Issuu

INSIDE Medtronic acquiring Covidien for $43B

Merz adds facial options with Ulthera buy 12 CASE STUDY: Lower extremity edema 20

AUGUST/SEPTEMBER 2014 Vol. 7 No. 5

Take the bacterial ride to the lobby 22

VEINTHERAPYNEWS.COM

AGENTS OF CHANGE

Vein Experts use low cost foam sclerotherapy technique to treat patients in Haiti By Larry Storer

By Deborah Manjoney, MD, FACS, RPVI

Ron and Peggy Bush have returned from a June mission trip to Haiti, now officially the poorest place on earth, where they taught local health care providers how to effectively treat patients with venous disease for as little as $5 per patient and still obtain results comparable to conventional treatment at a much higher cost in the United States. Ronald Bush, MD, FACS, and his wife, Peggy, APN, have been going to Haiti since 2007, working with various organizations including United Methodist Missions, Friends of the Children of Haiti and Life’s Path, which also supports a school in Cyvadier, Haiti. “Our goal at this time is to provide treatment

Dr. Joseph Leon Paul, a Haitian orthopedic surgeon, and Dr. Ron Bush provide venous surgery at Complexe Medico-Chirurigal Rose.

Jacmel patient with saphenous insufficiency and multiple varicosities left leg.

‘Cost controls’ breaking backs of practitioners

not only for patients with venous disease, but to educate health providers in Haiti on how to effectively treat venous disease for as little as $5 per patient,” Dr. Bush said. Peggy Bush said that they also plan to provide this same low-cost treatment to patients in Florida who do not have insurance and have limited ability to pay. “They deserve care as well

and cannot afford a thermal ablation.” By making venous treatment available to even the poorest patients in Haiti, Dr. and Mrs. Bush have created a huge shift in terms of patients they can help and the cost of helping. The poverty and destruction from the 2010 catastrophe

The media and government agencies keep announcing that medical costs need to be controlled, but they fail to recognize that much of the cost escalation is from government regulations that are being forced on physicians and hospitals. In addition, delays in implementation of regulations, while giving a reprieve when the timelines have been unreasonable, continue to strain every aspect of the healthcare industry. These governmental mandates are, without doubt, some of the main reasons why so many physicians are allowing their practices to be purchased by hospital systems or larger healthcare organizations. Implementation of the rules requires too much money, too much time and too little reason to continue in private practice. Staying independent means that the physician must absorb the costs within the practice. Do any of these rules lead to better patient care? Will physicians ever revolt? Because many phlebology practices are single physician or small group oriented, it is appropriate to reflect on the demands being made by governmental agencies.

MEANINGFUL USE

In 2009, The American Recovery and Reinvestment Act amended portions of the Social Security Act to “authorize incentive

AGENTS OF CHANGE

COST CONTROLS

continued on page 24

continued on page 16

Nov. 6-9 in Phoenix • ACP Program News • ACP Update • VTN Directory

Page 9 Pages 10-11 Page 28

VEIN THERAPY NEWS 13552 Highway 183 N, Suite A, Austin, Texas 78750 CHANGE SERVICE REQUESTED

PRSRT STD US POSTAGE PAID SAN ANTONIO, TX PERMIT#244

Every day a step further Every day a step further Every day a step further

Give your legs Give legs they deserve theyour attention Give your legs the attention they deserve with measured compression for the... attention they deserve ... with measured compression for better health, great looks, ... with measured compression for better health, great looks, and more strength. better health, great looks, and more strength. and more strength.

SIGVAR IS SIGVAR IS Graduated Compression SIGVAR IS Graduated Compression She’s wearing SOFT OPAQUE Pantyhose She’s wearing Compression Level SOFT She’s OPAQUE Pantyhose 20–30mmHg wearing Compression Level SOFT OPAQUE Pantyhose 20–30mmHg Compression Level 20–30mmHg

He’s wearing MIDTOWN He’s wearing MICROFIBER Socks MIDTOWN Compression Level He’s wearing MICROFIBER Socks 20–30mmHg MIDTOWN Compression Level MICROFIBER Socks 20–30mmHg Compression Level 20–30mmHg

Socks and Hosiery Graduated Compression Socks and Hosiery Socks and Hosiery

■ S I G VA R I S M E D I C A L ■ S I G VA R I S W E L L B E I N G ■ S IG VARIS SPO RTS ■ S I G VA R I S M E D I C A L ■ S I G VA R I S W EFor L L B E Iinformation, N G ■ S IG VARIS SPO RTS visit sigvarisusa.com ■ S I G VA R I S M E D I C A L ■ S I G VA R I S W E L L more B E I N G ■ please S IG VARIS SPO RTS SIGVARIS is a registered trademark of SIGVARIS AG, CH-9014 St.Gallen/Switzerland, in many countries worldwide. © Copyright 2014 SIGVARIS, Inc. SIGVARIS is a registered trademark of SIGVARIS AG, CH-9014 St.Gallen/Switzerland, in many countries worldwide. © Copyright 2014 SIGVARIS, Inc.

For more information, please visit sigvarisusa.com For more information, please visit sigvarisusa.com

VeinTherapyNewsAd0714_FullPageSize.indd 1

7/14/14 2:29 PM

VeinTherapyNewsAd0714_FullPageSize.indd 1

7/14/14 2:29 PM

9 PM

Disclaimer and Liability Statement The information contained in this publication, including text, graphics and images, is for informational purposes only, and is not intended to be a substitute for professional medical advice. Publications & Communications LP (PCI), Publications and Communications LP, and Vein Therapy News, via its Editors, Publisher, Editorial Board members, or staff, accept no responsibility for any injury or damage to persons or property occasioned through the implementation of any ideas or use of any product described herein. In consideration that great care is taken by the Publisher, Editors, staff, and Editorial Board to ensure all information is accurate, we recommend each reader seek independent verification of all product or drug usage, surgical techniques and clinical processes prior to their use or implementation. The opinions expressed in this publication and all related marketing or sales material of this publication are those of the authors and are not attributable to the publication, Publisher, Editor, staff, Editorial Board, advertisers, or sponsors. References made in articles may indicate uses of medical equipment or medical procedures, or of drugs at dosages, for periods of time, and in combinations not included in the current prescribing information. Inclusion of advertising material in this publication, or in reproduction of articles and pages, or in supplemental materials, does not constitute any representation or guarantee by Publications & Communications LP (PCI), Publications and Communications LP, and Vein Therapy News, via its Editors, Publisher, Editorial Board members, or staff, of the quality of such products, or of the claims made by the manufacturers. Trademarks are used in an editorial fashion with no intent to infringe. Reproduction in whole or in part of this publication is strictly prohibited.

Reader Services SUBSCRIPTIONS To subscribe or to purchase back issues of the magazine, please call 800-678-9724 ext. 344 or e-mail Beth Chorba at bethc@pcinews.com. For more information, please visit www.veintherapynews.com and click on the Subscribe link. ADVERTISING INFORMATION If you are interested in advertising in Vein Therapy News magazine, online or in our Marketplace, please contact one of our account executives: Gary Pittman, Jr., 512-637-0373, garypjr@pcinews.com, or Dennis Carter, 512-637-0371, dennisc@pcinews.com. EDITORIAL SUBMISSIONS Doctors, nurses, clinics, managers, vendors, patients, professors and others are encouraged to submit abstracts, white papers, writings, and ideas for editorial consideration. If you have a paper or story idea to submit, please e-mail larrys@pcinews.com UPCOMING EVENTS AND PRESS RELEASES Vein Therapy News would like to hear about your organization’s upcoming event, product launch, or announcement. Please e-mail press releases or event listings at least two months in advance to larrys@pcinews.com

Volume 7, Number 5

Editor

NEWS 4

The American Venous Forum has set Sept. 8 as the deadline for abstract submissions for its 27th Annual Meeting Feb. 25-27, 2015, in Palm Springs, Calif. But before then, the AVF is promoting World Thrombosis Day, Oct. 18, with its National Venous Screening Program kit.

Larry Storer larrys@pcinews.com 254-399-6484

Art Director Robin Remaley robinr@pcinews.com

Advertising Executives Gary Pittman, Jr. 512-637-0373 garypjr@pcinews.com Dennis Carter 512-637-0371 dennisc@pcinews.com

President Gary L. Pittman garyp@pcinews.com Publications & Communications, LP 13552 Highway 183 N, Suite A Austin, TX 78750 512-250-9023 • 512-331-3950 fax Vein Therapy News is published bimonthly by Publications & Communications, LP, Gary L. Pittman, President, 13552 Highway 183 N., Suite A, Austin, TX 78750 512-250-9023. Subscriptions are available for $45 per year. Payment must accompany orders. Copyright 2014 by Publications & Communications, LP. All rights reserved. Reproduction in any form without written consent from the publisher is strictly prohibited. Postmaster: Send changes to Vein Therapy News Circulation Department, 13552 Highway 183 N., Suite A, Austin, TX 78750. ADVERTISING

512-637-0373

CIRCULATION

512-637-0344

EDITORIAL

254-399-6484

VEIN THERAPY NEWS ✜ AUGUST/SEPTEMBER 2014

The 4th Annual National Venous Interventional Summit (VEINS) for cardiologists of all specialties will be Oct. 9-12 in Chicago. The summit provides comprehensive “how to” education for the treatment of patients with venous disease for developing skills and possibly developing their own venous international program.

