & Hepatology News that addresses issues pertinent to trainees and early-career GIs – will switch to a primarily digital format. We are excited about this change and confident that it will allow for a more effective and widespread dissemination of content that is valuable to both AGA members and our readership more broadly.

AGA Institute

[email protected]

Beginning in February 2018, The New Gastroenterologist (TNG) – a supplement to GI & Hepatology News that addresses issues pertinent to trainees and early-career GIs – will switch to a primarily digital format. We are excited about this change and confident that it will allow for a more effective and widespread dissemination of content that is valuable to both AGA members and our readership more broadly.

AGA Institute

[email protected]

Research done? Submit it as an abstract for the 2018 Vascular Annual Meeting, set for June 20-23, 2018, in Boston. Plenaries are June 21-23 and exhibits are June 21-22.

The submission site opened Monday. The deadline for submitting abstracts is Wednesday, Jan. 17, 2018.

Abstracts may be submitted in the following categories:

• Plenary
• Vascular and Endovascular Surgical Society
• International Forum
• International Fast Talk
• Poster Competition
• Interactive Poster

Guidelines, submission policies and general information on VAM are available online.

Research done? Submit it as an abstract for the 2018 Vascular Annual Meeting, set for June 20-23, 2018, in Boston. Plenaries are June 21-23 and exhibits are June 21-22.

The submission site opened Monday. The deadline for submitting abstracts is Wednesday, Jan. 17, 2018.

Abstracts may be submitted in the following categories:

• Plenary
• Vascular and Endovascular Surgical Society
• International Forum
• International Fast Talk
• Poster Competition
• Interactive Poster

Guidelines, submission policies and general information on VAM are available online.

Research done? Submit it as an abstract for the 2018 Vascular Annual Meeting, set for June 20-23, 2018, in Boston. Plenaries are June 21-23 and exhibits are June 21-22.

The submission site opened Monday. The deadline for submitting abstracts is Wednesday, Jan. 17, 2018.

Abstracts may be submitted in the following categories:

• Plenary
• Vascular and Endovascular Surgical Society
• International Forum
• International Fast Talk
• Poster Competition
• Interactive Poster

Guidelines, submission policies and general information on VAM are available online.

Original Research

Pharmacotherapy for Non-Cystic Fibrosis Bronchiectasis: Results From an NTM Info and Research Patient Survey and the Bronchiectasis and NTM Research Registry.

By Dr. E. Henkle, et al.

Commentary

Crotalaria (Monocrotaline) Pulmonary Hypertension: The Fiftieth Anniversary.

By Dr. J. Kay.

Original Research

Pharmacotherapy for Non-Cystic Fibrosis Bronchiectasis: Results From an NTM Info and Research Patient Survey and the Bronchiectasis and NTM Research Registry.

By Dr. E. Henkle, et al.

Commentary

Crotalaria (Monocrotaline) Pulmonary Hypertension: The Fiftieth Anniversary.

By Dr. J. Kay.

Original Research

Pharmacotherapy for Non-Cystic Fibrosis Bronchiectasis: Results From an NTM Info and Research Patient Survey and the Bronchiectasis and NTM Research Registry.

By Dr. E. Henkle, et al.

Commentary

Crotalaria (Monocrotaline) Pulmonary Hypertension: The Fiftieth Anniversary.

By Dr. J. Kay.

In mid-September, NAMDRC, along with the American Thoracic Society, the American Association for Respiratory Care, the COPD Foundation, the American Lung Association, and others met to discuss the components of a legislative agenda for the coming years. The primary purpose behind the meeting was the premise that IF the current Republican majority would shift in either the House or Senate after the 2018 election, the community should be prepared to move an already agreed upon legislative agenda. CHEST was involved in the preliminary discussions, as well as follow-up, but was not in attendance at the meeting due to a scheduling conflict. There was also tacit agreement that as these policies are fleshed out and crafted into specific legislative language, the community would re-evaluate the current political climate to determine the value of pushing an agreed upon agenda prior to the 2018 elections.

Various patient groups were also invited to participate, but scheduling conflicts precluded some societies from participating but signaled their desire to work with the broad pulmonary medicine community to pursue common goals.

Each society brought its legislative priorities to the table, and there was active discussion on issues ranging from funding for NIH/NHLBI, to CDC and its COPD Action Plan, to a range of Medicare-related issues.

NAMDRC brought three specific Medicare coverage and payment issues to the discussion: home mechanical ventilation, payment for high flow oxygen therapy, and site of service/Section 603 issues.

Home mechanical ventilation is admittedly a complex issue, but it is moving forward in at least two political directions. First, Senator Bill Cassidy (R-LA) and a physician by training, has signaled his desire to move this issue forward, either legislatively or giving CMS one last chance to move forward through the regulatory structure. He agrees that a payment system that inhibits access to appropriate bi-level mechanical ventilators and encourages access to more complex life-sustaining ventilators, regardless of documented medical need, is appropriate. While CMS does have the authority to act, it has chosen to ignore repeated requests for action over the past 4 years.

