NEW YORK – At a time of increasing scrutiny of procedures to open blocked heart arteries, cardiologists are turning to – and reaping huge payments from – controversial techniques that relieve blockages in the arms and legs.
Unlike heart procedures, which must be done in a hospital or outpatient facility, where oversight is typically more intense, the opening of the peripheral arteries and veins of the arms and legs can be done in a doctor’s office.
Medical experts are questioning the necessity of some of these treatments, and many of them believe that the condition is more safely treated with drugs and exercise.
Nonetheless, some of the nation’s most highly reimbursed cardiologists are making millions of dollars from Medicare for performing these procedures, as payments for relieving blockages in the heart have fallen.
This month, the Justice Department said that it joined two whistleblower lawsuits accusing one of these doctors of performing unnecessary procedures, including placing a stent in the leg of a patient who died of complications. The cardiologist in question, Dr. Asad Qamar of Ocala, Fla., was paid $18 million by Medicare in 2012, making him the top-billing cardiologist in the country, according to an analysis by the New York Times of Medicare data. Qamar was also the leader in billing for procedures to treat peripheral blockages.
Nationwide, the shift in doctors’ emphasis is significant. The number of procedures to open blockages in heart vessels fell by about 30 percent from 2005 to 2013, to about 323,000 for patients covered under Medicare. Over the same time, the number of similar procedures for vessels outside the heart soared by almost 70 percent, to 853,000, according to the Advisory Board Co., an analytics and research firm that analyzed Medicare payment data.
The Times’ analysis of the 2012 billing records for the 10 top-billing cardiologists in the country showed that eight of the doctors made about half of their reimbursements from Medicare by performing procedures to ease the narrowing in an artery or vein in patients’ arms or legs. Some continue to do a high number of coronary interventions.
These types of lucrative procedures – in 2012, Medicare paid nearly $12,000 for one type of these operations – have been the focus of a turf battle among specialists.
The county’s top billers for these procedures included a handful of vascular surgeons and radiologists in addition to the cardiologists.
The doctors who perform the procedures say they that are saving Medicare money by doing them outside a hospital, that they reduce the number of more serious conditions, and that the Medicare payments are justified to cover their high expenses.
While there is considerable agreement among specialists about how and when to treat heart blockages, there is far less consensus in the treatment of blockages elsewhere.
As in the vessels of the heart, plaque can build up in peripheral arteries, restricting blood flow. One common condition in the legs, known as peripheral artery disease, can cause pain or a burning sensation and make walking difficult.
Many medical experts say that most patients can be treated with exercise, weight loss and medication, although patients with extreme cases are at risk for amputations. About 1 in 20 people older than 50 has the condition in some form.
As the number of procedures to treat these blockages has climbed sharply, the debate around their appropriateness is intensifying. The Society for Vascular Medicine, for example, warns that people typically do not need invasive treatment.
“We’re pretty conservative with how we treat peripheral artery disease,” said Dr. Darren B. Schneider, chief of vascular and endovascular surgery at NewYork-Presbyterian Hospital/Weill Cornell Medical Center. “We only perform revascularization procedures on patients with peripheral artery disease who have disabling leg pain or who are at risk of amputation, which is less than 10 percent of all the patients we see.”
Dr. Ashish Pal, a cardiologist in Davenport, Fla., who says he was one of the early heart doctors to branch out and begin treating peripheral vessels, disagrees. “These patients are grossly undertreated,” he argued. In 2012, Pal received $4.5 million from Medicare with the bulk coming from procedures done outside the heart, according to federal data.
But the spike in procedures comes after a crackdown by regulators on unnecessary heart procedures.
The Justice Department joined a whistleblower lawsuit in 2011 contending that Dr. Elie H. Korban, a cardiologist based in Jackson, Tenn., falsely billed Medicare for medically unnecessary cardiac procedures in patients.
While he continued to insert coronary stents, Korban made more than half of his $2.4 million in Medicare payments the next year from peripheral vessel procedures.
In late 2013, Korban settled with the Justice Department without admitting wrongdoing in the cardiac procedures, paying $1.15 million and entering into an agreement for enhanced monitoring.
Not that long ago, peripheral artery treatments were largely done in hospitals, which could determine who was best qualified to perform the procedures as well as regularly review outcomes.
But these days, peripheral artery treatments, which typically carry less risk than a heart procedure, are being done in doctors’ offices. That is one of the reasons that experts, including the Advisory Board Co., say they expect to see volumes continue to rise. Doctors are also performing high numbers of “ablations,” which use a laser or radio wave to close off a damaged vein.
Because the field has been viewed as something as a “stepchild,” as Pal described it, less research and fewer studies have been conducted into what treatments work best and when to intervene.
“The evidence base is not as clear,” said Brian Contos, an executive director of the Advisory Board Co., noting that only in the last year did a doctors’ professional society issue general guidelines on revascularizations done outside the heart.
Doctors have not reached agreement on what treatments should be followed, as they have over the years in coronary disease, according to Dr. Curtiss T. Stinis, a cardiologist and the director of peripheral interventions at Scripps Clinic in La Jolla, Calif.
“The guidelines are not as focused or narrow,” Stinis said.
The uncertainty surrounding when it is appropriate to do these types of peripheral procedures is likely to be one of the key issues in the case against Qamar, who heads the Institute of Cardiovascular Excellence in Ocala.
According to one of two lawsuits joined by the Justice Department, Qamar’s cardiac procedures had come under strict review by Medicare as early as 2010. By 2012, a majority of Qamar’s billings – $13 million of the total $18 million in payments he received from Medicare – came from operations to treat arteries mainly in the legs, The Times’ analysis showed.
Qamar denies accusations that he performed unnecessary procedures. In a video response posted on YouTube, Qamar called the accusations “baseless” and “fiction.” He said his clinic had the lowest amputation rates for peripheral disease in the country.
Doctors and others say it is only a matter of time before the same spotlight that has been focused on cardiac procedures starts to shine on possible unnecessary peripheral revascularizations.
“There is just a wide gray zone that is going to receive additional scrutiny,” Contos said.