10 Notes from the program chair

Sandra Spruiell, DO, FACPh, RPVI and program chair for the America College of Phlebology 28th Annual Congress Nov. 6-9 in Phoenix, details the program of the upcoming Congress. The overall approach will be to allow as much interaction with faculty as possible so that attendees can leave with the tools they need to personally improve the quality of care in their own practices.

Beth Chorba bethc@pcinews.com Joel Nosal joeln@pcinews.com

VEINS group meets Oct. 9-12

ACP UPDATE

Accounting

Web and Network Manager

AVF abstracts due Sept. 8

THE PRACTICE 1

The cost of ‘cost controls’

Congress and the media are constantly screaming about the rising cost of healthcare. In this no-nonsense article, the actual cost of medical “cost controls” is laid at the feet of forced government regulations, delays in implementations and unreasonable timelines. Implementing the rules requires too much money, too much time and too little reason to continue in private practice. Staying independent means the physician must absorb the costs within the practice.

18 Business Side of Medicine

The case for hiring a physician liaison is a way of insuring a regular stream of referrals from other doctors. In this first part of a series, the principles are established. The next article will detail the execution of the principles; and the final article will offer the proof: comparative numbers of five practices in 2011 and 2012 when they did not use a physician’s liaison to 2013 when they did.

SECOND LOOK 22 This isn’t ‘rocket science’

Good doctoring is not rocket science. But it is also not digital. It is not on a white screen. It is not numbers from a pulmonary artery. And it does not come quickly. It requires seeing patients alongside mentors over years.

DEPARTMENTS Product News VTN ACP Directory

26 28

NEWS AVF 2015 sets abstract due dates by Sept. 8 The American Venous Forum (AVF) will hold its 27th Annual Meeting Feb. 25-27, 2015, in Palm Springs, Calif. Abstract submission is open through Sept. 8, 2014. To submit an abstract, see details at www.veinforum.org/medicaland-allied-health-professionals/avf-annualmeetings/2015-annual-meeting-palm-springsca/call-for-abstracts. Abstracts must be submitted under one of the following categories: Anti-Coagulation, Basic Science, Chronic Vein Obstruction, Compression/Wound Care, Diagnostic Testing and Imaging, Lymphedema, Superficial Vein Disease or Venous Thromboembolism/IVC Filters. Fedor Lurie, MD, who specializes in vascular and thoracic surgery with an office in Hawaii, will deliver the presidential address. A highlight of the conference is the presentation of the 2015 BSN-Jobst Research Grant, which has been increased to a $100,000, twoyear grant. The BSN-JOBST Research Grant is intended as seed money for research in clinical or basic sciences in the field of venous and lymphatic disorders and is intended for residents, fellows, and young faculty of less than five years from the end of their vascular training. The grant is designed to provide a foundation of research to build on future work and grants for mentored and independent research. The Servier Traveling Fellowship will provide two fellows/residents an opportunity to travel to the AVF 27th Annual Meeting and then to the European Venous Forum in June of 2015 to present their research. The award is open to fellows and residents in a vascular training program in the continental United States. Applicants must submit an abstract on the AVF submission site and indicate their interest in being considered for the award.

VTN

READ MORE: www.veinforum. org

AVVI garners Colorado honor American Vein & Vascular Institute (AVVI), a network of vein diagnosis and treatment centers in Colorado and Texas, was selected as a 2014 Colorado Companies to Watch winner. Winners were announced June 20 at the Colorado Companies to Watch Gala held at the Marriott City Center in downtown Denver. “We are honored to receive such select and prestigious recognition,” says AVVI CEO Erin Gibbs. “Our team is an incredible, patientcentric and over-achieving group of healthcare professionals and support staff. Without the

additional dedication and support from our business and banking partners, and our great relationships with industry vendors, this award would not be possible.” The 50 Honorees, chosen from approximately 1,200 nominees, are second-stage companies that are developing valuable products and services, creating quality jobs, enriching communities and creating new industries throughout the state. Winning companies met criteria that included moving beyond the start-up phase, being privately held, and facing issues of growth, not survival. Gibbs and her husband, Chief Medical Executive Gordon Gibbs, MD, co-founded AVVI (then known as Rocky Mountain Vein Institute) in 2009 in Pueblo, and subsequently opened facilities in Parker, Cañon City and Vail. Expanding in 2012 into Arlington, Texas, was pivotal for the company, which began with three employees and now employs almost 50. In the past year and a half, AVVI has become the largest network of vein and vascular centers in Colorado, and is focusing on further expansion, including the fall opening of a new clinic in Colorado Springs. VTN READ MORE: www.avviusa.com

VEINS meeting convenes Oct. 9 The 4th Annual National Venous Interventional Summit (VEINS) will be Oct. 9-12 in Chicago at the Swissotel. This conference is the national venous meeting for cardiologists of all specialties, providing comprehensive education for the treatment of patients with venous disease. The VEINS is an established venous endovascular interventional strategies group comprised of experts whose primary aim is to provide a “how to” meeting for cardiologists and other healthcare providers who are interested in advancing their knowledge and skills in venous interventions and whose ultimate goal is developing their own comprehensive venous interventional program. Spokesmen say VEINS 2014 will feature cutting-edge and future strategies for venous treatment and several fast-paced didactic lectures given by a multidisciplinary group of physicians who are experienced in developing venous programs. Sessions will highlight real-world experience and allow several opportunities for attendee and faculty to interact. Additional highlights include hands-on breakout sessions, industry symposia, and case reviews. Topics at this year’s meeting include: VEINS 101; New Trials and Continued Controversies; Superficial Venous Disease, Medical Therapy, and Wound Management; Medical Therapy; Deep Venous Disease and Device Therapy; Acute Deep Vein Thrombosis; Endovascular Treatment of Iliofemoral Chronic Post

Thrombotic Venous Flow Obstruction; Contemporary Management of Pulmonary Embolism; Venous Chronic Total Occlusions; Inferior Vena Cava Filters; and Vascular Potpourri – Case-Based Session. Course directors include Raghu Kolluri, MD, FSVM, FSCAI of OhioHealth and Riverside Methodist Hospital in Columbus, Ohio; and Gregory Mishkel, MD, FSVM, FSCAI of Prairie Cardiovascular Consultants Ltd. in Springfield, Ill. VTN To register, email jromero@crf.org

AVF joins ISTH, others supporting World Thrombosis Day eﬀort Oct. 18 World Thrombosis Day, Oct. 18, is an initiative to bring together thrombosis-related organizations from every continent to foster public and professional educational activities to heighten awareness, spark action, and ultimately save lives. The primary goal of the Screening Program matches that of World Thrombosis Day – to create a heightened level of national awareness about venous problems. The AVF believes that venous disease must become a national healthcare priority. In this cooperative partnership of more than 100 thrombosis and cardiovascular societies, the objective is promoting awareness of this day because there is little public awareness of thrombosis as the common underlying mechanism of the three leading causes of cardiovascular death: heart attack, stroke and venous thromboembolism (VTE). Evidence suggests that in many locales, healthcare professionals may not be doing all they should to correctly diagnose it, prevent it and appropriately treat patients. The American Venous Forum (AVF), which has pledged support of World Thrombosis Day, will provide information about all forms of thrombosis and over time address all thrombotic disorders, but efforts for this first year will focus initially on venous thromboembolism (VTE), one of the most common and potentially deadly, yet under-appreciated, thrombotic events. The AVF’s National Venous Screening Program is a tool for spreading awareness of venous health issues to the public. The Screening Program was designed to promote a nationwide focus on venous disorders such as varicose veins, chronic venous insufficiency and venous thromboembolism. A Comprehensive Venous Screening Kit for conducting free public screenings locally is available for purchase at the AVR website. The screening program uses simple, non-invasive ultrasound techniques and a risk assessment tool to evaluate for venous disease.