Ironically, the House Energy and Commerce Committee, which shares jurisdiction on the House of Representatives with the Ways and Means Committee on Medicare issues, has sent a request to the Congressional Budget Office to provide a cost estimate (a “score” in Washington vernacular) of likely savings from a legislative solution to this matter. In the current political climate, a legislative proposal that actually saves $$$ is politically attractive, and we are working both the regulatory and legislative pathway to seek a workable solution.

On the oxygen therapy issue, there is growing evidence that, for a small group of Medicare beneficiaries who need high flow oxygen therapy as their disease progresses (pulmonary fibrosis, end-stage COPD, etc), there are no oxygen systems readily available to meet that need outside the home. At home, numerous concentrators can meet that need, but outside the home, the ideal solution, liquid systems, is not readily available because of the payment system tied to competitive bidding. CMS payment data indicate that a very low percentage of oxygen users need more than 4 liters per minute, and current law would make a payment adjustment unique to certain patients a very difficult hurdle, particularly in the era of competitive bidding, a legislative change is the best solution facing the community. The challenge is to craft legislative language that addresses the need but would preclude abuse by suppliers who might jump at the chance for higher payment for liquid, well above current payment levels. And because liquid systems fit into a “delivery model” business plan, contrary to portable oxygen concentrators and transfill systems, the solution is not as easy as a payment bump to make provision of liquid systems more attractive.

Site of service regulations are hitting pulmonary rehabilitation particularly hard, and CMS concedes that the only solution is a legislative one. Under current policy, a pulmonary rehab program that is located off campus but needs to expand or move from its current location (losing a lease, for example), if the expanded program is NOT within 250 yards of the main hospital campus, the program is then reimbursed at the physician fee schedule rate, a rate cut of approximately 50%. Needless to say, hospitals are not pursuing that approach. Likewise, a hospital that chooses to open a NEW program is also constrained, needing to locate within 250 yards of the main campus or face the dramatic cut in payment.

As these issues evolve and the political climate perhaps opens unique opportunities, we can expect the broad pulmonary community to pursue these and other issues.

In mid-September, NAMDRC, along with the American Thoracic Society, the American Association for Respiratory Care, the COPD Foundation, the American Lung Association, and others met to discuss the components of a legislative agenda for the coming years. The primary purpose behind the meeting was the premise that IF the current Republican majority would shift in either the House or Senate after the 2018 election, the community should be prepared to move an already agreed upon legislative agenda. CHEST was involved in the preliminary discussions, as well as follow-up, but was not in attendance at the meeting due to a scheduling conflict. There was also tacit agreement that as these policies are fleshed out and crafted into specific legislative language, the community would re-evaluate the current political climate to determine the value of pushing an agreed upon agenda prior to the 2018 elections.

Various patient groups were also invited to participate, but scheduling conflicts precluded some societies from participating but signaled their desire to work with the broad pulmonary medicine community to pursue common goals.

Each society brought its legislative priorities to the table, and there was active discussion on issues ranging from funding for NIH/NHLBI, to CDC and its COPD Action Plan, to a range of Medicare-related issues.

NAMDRC brought three specific Medicare coverage and payment issues to the discussion: home mechanical ventilation, payment for high flow oxygen therapy, and site of service/Section 603 issues.

Home mechanical ventilation is admittedly a complex issue, but it is moving forward in at least two political directions. First, Senator Bill Cassidy (R-LA) and a physician by training, has signaled his desire to move this issue forward, either legislatively or giving CMS one last chance to move forward through the regulatory structure. He agrees that a payment system that inhibits access to appropriate bi-level mechanical ventilators and encourages access to more complex life-sustaining ventilators, regardless of documented medical need, is appropriate. While CMS does have the authority to act, it has chosen to ignore repeated requests for action over the past 4 years.

Ironically, the House Energy and Commerce Committee, which shares jurisdiction on the House of Representatives with the Ways and Means Committee on Medicare issues, has sent a request to the Congressional Budget Office to provide a cost estimate (a “score” in Washington vernacular) of likely savings from a legislative solution to this matter. In the current political climate, a legislative proposal that actually saves $$$ is politically attractive, and we are working both the regulatory and legislative pathway to seek a workable solution.

On the oxygen therapy issue, there is growing evidence that, for a small group of Medicare beneficiaries who need high flow oxygen therapy as their disease progresses (pulmonary fibrosis, end-stage COPD, etc), there are no oxygen systems readily available to meet that need outside the home. At home, numerous concentrators can meet that need, but outside the home, the ideal solution, liquid systems, is not readily available because of the payment system tied to competitive bidding. CMS payment data indicate that a very low percentage of oxygen users need more than 4 liters per minute, and current law would make a payment adjustment unique to certain patients a very difficult hurdle, particularly in the era of competitive bidding, a legislative change is the best solution facing the community. The challenge is to craft legislative language that addresses the need but would preclude abuse by suppliers who might jump at the chance for higher payment for liquid, well above current payment levels. And because liquid systems fit into a “delivery model” business plan, contrary to portable oxygen concentrators and transfill systems, the solution is not as easy as a payment bump to make provision of liquid systems more attractive.

