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Vascular Specialist | Thursday 16 June 2022
CRAWFORD FORUM
Trust, transportation, insurance hamper ‘quality vascular surgery care for all’ In a session focusing on disparities in care, an absence of patient trust in their doctors and hospital systems yesterday morning emerged as a key talking point amid a comprehensive deep dive into some of the problems vascular surgeons tackle in their efforts to broaden access to quality vascular care. A PANEL OF EXPERTS ASSEMBLED BY SOCIETY FOR Vascular Surgery (SVS) President-elect Michael Dalsing, MD, for the E. Stanley Crawford Critical Issues Forum probed impediments to universal access across the U.S., covering workforce numbers and distribution, rural isolation, urban care deserts, access to insurance, and diversity and inclusion. A question from the audience that came after the panel had each delivered a presentation on access hurdles—posed by Mahmoud B. Malas, MD, chief of vascular and endovascular surgery at the University of California Davis—raised the specter of the trust patients place in their providers based on care received in the past. Part of the problem is transportation, Malas said, but trust, he insisted, figures greatly in the conundrum. “When we were trying to understand why a majority of African Americans were getting PTFE grafts instead of vein, even though they have good veins, or that they were getting a catheter a lot more to start their dialysis than fistulas, we didn’t really understand what was going on until we started interviewing patients,” he said. He referred to a study of all U.S. dialysis patients that he was involved in while based at Johns Hopkins Hospital that looked at racial disparities. “Every single patient said I don’t trust Hopkins, doctors, or hospitals. There is a lot of concern that they have no trust in us as doctors, hospitals and providers, because they had a historically bad outcome, and had no trust in the hospital system.” Samantha Minc, MD, who delivered a talk looking at the issues surrounding access to care in rural America, said Malas’ example was “an exact reason why mixed methods research is going to be the way for us to understand these issues related to disparities.” Community engagement and reversing lack of trust, said Andrew Gonzalez, MD, assistant professor of vascular surgery at Indiana University School of Medicine in Indianapolis, are dimensions that build through the development of long-term partnerships. He described how his mother, a pediatric hematology oncologist in the 1960s, would brave her urban setting to give out childhood vaccinations. That was realistic then as it was a practice incentivized by the county hospital. “But I think
Panelists at the Crawford Forum
most of us, if we announced to our division chief, that we had a plan to get the doppler and roll through the ’hood checking ABIs [ankle-brachial indices], we would probably be laughed out of the room.” Gonzalez, who in his talk laid out the access problem in “urban vascular care deserts,” emphasized “the need to think of multilevel, multilateral interventions—and we probably need to do this by partnering.” One of the ways in which this can be achieved, he said, is through financial incentives being aligned for both hospitals and government entities. “It is also important we have a role in being seen in the community,” he said. Minc, meanwhile, suggested that should a way be found to make transportation grant feasible “a lot of communities are going to benefit.” Her work right now, said said the assistant professor of vascular surgery at West Virginia University in Morgantown, West Virginia, is focused on community engagement. “As vascular surgeons, what a community is to us may differ a little bit.” Primary care providers (PCPs), Minc pointed out, represent a community with which to partner. “In rural areas, especially where we are, very isolated areas, these PCPs do everything. They are very independent. They multitask. They come to me and say, ‘Just show us how to do the wound care and we’ll do it.’”