The screening process for participants consists of four simple steps: completion of a brief demographic questionnaire; assessment of venous VTE risk and venous-specific quality of life; abbreviated venous ultrasound exam; and lower extremity inspection for signs of chronic venous insufficiency. Participants receive a report card, as well as disease-specific educational materials during the exit interview. Those screened are encouraged to share their results with their primary care provider. The AVF encourages doctors to help spread awareness of VTE by partnering with AVF supporting World Thrombosis Day by educating the public with free venous screening events in the community featuring the World Thrombosis Day message. AVF will provide posters for World Thrombosis Day, and the screening kit is available at a special discounted rate. While organizations around the world are collaborating to spread awareness of VTE and World Thrombosis Day, the heart of the movement will be on the local level. AVF encourages all physicians to participate by informing the public of the serious health risks of venous thromboembolism. The International Society of Thrombosis and Haemostasis (ISTH) has provided a wealth of information and resources to use, including a unified message, educational graphics, marketing tips and more. For more information see www.isth. org/?WTD or email info@veinforum.org for posters and screening kits. VTN

FDA increases foreign medical device checks FDA inspectors have stepped up their surveillance of foreign medical device manufacturers, finding that they make up a disproportionate number of process and quality violations that result in formal warning letters. Foreign firms accounted for about 10 percent of inspections conducted in 2012, but received 40 percent of the FDA warning letters. China alone was responsible for 12 percent of all the quality systems warning letters issued that year. The most common violations were related to corrective and preventive action procedures, complaint files and quality audits, the FDA reported. Regulators noted a significant increase in violations of device history records, which capture manufacturing, distribution, identification and control data. U.S. regulators really stepped up their game in 2012, saying that they conducted 37 percent more inspections that year in efforts to close in on poor practices. Foreign inspections in particular increased by 93 percent. VTN

AUGUST/SEPTEMBER 2014 ✜ VEIN THERAPY NEWS

Two Wavelengths The Ideal Combination

Medilas D LiteBeam+ • 1470 nm Wavelength • Water Absorption for ELT

Before

Medilas D FlexiPulse • 940 nm Wavelength • Hemoglobin Absorption for Spider Veins

Before After

After

Comprehensive Solution • Lightguide Protection System (LPS) • Compact and Transportable • Variety of Flexible Fibers Available • Intuitive Graphical Interface DMTA-350B

VEIN THERAPY NEWS ✜ AUGUST/SEPTEMBER 2014

(800) 367-6437 or www.dornier.com

(8 55 C ) M all T D od A ay! D V IS O R

VSA is a phlebology-specific physician practice management and advisory consulting firm Our management and marketing programs are flexible and individually designed to address each client’s specific needs.

Management On Request (M.O.R.) Practice Management… as you need it… when you need it. VSA gives you MOR(e) with Management on Request.

In any competitive environment… experience helps keep you in the lead.

Many of our long-term practice management and marketing clients began their relationship with VSA by utilizing our advisory services. This is a low risk, cost-effective program where practice problems and solution strategies are discussed via weekly, bi-weekly or monthly conference For as little as $595 per calls. This process allows our month, an experienced consultants to demonstrate their VSA practice management business acumen. and marketing consultant is This may include assistance with available to assess, advise practice operations, personnel and guide your practice at management, marketing, revenue a price point that fits your cycle management, strategic needs. planning or business coaching.

The Power of Partnership VSA focuses on implementation management and results-oriented consulting, which enables us to help our clients realize the true strategic and operational potential of the medical practices they own and operate.

Established in 2005 as a stand alone company, our operational model is to partner with physicians and their existing management team to assist in the delivery of high-quality, cost-efficient, medical care by focusing on the timeconsuming and complex

Revenue Cycle Management VSA works with your staff to make sure that each paid claim is adjusted at their contracted rates. Achieving this simple goal involves an advanced understanding of revenue cycle management processes – it is not simply “billing and collections”. We seek opportunities to increase your revenues by identifying operational deficiencies, creating action plans to address them, and then establishing reporting and follow-up systems to ensure ongoing success.

Practice Management Today’s challenges demand skilled, appropriately focused management. PRACTICE DEVELOPMENT Our approach helps you heighten awareness of your practice, improve patient satisfaction and increase market share. We help you optimize every aspect of claims submission – claims payment, and accounts receivable management, including both insurance and patient balances.

STRATEGIC PLANNING We focus on helping the practice develop an approach that will provide a strategic advantage through differentiation in the marketplace and the crafting of a strategy that can be supported, implemented, and sustained.

STAFFING VSA identifies staffing requirements, develops personnel policies, and establishes wage scales by position to maintain efficient staffing levels.

DEVELOPING GROUP PRACTICE GOVERNANCE We help physician management capitalize on individual staff skills and create a cohesive group.

Internet Marketing If you’re looking to succeed in this digital era, it’s time to integrate your marketing efforts. Creating a marketing strategy that includes SEO, pay-perclick, social media, email marketing, content marketing, mobile marketing and content analytics is the most efficient way to structure and drive your 2014 online marketing efforts. When a current or potential patient visits your website for the first time, you want that patient to quickly understand what your practice does, who you are and why you are the best.

administrative functions that distract from clinical practice imperatives. Our vision is to distinguish ourselves in the market by providing our clients with innovative and valuable business tools and solutions that allow them to realize their own

Relationship Marketing Increasing patient referrals from physicians should be an important component of any marketing plan implemented in a VEIN practice. VSA consultants can help you find, train and manage a Physician Liaison to help you generate new PCP patient referrals. Visit our web site to download your FREE Physician Liaison ROI case study booklet at www.veinbusiness.com/physician_liaison_roi/

particular strategic visions and business plans. It is for this reason that we don’t view ourselves as a solution or a service; but rather as a business partner.

BOSTON

CHICAGO

900 Oakmont Lane, Suite 100 Westmont, IL 60559 www.VeinBusiness.com

DALLAS

MIAMI

PHOENIX

Call (855) MD ADVISOR today for a complimentary 30-minute consultation

NEWS

Dr. Almeida approached Medtronic to buy Covidien After the initial shock of the mid-June announcement of Medtronic’s acquisition of Covidien for $43 billion, the genesis of the deal was just as intriguing. Jose Almeida, MD and CEO of Covidien, approached Omar Ishrak, CEO of Medtronic, to proposed the buyout, which is expected to close during the 4th quarter or early next year. Bill George, the Harvard Business School professor who formerly led Medtronic, said on Squawk Box that the buyout was a “totally friendly deal based on a first move by Dr. Almeida.” “They just fit like a glove, and it’s going to have great value for earnings per share and everything else,” George said. “Medtronic is planning to use Covidien Dr. Jose Almeida, to broadly expand its position, to enhance Covidien CEO its R&D, to spend more. Medtronic is planning to use some of the $13 billion to $14 billion it has trapped overseas to help fund the buyout.” Because it is an inversion deal, Medtronic will re-incorporate in Ireland. Medtronic plans to maintain its presence in Minnesota where it employs about 8,000 workers, and shift most Covidien workers from Massachusetts to Minnesota. Omar Ishrak, Medtronic spokesmen said it expects the Medtronic CEO deal to add to adjusted earnings in fiscal 2016, fueled by an estimated $850 million in annual pre-tax savings. If consummated, the combination would create a Minneapolis-based giant with about 87,000 employees worldwide and annual sales of some $27 billion. Dr. Almeida said Covidien and Medtronic, when combined, will provide patients, physicians and hospitals with a compelling portfolio of offerings that will help improve care and surgical performance. “This transaction provides our shareholders with immediate value and the opportunity to participate in the significant upside potential of the combined organization,” he said. “I’d like to thank our 38,000 employees whose hard work and dedication has enabled Covidien to deliver innovative health solutions that improve patient outcomes.” Some early Internet comments indicated that Medtronic might spin-off the former VNUS Medical Technologies and its intellectual RF laser property, but Peter Lucht told Vein Therapy News that all aspects of Covidien’s offerings and operations are included in the sale. ”At this time there are no plans to divest any of the businesses of either company,” Lucht said. “Our businesses are highly complementary and there are strong teams at both companies with very little overlap in our sales, marketing and R&D organizations.”

of its total revenues. Also in the BBJ, Morningstar analyst Debbie Wang agreed. “Vascular will be one pretty high-profile target within the combined company where they can rationalize and eliminate certain redundancies, whether it’s in the R&D area or the administrative or sales and marketing area. It seems like they will be able to trim there.” But Stacy Enxing Seng, the president of Covidien’s $1.6 billion vascular product group, said that the impending merger with Medtronic was necessary from her perspective because being a vascular player without cardiovascular would have been a real issue. Covidien makes a variety of neurovascular, peripheral and other vascular products, but not cardiology ones. In addition to the companies’ complementary portfolios, Seng stressed the importance of vertical integration without addressing any overlaps. Customers such as public and private insurers and rapidly consolidating hospital systems “want to work with not just one supplier, they want to work with a partner. It’s a partner that’s now going beyond product and moving into services and solutions, and you really can’t do that unless you have scale,” she said, in an interview with Mass Device during the DeviceTalks conference in Minnesota. Seng is a veteran of previous takeovers of American Hospital Supply by Baxter in 1985, Scimed Life Systems by Boston Scientific in 1995, ev3 by Covidien in 2010 and now Covidien by Medtronic. She was on the acquired company end of each transaction. “I was pleased to hear in the announcement with Medtronic and Covidien the concept of an integration office, because I think it allows you to really focus on the vital few things that we need to get right,” she said in the interview. “What are the real drivers of this acquisition that we need to nail and ensure that we get right so we can deliver on our shareholder commitment? And then on those other things, letting those kind of come in due time.” Despite much that has been made of the deal’s tax inversion status, Seng told Mass Device it’s not really a tax rate issue. “I think that’s a very important clarification. It’s really about getting access to your outside-the-United States capital.” The Wall Street Journal stated that Covidien’s effective tax rate was 21 percent in 2013 (though it was 14.7 percent in 2012), compared to Medtronic’s 18.4 percent. But by shifting its tax domicile to Ireland, Medtronic can pay dividends from foreign profits without paying the United State’s 35 percent corporate tax rate. In fact, the company announced an 8 percent increase in its dividend on June 20, soon after the acquisition was made public. Seng said the evolving industry landscape is also at play in the acquisition. “Innovation is now really moving beyond product, to pre- and post- care. It’s moving beyond the actual disease treatment itself, and it’s moving beyond the hospital in terms of a place,” she said, adding Covidien often discusses methods of enabling devices to be used in the home, for example.