Site of service regulations are hitting pulmonary rehabilitation particularly hard, and CMS concedes that the only solution is a legislative one. Under current policy, a pulmonary rehab program that is located off campus but needs to expand or move from its current location (losing a lease, for example), if the expanded program is NOT within 250 yards of the main hospital campus, the program is then reimbursed at the physician fee schedule rate, a rate cut of approximately 50%. Needless to say, hospitals are not pursuing that approach. Likewise, a hospital that chooses to open a NEW program is also constrained, needing to locate within 250 yards of the main campus or face the dramatic cut in payment.

As these issues evolve and the political climate perhaps opens unique opportunities, we can expect the broad pulmonary community to pursue these and other issues.

In mid-September, NAMDRC, along with the American Thoracic Society, the American Association for Respiratory Care, the COPD Foundation, the American Lung Association, and others met to discuss the components of a legislative agenda for the coming years. The primary purpose behind the meeting was the premise that IF the current Republican majority would shift in either the House or Senate after the 2018 election, the community should be prepared to move an already agreed upon legislative agenda. CHEST was involved in the preliminary discussions, as well as follow-up, but was not in attendance at the meeting due to a scheduling conflict. There was also tacit agreement that as these policies are fleshed out and crafted into specific legislative language, the community would re-evaluate the current political climate to determine the value of pushing an agreed upon agenda prior to the 2018 elections.

Various patient groups were also invited to participate, but scheduling conflicts precluded some societies from participating but signaled their desire to work with the broad pulmonary medicine community to pursue common goals.

Each society brought its legislative priorities to the table, and there was active discussion on issues ranging from funding for NIH/NHLBI, to CDC and its COPD Action Plan, to a range of Medicare-related issues.

NAMDRC brought three specific Medicare coverage and payment issues to the discussion: home mechanical ventilation, payment for high flow oxygen therapy, and site of service/Section 603 issues.

Home mechanical ventilation is admittedly a complex issue, but it is moving forward in at least two political directions. First, Senator Bill Cassidy (R-LA) and a physician by training, has signaled his desire to move this issue forward, either legislatively or giving CMS one last chance to move forward through the regulatory structure. He agrees that a payment system that inhibits access to appropriate bi-level mechanical ventilators and encourages access to more complex life-sustaining ventilators, regardless of documented medical need, is appropriate. While CMS does have the authority to act, it has chosen to ignore repeated requests for action over the past 4 years.

Ironically, the House Energy and Commerce Committee, which shares jurisdiction on the House of Representatives with the Ways and Means Committee on Medicare issues, has sent a request to the Congressional Budget Office to provide a cost estimate (a “score” in Washington vernacular) of likely savings from a legislative solution to this matter. In the current political climate, a legislative proposal that actually saves $$$ is politically attractive, and we are working both the regulatory and legislative pathway to seek a workable solution.

On the oxygen therapy issue, there is growing evidence that, for a small group of Medicare beneficiaries who need high flow oxygen therapy as their disease progresses (pulmonary fibrosis, end-stage COPD, etc), there are no oxygen systems readily available to meet that need outside the home. At home, numerous concentrators can meet that need, but outside the home, the ideal solution, liquid systems, is not readily available because of the payment system tied to competitive bidding. CMS payment data indicate that a very low percentage of oxygen users need more than 4 liters per minute, and current law would make a payment adjustment unique to certain patients a very difficult hurdle, particularly in the era of competitive bidding, a legislative change is the best solution facing the community. The challenge is to craft legislative language that addresses the need but would preclude abuse by suppliers who might jump at the chance for higher payment for liquid, well above current payment levels. And because liquid systems fit into a “delivery model” business plan, contrary to portable oxygen concentrators and transfill systems, the solution is not as easy as a payment bump to make provision of liquid systems more attractive.

Site of service regulations are hitting pulmonary rehabilitation particularly hard, and CMS concedes that the only solution is a legislative one. Under current policy, a pulmonary rehab program that is located off campus but needs to expand or move from its current location (losing a lease, for example), if the expanded program is NOT within 250 yards of the main hospital campus, the program is then reimbursed at the physician fee schedule rate, a rate cut of approximately 50%. Needless to say, hospitals are not pursuing that approach. Likewise, a hospital that chooses to open a NEW program is also constrained, needing to locate within 250 yards of the main campus or face the dramatic cut in payment.

As these issues evolve and the political climate perhaps opens unique opportunities, we can expect the broad pulmonary community to pursue these and other issues.