SPOTLIGHT ON THURSDAY@VAM OPENING DAY IS IN THE REAR-VIEW MIRROR, with attendees enjoying a wide range of presentations. What’s on tap for Thursday? A plethora of education, exhibits and, of course, the chance for participants to get together with friends and colleagues. The day starts, for the convenience of international registrants livestreaming VAM 2022, with the International Chapter Forum, from 6:30 to 8 a.m. at the Hynes Convention Center, Room 210. Speakers will discuss a wide range of topics, including attracting medical students to the specialty, digital strategies to update vascular surgeons in Mexico, research presentations, and the Medical University of Warsaw’s report on complex endovascular treatment of 840 patients with aortic diseases. Jan S. Brunkwall, MD, PhD, vascular surgeon at the University of Cologne in Germany will present the Roy Greenberg Distinguished Lecture, “More is Less and Less is More!” from 9:30 to 10 a.m. at HCC, Ballroom A/B. An important VAM moment occurs at 10 a.m. with the opening of the VAM Exhibit Hall, at HCC, Hall C/D. Be sure to save time to stop by exhibitors’ booths, enjoy Vascular Live presentations during coffee breaks and lunch, and stop by the SVS Booth (No. 607) to update information, get answers to questions and, from 10 a.m. to 2 p.m., have professional headshots taken at no charge. Who will take home the prize? This year’s recipient of the prestigious SVS Lifetime Achievement Award will be announced at the Awards Ceremony, 10:30 to 10:45 a.m., HCC, Ballroom A/B. Learn how others tackle procedures and treatments in the always popular “How I Do It” session of video abstracts, from 1:30 to 2:30 p.m. HCC, Room 312. Six presentations are scheduled. Membership section sessions have been added to this year’s VAM. Women will meet from 1:30 to 3 p.m. and young surgeons from 3:30 to 5 p.m. for educational sessions specifically targeted to their needs, both in HCC, 210. Get tickets at registration. What’s VAM without fun? There’s plenty of the schedule for Thursday, from the Opening Reception from 5 to 6:30 p.m. in the Exhibit Hall, along with the Interactive Poster Session and the International Poster Competition PLUS a raffle; to targeted receptions for training programs and other groups.—Beth Bales
ADVOCACY SESSION MEDICARE CUTS: ‘IT IS CRUCIALLY IMPORTANT WE STAY ENGAGED IN THE PROCESS’ SOCIETY FOR VASCULAR SURGERY (SVS) members deemed payment and reimbursement among the top advocacy priorities for 2022. A session Wednesday at VAM informed attendees about Medicare payment issues and relayed information on the past, what’s going on in the present and how members can impact the future. Matthew Sideman, MD, chair of the SVS Advocacy Council, kicked off the session, hosted by the Government Relations Committee, by briefly reviewing the process of the legislative and regulatory processes. While laws are in discussion, vascular surgeons have many chances to impact what those laws look like. “It’s crucially important we stay engaged in the process.” Surgeons fought the Medicare Sustain-
able Growth Rate (SGR) for 15 years. Its replacement, the Medicare Access and CHIP Reauthorization Act (MACRA) of 2015, hasn’t provided its planned financial stability. “Many in Washington, D.C. view it as a failed policy” Current advocacy efforts are focused not only on replacing MACRA but also on shorter-term issues on important legislation, including prior authorization. Megan Tracci, MD, Advocacy Council vice chair, explained why Medicare payments are still going down. Seventeen SGR patches over 12 years cost more than $169 billion, to no good effect. SGR was then replaced by MACRA; results have been mixed and MACRA has meant vascular surgeons losing ground in every single year” since its passage.
“Our conversion factor is essentially the same as it was in 1998,” said Tracci. “Physicians have “been tightening our belt for 25 years and aren’t really the problem, she said. Medicare spending has continued to grow, but its distributions have shifted. “It’s now $787 billion, and we’re down to 9 % of that. We’re not going to save our way out of the U.S. government on healthcare.” With the funding trend unsustainable, she said, “We need to drive change.” Fixing the payment model and fixing funding must go hand-in-hand, she said. “Advocacy must be data-driven, and we have to bring our data to the table.” “We are one vascular surgery team,” emphasized Sean Lyden, MD, committee chair, who discussed recent committee efforts to impact change. “We represent all portions
of vascular surgery (in all settings) and represent everybody equally.” He stressed the necessity to donate to the SVS Political Action Committee, which currently receives donations from only 7% of SVS members. “If government doesn’t feel like we’re a big voice, they don’t care,” he said. “Government relations is about building relationships and getting in front of lawmakers. This requires money, he said. It also means continued reaching out to lawmakers and vital grassroots advocacy. Despite some legislative success, such as mitigating proposed payment cuts, battles remain on the horizon, said Lyden. These include the 2023 Medicare Physician Fee Schedule proposed rule and identifying system payment reform options.—Beth Bales
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