VASCULAR PRODUCT GROUP

Medtronic’s pending $43 billion acquisition of Covidien contains about $80 million in golden parachute provisions for Covidien’s senior management team. If the top executives at Covidien decide to leave the company after a $43 billion acquisition by Medtronic goes through, they’ll do it under a golden parachute worth a collective $80 million, regulatory filings show. The top 5 named executives at Covidien, led by Almeida, are in line for an average payout of about $16 million if they leave after the deal’s consummation. And that’s apart from the holdings in Covidien stock the executives are expected to maintain (five times

The Boston Business Journal (BBJ) reported that Leerink Partners analyst Richard Newitter told the BBJ that while there is “very little overlap” in the companies’ products, the one exception is Covidien’s endovascular business, which employs about 1,000 people. Both companies have vascular therapies, but Medtronic’s unit is historically the stronger performer. In its most recent quarter, Medtronic reported $2.4 billion from its Cardiac and Vascular Group or 52 percent of its total revenues, while Covidien turned in $409 million from its vascular therapies, or 16 percent

GOLDEN PARACHUTES

base salary for Almeida and three times base salary for the other executives, according to the SEC filing. In the case of Almeida, who received $11.2 million in total compensation during fiscal 2013, that amounts to another $60.3 million worth of stock based on Covidien’s $72.02-per-share closing price June 13, the last trading day before the deal was announced. The SEC filings show “change in control” provisions are available to the top five named executives: Almeida, CFO Charles Dockendorff, medical device division president Bryan Hanson, developed markets president Peter Wehrly and chief counsel John Masterson – only if Covidien’s provisions are met: Involuntary termination or good reason resignation from 60 days before to two years after the deal closes.

ANTI-INVERSION BILLS

One of the reasons every Medtronic or Covidien source who has spoken on the record denies that this acquisition is a corporate inversion deal is because U.S. lawmakers are up in arms about companies shifting their headquarters overseas in order to evade U.S. taxes. The Obama Administration is looking to clamp down on companies that relocate their headquarters overseas in order to benefit from lower tax rates, a measure that could apply retroactively to deals such as Medtronic’s $43 billion acquisition of Covidien. Part of this deal includes moving Medtronic’s official headquarters from Minnesota to Covidien’s base in Ireland, allowing Medtronic to take advantage of the Ireland’s more favorable corporate tax rate. This is corporate inversion. In a letter obtained by the Wall Street Journal, the White House urged congressional tax committee leaders to “prevent companies from effectively renouncing their citizenship to get out of paying taxes.” Treasury Secretary Jacob Lew asked lawmakers in the letter to support the Administration’s proposal to prohibit companies from changing their corporate tax domicile if there is a change in control of the company itself. Lew asked Congress to pass swift legislation to take the wind out of the rising trend of companies seeking inversion deals, and for lawmakers to further address the exodus through more broad tax reform. The bill would be retroactive to early May, which would affect the Medtronic-Covidien proposal. “What we need as a nation is a new sense of economic patriotism, where we all rise or fall together,” Lew stated in the letter. “We should not be providing support for corporations that seek to shift their profits overseas to avoid paying their fair share of taxes.” Medtronic and Covidien executives have said since the announcement that their merger wasn’t motivated by the inversion, saying that the main drivers were strategic. “The real purpose of this, in the end, is strategic, both in the intermediate term and the long term,” Ishrak said. “It is good for the U.S. in that we will make more investment in U.S. technologies, which previously we could not.” The merger will allow Medtronic to use the billions it has stored in outside-U.S. tax havens without having to pay U.S. corporate taxes upon paying for the Covidien shares. The Journal, however, said the measure prohibiting inversions may not be a deal-breaker for Medtronic and Covidien, but many new acquisition negotiations include provisions that allow buyers to walk away from deals penalty-free should a tax benefit disappear. Covidien has been based in Ireland since 2009, saying that the company hoped to benefit from the lower corporate tax rate there, and Medtronic plans to make the same move when the merger closes later this year or early in 2015. VTN

AUGUST/SEPTEMBER 2014 < VEIN THERAPY NEWS

NEWS Drs. Maleti, Lugli join ACP faculty at 28th Congress Oscar Maleti, MD, and Marzia Lugli, MD, will be speaking at the 28th Annual ACP Congress on “From Superficial to Deep Veins,” in association with the Deep Venous Reconstructive Surgery in Chronic Venous Insufficiency (DVRSCVI) Club. Dr. Maleti, chair of the symposium, and Dr. Lugli come from the vascular surgery unit in Modena, Italy, which was recently named one of the

Drs. Maleti and Lugli come from one of the top 10 medical centers in the world.

top 10 centers in the world, and the only program in Italy recommended for the training of vascular surgeons on the surgical reconstruction of the deep venous system in lower limbs. “The Program Committee has created a blend of topics incorporating expertise from the multiple disciplines that treat venous and lymphatic disorders,” Program Chair Saundra S. Spruiell, DO, FACPh, RPVI, stated. “The result is a composite curriculum for ‘the consummate phlebologist.’ Expert faculty from the U.S. and abroad will stimulate both foundational topics and new ideas to create a wellrounded experience for practitioners of diverse backgrounds and skill levels. Simply stated, there is something for everyone!” Among the many program events are: • Presentation of quality scientific abstracts on timely topics inclusive of award-winning abstracts from the European Venous Forum and American Venous Forum. • Early morning special interest sections that address small audiences in intimate settings to allow interaction with the experts discussing complications in sclerotherapy, thrombophilia, novel anticoagulants, venous stents and more. • Opportunities for all levels of practitioners to participate in Hands-on Workshops conducted by hand-picked ACP PROGRAM

THE TOTAL VEIN SYSTEMS THIN WALL LASER FIBER IS THE SIZE OF THE PERIOD

AT THE END OF THIS

SENTENCE

600 micron fiber fits through a 20g needle.

888-868-8346

TVS Thin Wall Fibers and TVS Ultra Thin Wall Needle

Ideal for Perforators!

continued on page 17

VEIN THERAPY NEWS ✜ AUGUST/SEPTEMBER 2014

ACP Update

2014 ACP Congress to convene Nov. 6-9 in Phoenix After hosting the most successful vein care meeting in the history of the International Union of Phlebology (UIP) in Boston last year, the American ColSandra Spruiell, DO, lege of Phlebology FACPh, RPVI (ACP) is preparing 28th ACP program chair for another extraordinary educational meeting with the 2014 ACP Annual Congress Nov. 6-9 at the JW Marriott Desert Ridge Resort in Phoenix, Ariz. This year marks the 28th year the ACP will host what has become the largest and most comprehensive meeting dedicated to venous and lymphatic disorders in the United States. Under the direction of Program Chair, Sandra Spruiell, DO, FACPh, RPVI, the scientific program will continue to set the pace with innovative and engaging content, respected faculty from around the world and opportunities for all levels of skill and knowledge. “The overall approach the program committee took was to allow for as much interaction with faculty as possible,” Dr. Spruiell stated. “We want attendees to walk away with the tools they need personally to improve the quality of care in their practices.” Building on that interactivity, program highlights include hands-on simulated workshops in sclerotherapy, duplex ultrasound and compression therapy. In addition, special symposia are designed to produce the “consummate phlebologist” through the creation of new content, such as how to distinguish venous skin changes, and topics often considered the forgotten orphans of vein care – venous pain, RLS, vascular malformations, CCSVI, and venous entrapment and nerve compression. “It was important that we took a global view of vein care, to include aspects not covered at other venous symposia,” Dr. Spruiell said. “In doing so, we added an extensive

JW Marriott Desert Ridge Resort in Phoneix

The saguaro cactus rises above the Saguaro National Park.

