Morning Consult: Medicare Advisory Committee Examines Benefits of Vascular Disease Intervention

Vascular disease is becoming increasingly common in America – particularly among Medicare aged individuals – however, it’s a health condition less commonly understood by patients and policymakers alike.

An estimated 18 million Americans are living with Peripheral Arterial Disease, a condition where blood flow to the extremities is restricted, resulting in pain, infection and deterioration of a limb.[i] When blood can’t reach a patient’s extremity because of poor circulation, the tissues will eventually die – with potentially lethal, systemic results. Left untreated, PAD in its worst form can lead to lower extremity amputation and even death.

Modern interventions and greater access to vascular interventions however, are helping to preserve both life and limb. Yet, while data exists to illustrate both the physical and economic benefits of increased vascular care and intervention, the nation’s largest insurer – Medicare – is still grappling with evidence and outcomes associated with the treatment of PAD and other associated vascular diseases.

Scientific evidence and outcomes were the topics of a Medicare Evidence Development & Coverage Advisory Committee meeting last month – during which experts were called upon to address what is known, and unknown, about successfully treating PAD. The meeting was a positive step toward federal regulators more fully understanding vascular disease, its patient populations, effective treatments, costs and the ramifications – both clinical and fiscal – of inaction.

Part of that discussion was how Medicare should approach important coverage decisions for millions of its beneficiaries living with PAD.

For any American who has benefitted from life and limb saving interventions, and their providers, the evidence is clear.

Data show increased access to PAD interventions, including revascularization through stenting, angioplasty and atherectomy, has resulted in a measureable decline in the total number of lower-limb amputations in the United States, despite increases in the number of patients living with PAD – up nearly 25 percent globally in ten years.[ii]By offering patients appropriate, clinically-effective peripheral vascular intervention in convenient community-based vascular centers, we have witnessed a reduction in amputations, which spare patients the emotional, physical, and even financial pain that often accompanies amputation.

Data show limb preservation benefits patients, payers and our healthcare delivery system as a whole:

  1. Saving a patient’s limb overwhelmingly preserves quality of life. Research shows that 80 percent of revascularization patients are walking again after two years, whereas up to 80 percent of amputees will never walk again. Immediately following a revascularization procedure, fewer than 20 percent of patients require discharge to a nursing home, compared to 70 percent of amputation patients who require either nursing home or inpatient rehab care.
  1. Intervention improves patient mortality rates. Overall, 2-year mortality for revascularization patients falls between 16 to 24 percent, while amputees face mortality rates of up to 50 percent. [iii]
  1. Limb preservation is good for Medicare and other insurers. Between 1996 and 2011, peripheral vascular interventions helped reduce the number of Medicare patients requiring lower extremity amputations by 45 percent.[iv] That’s a remarkable drop when you consider that major amputation is the sixth most costly surgical procedure in the United States – costing taxpayers $10.6 billion annually. Medicare alone is the highest payer of major amputations in the United States – covering 66 percent of all amputations in 2010.[v]
  1. Vascular intervention in the physician-office setting ensures patient choice, increases access and reduces delays in treatment. Vascular care in the community-based setting offers patients readily available access to treatments to alleviate their pain and halt the progression of PAD.

Despite what MEDCAC ultimately recommends to CMS, or the economic savings to the healthcare system and the American taxpayer, most of my patients would say that avoiding an amputation is immeasurably valuable. Revascularization not only helps preserve a limb, but usually restores function and relieves years of unrelenting pain.  It can help patients return to work, spend quality active time with their families, and improve their outlook on life.

And you can’t put a price on that.

[i] SAGE Group, 2010]

[ii] Fowkes, Gerald, The Lancet, “Comparison global estimates of prevalence and risk factors for peripheral artery disease in 2000 and 2010: a systematic review and analysis.” August 2013.

[iii] Yost, Mary. Cost-Benefit Analysis of Critical Limb Ischemia in the Era of the ACA, May 2014.

[iv] JAMA Surgery, Fifteen-Year Trends in Lower Limb Amputation, Revascularization, and Preventative Measures Among Medicare Patients, January 2015.

[v] Yost ML. The economic cost of dysvascular amputation. Atlanta (GA): The Sage Group. In press.

Dr. Jeffrey G. Carr is an Interventional Cardiologist and Endovascular Specialist. He is the Founding and Immediate Past President of the Outpatient Endovascular and Interventional Society, a multispecialty medical society. He is also the physician lead on the CardioVascular Coalition, a group dedicated to raising awareness for PAD and advocating for national healthcare policy and amputation prevention. Trained at UCLA Medical Center, he practices full time in a single specialty group in Tyler, Texas.


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