Aesthetic Track on Sunday, as well as looking to the future with topics such as Regenerative Therapy in Venous and Lymphatic Disease.” The Annual Congress will also present controversies and complications encountered in endovenous thermal ablation, venous disease in women, use of novel anticoagulants, modern management of VTE, lymphedema & lipedema and new treatment strategies. While the curriculum will challenge attendees, the location will allow for relaxed networking. Hosted at the JW Marriott Desert Ridge Resort, the southwestern backdrop will provide the perfect setting to gather with colleagues and friends. Several social events are planned including the Dinner & Social, Silent Auction and the ACP Foundation’s 8th Annual Golf Outing held on property at the Wildfire Country Club, always a fun way to start the Annual Congress. As the field of vein care continues to grow, so too does the need for educational offerings at all levels of skill. Attendees of the 2014 ACP Annual Congress

will find sessions which meet their specific needs, from basic to advanced. Join the ACP Nov. 6-9 in Phoenix for this essential educational event.

For more information about the Congress and to register, please visit www.acpcongress. org. VTN

Phoenix, Ariz., skyline

AUGUST/SEPTEMBER 2014 ✜ VEIN THERAPY NEWS

ACP 2014

28TH ANNUAL CONGRESS

November 6 – 9, 2014 | JW Marriott Desert Ridge Resort | Phoenix, AZ Join your colleagues at the American College of Phlebology’s 28TH Annual Congress for the latest techniques and education in the treatment of venous and lymphatic disease. The accessible scientific program addresses the full spectrum of deep and superficial vein care in didactic, interactive, debate and hands-on demonstration sessions, providing practitioners with: + + +

Opportunities to improve patient care at all levels of skill from foundational through advanced Presentations and exhibitors of leading research, technology and trends in the field of vein care Hands-on workshops and demonstrations with renowned experts from all over the world

Topics Covered: +

Thrombus Debates

Compression

Nursing Multidisciplinary

Sclerotherapy

Research

Aesthetics and Venous Patients

Endovenous Ablation

Challenging Cases

Modern Management of VTE

Practice Management

And more…

Ultrasound Duplex Diagnosis

Lymphedema and Lipedema

ACP Members Save

25% On Registration

Accreditation The American College of Phlebology is accredited by the Accreditation Council for Continuing Medical Education to provide continuing medical education for physicians.

acpcongress.org www.phlebology.org | 510.346.6800

advancing vein care

NEWS Merz acquires Ulthera for $600M to expand its facial aesthetics By Larry Storer Just as Germany-based Merz was wrapping up its May 26th merger agreement to acquire ultrasound company Ulthera Inc. at a cost of $600 million and milestone payments, the Food and Drug Administration (FDA) came along and presented the two companies with a great big aesthetically pleasing bow for that acquisition package making it Christmas in July.

On July 7, the FDA announced that the company’s Ultherapy Decolletage Treatment was approved for non-invasive treatment to improve lines and wrinkles of the décolletage, French for the upper part of a woman’s torso that comprise her neck, shoulders, back and chest. This new application of the Ultherapy procedure will become a favorite of women wearing the low-cut necklines that are a fashion feature of ball gowns, evening gowns, leotards, lingerie and swimsuits, among other fashions.

1,500 PRACTICES IN U.S.

Starting in the third quarter, the Ultherapy Decolletage Treatment will be available in more than 1,500 physician practices across the United States. The treatment, already cleared for use in more than 40 other countries world-

wide, has been selectively available since 2012. Ulthera, a global medical device company focused on developing and commercializing technologies for aesthetic and medical applications using its therapeutic ultrasound platform technology, is a prize for Merz because it has the potential to accelerate Merz’s growth in the aesthetics area and expand the company’s portfolio of treatment options in facial aesthetics. Ulthera expected sales of more than $100 million in 2014, but that was before the FDA opened the door for the Ultherapy Decolletage Treatment. Principal investigator Dr. Sabrina Fabi, a dermatologist at Cosmetic Laser Dermatology in San Diego, said the Ultherapy Decolletage Treatment is a welcome addition to her practice. “At my practice, there is high patient demand for a safe and effective solution to

treat the chest, but the only options available involved needles, multiple treatments, recovery time, and/or required restricted sun exposure.” Matthew E. Likens, president and CEO of Ulthera, said the decolletage indication fills a very clear void for patients and reinforces Ulthera’s commitment to expanding its platform technology. “Our goal is to reward Ultherapy practices by bringing more value to the Ulthera System during each year of ownership,” he said. “Now, the Ultherapy Treatment addresses four total treatment areas - from the brow to the chest making it apparent that our investment in clinical advancements and dedication to R&D is producing results for our customers.”

HOW IT WORKS

The Ulthera System consists of a control unit,

Cardiovascular Credentialing International Credentialing Cardiovascular Professionals since 1968 (800) 326-0268 • www.cci-online.org

What is on the RPhS exam?

Content Category Maintain Information, Facility, & Safety Diagnose Patients Perform Diagnostic Test Treat Patients Non-Surgically Treat Patients Surgically Total

Approx % of Exam 10% 20% 30% 12% 28% 100%

Credentials administered by CCI are accredited by the American National Standards Institute (ANSI) based on the ISO/IEC 17024 Accreditation Standard.

The Registered Phlebology Sonographer (RPhS) credential is for physicians, sonographers, nurses, physician assistants and other associate health professionals who utilize ultrasound to treat vein disorders. “I believe that the RPhS credential from CCI is the Gold Standard for venous disease ultrasound certification. It provides a solid foundation for understanding venous hemodynamics and its application towards treatment options. Competence in venous ultrasound is imperative to achieving excellent vein care and having happy patients who will speak highly of you and your practice.” —Craig Crippen, MSc, MD, CCFP, RPhS, ABPh DermMedica

Photo courtesy of Morrison Vein Institute and Compudiagnostics.

The following examination matrix is provided to illustrate the general distribution of questions and the relative weight or emphasis given to a skill or content area on the examination. A detailed outline can be found in the CCI Examination Application and Overview booklet or at www.cci-online.org.

Become a credentialed Phlebology Sonographer!

AUGUST/SEPTEMBER 2014 ✜ VEIN THERAPY NEWS

NEWS hand piece and a transducer that emits ultrasound technology to lift the skin. The doctor views a projection of the patient’s skin tissue to determine proper placement of the hand piece and transducer. The Ultherapy Decolletage Treatment uses the system’s signature imaging and microfocused ultrasound therapy capabilities and takes about 30 minutes to administer. The treatment stimulates the natural formation of collagen and elastin in the skin’s foundation to gradually smooth chest wrinkles. Results are visible after about three months. As with the FDA-cleared Ultherapy procedure for lifting the neck, eyebrow and under the chin, meaningful results are achieved in just one treatment, and there’s no downtime or post-treatment care requirements.

CORPORATE INTEGRATION

Bill Humphries, president and CEO of Merz North America Inc., said the aesthetic lift indication differentiates Ulthera from every other energy device available in the market today. “It is truly innovative technology, and we expect to leverage our in-house clinical expertise to develop further aesthetic and medical applications and bring them to the international marketplace.” Founded in 2004, Ulthera is a provider of non-surgical lifting and tightening treatments. Using therapeutic ultrasound technology, the Ulthera System is the first and only ultrasound platform device to receive FDA clearance for lifting skin on the eyebrow, on the neck and under the chin. Ulthera’s Likens told the Phoenix Business Journal the company was on the path to go public and even had a number of exchanges with the SEC. Ulthera had filed an $86 million initial public offering in April. “Then we just thought this deal made more sense, based on where the company is at this time and the nature of the acquiring firm.” Ulthera will maintain its operations in Mesa. Likens will keep his position as CEO, as will Ulthera’s 170 employees. About half of them are at the company’s Arizona headquarters, and the other half are salespeople scattered around the globe. “That was one of the really great parts of that discussion we had with Merz, is that they really wouldn’t have gone through with this unless the employees agreed to stay here and continue,” Likens said. “This is a new technology for their company. They need the expertise we have.” “Our top line growth through five months this year is 65 percent so far, so we’re continuing to hire and add folks,” Likens added. Likens positions Merz and Ulthera as having a shared mission: to bring innovations to market to meet the needs of physicians and improve the well-being of patients. He said this shared MERZ

continued on page 14

VEIN THERAPY NEWS < AUGUST/SEPTEMBER 2014

NEWS MERZ

continued from page 13

Add more... accuracy efficiency mobility comfort

...to your venous reflux studies The VenaPulse® Hands-Free Augmentation Device • Standardized* augmentations with the use of a foot pedal • Portable and user-friendly • Document valves throughout the entire limb - perforators included • Improved ergonomics - less bending and twisting involved * “Prospective comparison of the pneumatic cuff and manual compression methods in diagnosing lower extremity venous reflux” S. K. Kakkos, et al. Vasc. & Endovasc Surgery, Vol. 43 No. 5, pp. 480-484

long-term vision provides a solid foundation for the combined company. Likens said joining with a like-minded, growing global healthcare company is a major milestone in the life of the company. “Through our collaboration with Merz, we will be able to introduce the Ulthera System to new customers and markets around the world.” The transaction has been approved by the boards of both companies and is subject to customary closing conditions, including the expiration or termination of the applicable waiting period under the Hart-Scott-Rodino Antitrust Improvements Act of 1976. The transaction is expected to close in the third quarter of 2014. Merz is a privately held pharmaceutical company based in Frankfurt, Germany, with branches in various European countries as well as the Americas and Asia Pacific. The company is active in research, development and distribution of products in the areas of aesthetic medicine and dermatology, as well as in the field of neurologically induced movement disorders. Merz Aesthetics offers a tailored and harmonized portfolio of products for minimally invasive treatments, including the dermal fillers Radiesse, Belotero, Glytone,the neurotoxin Bocouture/Xeomin, as well as the NEOCUTIS line of anti-aging and post-procedure skincare products. For the treatment of neurologically induced movement disorders, Merz developed Xeomin, the first botulinum toxin that is free of complex proteins. VTN

READ MORE: www.merz.com or www.ulthera.com

FREE ONLINE PROFILE

Mention This Ad and Get Information About the Free Trial Program for Your Facility: Toll Free (888) 453-4356 ACIMedical.com/VenaPulse

To highlight our newly reconstructed website, all doctors are receiving a free online profile for one year. Just call 512-672-0342

TODAY!

Proudly made in the USA L 5.72 Rev. New, 03/21/14 VEINTHERAPYNEWS.COM

AUGUST/SEPTEMBER 2014 ✜ VEIN THERAPY NEWS

THEPRACTICE COST CONTROLS

continued from page 1

payments to eligible professionals (EPs)… to promote the adoption and meaningful use of certified electronic health record (CEHR) technology.” This was the statutory basis to provide Medicare incentive payments to users of electronic records, and penalize those who could not attest to specific electronic data collection requirements. Three stages of implementation of Meaningful Use (MU) rules were outlined; each requiring attestation of proof that benchmarks had been met. This is the bureaucratic vision of what would improve medical care. This is the last year that an EP can submit an attestation that certain percentage benchmarks have been met in the collection of the data to achieve Stage 1 of MU. Being able to extract specific data points over a 90-day period is required, now using a 2014 edition of certified software. After collection is completed, if the numbers don’t reach the required percentages, the time, effort, and expense spent in data collection and software installation may be wasted. No reimbursement for the electronic health record software and implementation will be available. Additionally, Medicare payments to the provider who fails Stage 1 attestation will decrease by 1 percent for the next year, and eventually reach 5 percent. Interestingly, 20 percent of the significant group of physicians who attested to Stage 1 in 2011 or 2012 had stopped participating as of 2013. Only four hospitals and 50 EPs had attested to MU Stage 2 by March of 2014, according to Centers for Medicare and Medicaid Services (CMS). The program is in trouble. It has been highly criticized by the American Medical Association (AMA), American Academy of Family Practice, hospital associations and many specialty organizations for the timeline and complex rules. In an open letter in May, the AMA stated that it was “concerned that the rigid program requirements and financial penalties will discourage physicians who are making good faith efforts to incorporate health IT into their practices.” The AMA strongly recommended changes to the MU incentive program. Multiple organizations also signed on to a letter to the Health and Human Services (HHS) in February saying, “We fear the success of the program is in jeopardy if steps are not taken now to address our shared concerns.” In response to the complaints, HHS published a proposed rule modification in the Federal Register on May 23. This likely has been approved by the time of this publication, as the 60-day period for public comment expired July 22, and the proposal had already been given tacit acceptance by many representative agencies of healthcare providers. The main changes addressed the issue that 2014 versions of CERT were not readily available to physicians and hospitals. The proposed modification referred to the edition of CERT used, and allowed the 2011 version, the 2014 version or a combination of the two for submitting criteria for MU. Attestation would be based on 2011 guidelines if that is the version of CERT used. The proposed change would also give EPs who completed Stage 1 in 2011 or 2012 an additional year to attest to Stage 2. It also delayed the implementation of Stage 3 till 2017, even if stage 1 had been achieved in 2011 or 2012. The proposed rule change failed to address some of the main complaints of the representative healthcare agencies. Specifically, the AMA and other groups believe that Stage 2 MU is not likely to be achieved by many physicians because they cannot control some of the mandated items, such as percentage of patients accessing patient portals, and transmitting exchange

care summaries at hospital discharge or referral. Many providers are trying to ascertain how to use HIPAA-compliant exchange of information to achieve the requirement! The AMA also requested that CMS streamline requirements, allow physicians to choose measures that are applicable to their specialty practices, align the MU quality reporting with the Physician Quality Reporting System to avoid duplication of effort, and other specifics not yet addressed. Michael Lee, MD, MBA and director of clinical informatics at Atrius Health in Massachusetts, testified that, “the all-ornothing approach is too stringent, and should be replaced with a 75 percent pass rate for achieving Meaningful Use.” And he recommended that, “physicians who meet at least 50 percent of Meaningful Use requirements be able to avoid financial penalties. “ So at this point, the question is whether it is truly worthwhile to pursue capturing the data to attest to MU? If unsuccessful, then it has been a total waste of time and money. Some practices have been audited by CMS, which has not always found agreement with the attestation. This has led to even more incurred cost by those practices. Solo practitioners and smaller independent practices must weigh the potential benefits against the burden placed on themselves and their staffs.

ICD 10

As we are all aware, implementation of the 10th revision of the International Classification of Diseases (ICD 10) has now been delayed for a second time. This coding mandate increases the current 13,000 codes in ICD 9 to 68,000 in ICD 10. Projected start date is unofficially Oct. 1, 2015, but that is not definite. At the end of March, Congress added the delay to the “patch fix” regulatory suspension of the sustainable growth rate mandate, which Congress again placed on hold for another 12 months instead of repealing it. This has certainly placated some medical associations that viewed delay of ICD 10 as a win for physicians, because it was estimated that as few as 10 percent of physicians seemed ready for the changes. The societies have also complained because transition to ICD 10 is a federal mandate that is unfunded, passing on the cost to the physician. Many fear the chaos that the unprepared providers and payers would face once the rules take affect because doctors anticipated prolonged delays in payment and multiple resubmissions to insurers. Not everyone views the delay as a win. Organizations representing health information technology and hospital groups claim that the postponement continues to add expense to medical overhead. The American Health Information Management Association estimated that a oneyear delay could cost as much as $6.6 billion. In addition, healthcare educators wail that all the newly trained coders and billers have been trained in ICD 10 and don’t know ICD 9 codes. The indefinite nature of the delay, because it was passed by Congress and not CMS, makes for very uncertain timing without guidance from CMS. Many practices have spent considerable time and money in preparation for the ICD 10 project start, and this very late delay is met with both frustration and relief. Those who have joined Accountable Care Organizations (ACO) know that the ACOs have been structured with ICD 10 in mind for analytics, and joining ACOs had its own set of rules and constraints. Doctors, who fail to see how it will improve medical care, still do not wholly accept the justification for ICD 10. It is data mining. Many non-clinicians say the U.S. doctors should just stop being arrogant, buck up and embrace ICD 10, because the

United States is the only member country in the World Health Organization (WHO) who isn’t yet using ICD 10. However, none of the other WHO countries tie the codes to billing and reimbursement. If ICD 10 truly does take effect in October of 2015, personnel will need to again intensively prepare in six to nine months. One worse scenario could still develop – the WHO is adopting ICD 11 in 2015. There is the possibility that CMS or Congress will simply push ICD 10 aside and opt for ICD 11. The delay may free up personnel in practices to work on Meaningful Use as a priority now.

HIPAA BUSINESS ASSOCIATE AGREEMENTS

The HIPAA Privacy and Security Rules expansion by the HITECH Act and Omnibus Rule now applies to virtually all business associates of healthcare providers. And the definition of “business associate” has become more encompassing. Failures to have specific agreements with these business associates, whereby they agree to comply with provisions related to protected health information (PHI), or a breach by the business associate, carries penalties of $100 to $50,000 per violation for the physician and/or the business associate. The final Omnibus rule took effect in September of 2013, but older business associate agreements (BAA) were allowed to be operational until Sept. 22. As of this date, all agreements must be more specific, and meet the new HIPAA requirements, which are quite lengthy. Business associates now must have BAAs with any of their subcontractors if there is any exchange of PHI. There might be a chain from subcontractor to subcontractor that could create significant unrecognized risk by action of the “lower tier” subcontractor. Third parties that may be electronically transmitting the information may also be considered business associates unless they fall within the “conduit exception.” That exception clarified that cloud service providers would be deemed business associates unless the PHI was held in a very transient manner. It is unclear whether cloud providers holding encrypted PHI, that they have no key to decrypt, would be deemed business associates. The complexity of the Final Rule is certainly too extensive for this article. However, providers must be aware of the hazards they face, with potential for financial damages and damage to professional reputation, for any violation of laws that are open to interpretation by different legal counsel. Even the association of a patient name or email address with a healthcare provider may be enough to be considered PHI. This adds another layer of caution to how a vein practice may market other aesthetic services to its own patients or provide notification of appointments if a third party needs to remotely access a patient’s email address or phone number to accomplish these tasks. Updated Notice of Privacy Practices and authorizations are requirements of the Omnibus Rule. Hacking of medical records is now considered rampant because of the estimated $50 per record value. A small practice had better consider if its electronic record data is safer on an in-house server or at a “cloud-based” facility. Be aware that even large, supposedly secure record keepers, like Intuit, have been hacked in the recent past. A hacker may decide that a larger target has more potential for financial gain. The Omnibus Rule now also presumes harm has been caused if any potential breach occurs. You must report a breach within 60 days of occurrence, and you must be prepared to defend your decision if you do not report it. Determination of a breach of PHI, and the necessity for notification of such a breach, must follow a specific assessment of risk that is also outlined in the Final Rule.

AUGUST/SEPTEMBER 2014 < VEIN THERAPY NEWS

THEPRACTICE The Omnibus Rule also clarifies that if one breach has occurred, likely more than one violation has taken place. A violation penalty can exceed $1.5 million. Criminal proceedings are now also included in penalties if a practitioner is charged with “willful” negligence.

improving medical care and communication between providers, instead need to be structured to meet governmental mandates of data collection benchmarks. I will rephrase the question, “Isn’t it time for physicians to revolt?” VTN

CONCLUSION

Government intervention has reshaped American medical practice by reducing the emphasis on excellent patient care. We have witnessed the creation of an industry of healthcare strategists, healthcare lawyers and program management specialists just to keep up with governmental regulations. Physicians now spend more hours in front of a computer and less in face-to-face interaction with patients. The most highly trained medical specialists now are scribing and entering orders that were previously placed by that extinct profession, “unit secretaries.” Specifically in private practice, (and especially in office-based practice), the physician must personally deal with governmental regulations and hire personnel to correctly implement the rules to avoid potentially losing everything. Electronic records, which should have the purpose of

Dr. Deborah L. Manjoney, MD, FACS, RPVI, opened the Wisconsin Vein Center and MediSpa in 2002, and in 2004 she left her 18-year practice in cardiovascular and thoracic surgery to devote herself to fulltime practice of phlebology. She offers a broad range of non-invasive and minimally invasive services, and she was one of the first in the area to add the “medispa” concept to her practice.

ACP PROGRAM

continued from page 9

experts focusing on: ultrasound, sclerotherapy, and compression therapy. • A look into the future through the eyes of an expert in stem cell regenerative therapy and its potential applications in venous and lymphatic disease. • Special Symposia focus on new content, such as how to distinguish venous skin changes from others of vascular origin and topics that are often considered the forgotten orphans within phlebology: venous pain, RLS, ulcers of nonvenous origin, etc. • Special focus on lymphedema and lipidema, veins in women, modern management of VTE and more. • Sunday Aesthetic Track that focuses on adding aesthetic procedures to the office. Content is appropriate for those who wish to enhance their cosmetic outcomes and or add cosmetic procedures to their practice.

VTN

Is Your EMR Working For You? 100% of VeinDraw clients who applied for incentive money have received payment

VeinDraw Works For Phlebologists • Organization • Efficiency • Ease of Use • Excellent Customer Service and Support

VeinDraw

™

EMR

software built exclusively for Phlebologists

To see how VeinDraw can work for you, schedule a live demo by calling 877.990.VEIN or visit or website at www.VeinDraw.com “VeinDraw is 2012/2013 compliant and has been certified by InfoGard Laboratories, an Authorized Testing and Certification Body (ONC-ATCB) in accordance with the applicable certification criteria adopted by the Secretary of Health and Human Services. This certification does not represent an endorsement by the U.S. Department of Health and Human Services or guarantee the receipt of incentive payments.” Meaningful Use 2014 Edition is currently in development.

VEIN THERAPY NEWS < AUGUST/SEPTEMBER 2014

THEPRACTICE

A case for hiring physician liaison for relationship marketing FIRST OF A THREE-PART SERIES

By David Schmiege The focus when hiring a physician liaison/ clinical liaison is gaining new, preferred referrals for your practice. While your physician liaison will call on your existing referral network to insure continued growth, they will also actively call on new or underserved sources for new referrals. Your physician liaison should use technology, patient testimonials, etc. to educate primary care physicians (PCPs) and their staff on new procedures and clinical technology unique to your practice, while they emphasize the David Schmiege value of your outcomes and the procedural experience of you and your clinical staff. You should make available multiple formats to achieve this – from simple brochures and marketing materials to clinical case study newsletters, webinars, CDs or a competent discussion based on a clinical research study. Every potential referral physician is different and you need to take an individual approach with each physician and group practice. Take the time to uncover the true needs and interests of each referral partner in an effort to build a professional relationship, create value and establish the trust needed to gain lasting referrals. Follow up is critical. Take the time to insure that your new referral colleagues are completely satisfied with your care and service so that the relationship grows. The majority of our clients that utilize a physician liaison want to communicate a caring and compassionate branding message that strongly differentiates them from everyone else. They want to grow by winning new doctor referrals, maintain current referral patterns and recapture referral sources that have slipped away. As you consider implementing relationship marketing techniques into your practice, remember that each referral source is looking for something completely different, but they all want their individual needs met. Build relationships with potential referral sources by meeting their needs as they have defined them, which might take some research. Once you understand their needs, align your services to meet those needs. That demonstrates your

practice’s value, how well you listen, and how much you care. In an increasingly competitive market to deliver vein care within your service area, physicians are faced with a multitude of issues threatening their success and viability as a standalone, independent medical practice. A constantly changing reimbursement structure and clinical protocols increasingly affect the practice of medicine. In order to stay competitive and succeed long-term, physician leadership must take an active, structured approach to the strategic planning process to remain competitive. The paramount goal of any medical practice should be to thoroughly and appropriately assess the value you provide within your service area, and to ensure that strategic planning will foster the continued delivery of clinical value in a dynamic health care market. Marketing is all about letting patients and referral physicians know about your qualifications and persuading them that your vein practice is the best choice for vein care in a crowded marketplace. For effective marketing, you have to deliver this message on an ongoing basis. Your marketing strategy is a summary of your practice’s clinical competencies and position in relation to other vein practices in your service area. Your sales and marketing plans are the specific actions you’re going to undertake to achieve the goals of your marketing strategy. To succeed in a competitive environment, it’s vital to distinguish your vein practice and your clinical capabilities in a way that builds trust and inspires patient and physician referrals. It’s increasingly important to raise your visibility with direct-to-consumer marketing activities and to extend your visibility with current and potential referral physicians through the use of a physician liaison. So whether you want to market to win more doctor referrals, open additional offices, overcome marketplace disadvantages, differentiate yourself from the competition or simply get more patients to call you, it all starts with developing a marketing strategy and a marketing plan. A marketing plan for a vein practice is a strategy that is designed to facilitate the achievement of specific growth goals. It is not simply scheduling an occasional free vein screening or patient event. It is an overall strategy that encompasses advertising, media relations/PR, physician referrals, patient referrals, as well as planned events to create practice exposure (free screenings, PCP lunch

n learns, community education seminars, etc.). Effective strategic planning must be understood as a process that equally emphasizes internal and external factors impacting the practice. The medical practice undertaking this process must be willing to challenge the very core of its business in light of patient needs, external PCP referral patterns, and the strengths and weaknesses of your current staff. What are the consequences of incorrectly assessing your competitive landscape? In the current environment of declining reimbursement, increased competition and rapidly changing technology, the stakes have changed and the consequences of not understanding your competitive marketplace have gone up.

INSIGHTFUL THINKING

Tailoring your clinical and administrative operations to be more time-sensitive and reliable than your competitors’ entrenches the working relationship. Your goal should be to make it easy to do business with you by being more responsive than your competitor(s). When was the last time you evaluated the effectiveness of your efforts to build a longlasting referral relationship with primary care physicians in your service area? Think about these proven tips to strengthen rapport and increase referral volume. 1. Think strategically about referral patterns. Do you know who refers to your vein practice, who doesn’t, and why? Ask your front desk staff to generate a weekly or monthly referring physician report by procedure. Which physicians currently refer and what types of cases do they send? Do the non-referrers know about all of the conditions you treat or has a patient of theirs experienced a less-thanfavorable visit to your office? Identifying the reasons why these physicians do and do not refer can provide the foundation for improving relationships and referral patterns. 2. Identify other vein practices c ourting your referral physicians. Success is not achieved by ignoring your competitors but rather by anticipating competitive issues and influences so you can always have a proactive plan and strategy for staying ahead of your competition. Referring physicians often report dissatisfaction with specialists who are slow or late in providing consultation reports. Review your internal processes to make sure communication flows back to the referring physician within 48 hours of seeing patients. Before and after pictures are a good idea to support your clinical skills in the referring physician’s mind

to encourage additional referrals. Use clinical case studies to bring attention to additional benefits of vein treatments. 3. Improve the speed of consultation reports by asking whether referring physicians can receive them via secure e-mail. This also allows you to build a valuable email database that gives you instant access to your referral physicians. 4. Be available. Get patients in as quickly as you can. 5. Listen carefully. Patients tell their doctor when specialists or their staff are rude or abrupt - which makes the referring physician look bad for sending the patient to you. 6. Say thanks. Whether it’s a telephone call or handwritten note, show your appreciation by thanking referring physicians for their confidence in you.

RELATIONSHIP MARKETING

Relationship marketing is one of several approaches you can use to promote your vein practice, but it is unquestionably the most valuable. Relationship marketing, supported by the right integrated strategy, produces more new patients than any other method. Relationship marketing can also be one of the least expensive marketing approaches, but it is rare to find practices executing it effectively because it is hard to do well. When most physicians think of relationship marketing, they think of establishing and entrenching their relationships with key referral sources, such as PCPs. That’s only partially right. While PCPs account for a lot of the referrals that vein practices get each year, some practices rely or focus on them too much and miss out on establishing solid relationships with their largest referral source: current patients. Market research has repeatedly shown that previous patients refer about 40 percent of all new patients. Interestingly, from a clinical standpoint, former patients are the least qualified to make those referrals. Instead, they base their referrals on how they feel about you as well as their experiences with your staff. Before you spend another dollar on external resources to market your vein practice, devote time to ensuring that the service you deliver to patients doesn’t just produce satisfaction or loyalty, but also creates patient advocacy. True patient advocates are your most valuable marketing assets. They not only return to you for additional services, but rave about you to others. VTN

AUGUST/SEPTEMBER 2014 < VEIN THERAPY NEWS

THEPRACTICE EDITOR’S NOTE: In the next issue, we will look at the meticulous execution of these principles.

Now Available

David Schmiege is the president and CEO of Vein Specialists of America Ltd. He can be reached at 630-638-0060 or at David.Schmiege@VeinBusiness.com.

Titanium

Croche

t Style

• High strength • Light weight • Non-corrosive • Temperature resistant up to 750o F

F Care Systems gets award

PH 12

Micrro Phlebectomy Hooks Mic 1.4 m

m Ho

k/1.5 mm S The French American Chamber of patula , Stain Commerce of South Florida has given its less St eel, 1 PH 12 8 cm 52 2014 Innovation Award to Patrick Danciu and F Care Systems for the monopolar 1.65 m 59.95 m Ho ea thermocoagulation device known as EVRF ok/2 m m Spa for treating vein diseases. With more than tula, S tainle ss Ste 15 years of experience, F Care is the inventor • High strength PH 12 el, 18 60 cm of the high frequency thermocoagulation Small technology. 59.95 • Light weight Ball Tip ea ped H ook/2 Each year the French American Chamber mm S patula of Commerce of Florida distinguishes the , Stain • Non-corrosive less St PH 12 company that contributed the most to eel, 1 50T 8 cm South Florida with its innovative product 1.4 m • Temperature resistan 59.95 m Ho ea or concept, whatever the field of action. ok/1.5 mm S up to 400˚ C patula F Care Systems is the manufacturer , Titan ium, 1 of the Veinwave, the private label of the 8 cm PH 12 52T TC3000, which is the original device called VeinXpert in the United States. A 1.65 m 79.95 ea m Ho ok/2 m few months ago, F Care introduced the m Spa t u la, Tita patented KAVS, a double-lumen catheter nium, 18 cm for GSV treatment with sclerotherapy. PH 12 60T Danciu said it is the first company to Micro Phlebectomy Hook, Mueller Style, Size 1, Stainless Steel PH 1291 59.95 ea Small 79.95 introduce the first FDA-cleared monopolar Ball Tip ea ped H thermocoagulation device, the TC3000/ ook/2 mm Veinwave, in the United States. 59.95 ea la, TitaPhlebectomy Hook, Mueller Style, Size 2, Stainless Steel PH 1292 SpatuMicro nium, In 2013, F Care systems presented the 18 cm EVRF, a device able to treat all types 79.9 of veins with the thermocoagulation ea 3, Stainless Steel PH 1293 Micro Phlebectomy Hook, Mueller Style, 5Size 59.95 ea technique. The thermocoagulator uses PH 12 microwaves to heat the vessels, using a very 71 high frequency energy pulse. This pulse Micro Phlebectomy Hook, Mueller Style, 5 Size PH 1294 9.954,eStainless Steel 59.95 ea a produces a thermal lesion, resulting in the Size 1 , Stain instant disappearance of the vessel. less S PH 12 He said there is no risk of lesion to the PH 1291T teel Micro Phlebectomy Hook, Mueller Style, Size 1, Titanium 79.95 ea 72 epidermis. The skin remains intact, but after treatment, a “papula” may appear 59.95 ea Size 2 which progresses to tiny crusts resembling , SPH 1292T 79.95 ea Micro Phlebectomy Hook, Mueller Style, Size 2, Titanium tainle s s Steel scratches. These disappear after a few PH 12 71T weeks. The EVRF, which offers instant and 79.95 ea Micro Phlebectomy Hook, Mueller PH 1293T 59.95 Style, Size 3, Titanium ea lasting results, treats: Size 1 , Titan • Spider veins with a non-invasive ium P H 127 probe for veins up to 1mm on face and legs; 79.95 ea 2T Micro Phlebectomy Hook, Mueller Style, Size 4, Titanium PH 1294T • Reticular perforators and collaterals 79.95 with the CR12i and CR30i patented ea Size 2 , Titan catheters; and iu m Total V • SSV and GSV with the CR45iein System s •9 ® 01 Yale catheter. S t re e t • Hous For more information, call Danciu 79.95 ton, Te ea xas 77 at 786-288-0740 or email pdanciu@ 008 59.95 ea Micro Phlebectomy Hook, Ramelet Style, Size 1, Stainless Steel 1241 • 888PH .8 6 8.8346 fcaresystems.us VTN

STAINLESS STEEL and now available in

TITANIUM!

Mueller Style

Stainless 59 $ 95 Titanium 79 Varady

Style

Ramelet Style

• www .totalv

VEIN THERAPY NEWS ✜ AUGUST/SEPTEMBER 2014

ein.co

SECONDLOOK

CASE STUDY Patient presents with pulsatile varicosities By Emma Stout, MD A 75-year-old male presented to the American Vein & Vascular Institute (AVVI) for an evaluation of bilateral lower extremity edema. For a few years, the patient complained of bilateral lower extremity edema and itching of the skin around the ankles and calves. As of late it appeared to be worsening. The patient was taking Hydrochlorothiazide for the swelling and it appeared to be helpful. On examination, the patient had severe stasis dermatitis associated with skin thickening on the right anterior lower leg; the left leg had mild discoloration from the ankle to the calf. In addition, the patient had pronounced varicosities in the great saphenous distribution of both legs, on the right more so than on the left. The varicosities located on the medial distal thigh appeared to pulsate when the patient was sitting down. He said that he had family history of varicose veins and he had not been wearing graduated compression stockings because of discomfort. He had no prior evaluation for lower extremity venous insufficiency. His past medical history was positive for chronic rate controlled atrial fibrillation, HTN, DM, facial skin cancer and dyslipidemia. The social history was negative for any alcohol intake; he was a former smoker and exercised occasionally. His medications included bisoprolol, lisinopril, warfarin, HCTZ, metformin, digoxin, niacin, pravastatin and losartan. A physical exam revealed a well-developed, well-nourished white male who was not in

How will you use Glass in your practice? How will you use Google Glass? Not, will you, but, how will you. A recent New York Times profile of Dr. Selene Parekh, an orthopedic surgeon at Duke Medical Center in Durham, N.C., who has been using the wearable, Internetconnected, optical display technology since the company started distributing them on a very limited basis more than a year ago. Dr. Parekh uses his set, which cost him and other so-called explorers $1,500, to

distress, and his pulse was regular with no JVD. There were no apparent skin temperature changes in the legs. The bilateral pitting edema and stasis dermatitis was worse in the right leg. Bilateral moderate to severe varicosities presented in the medial thigh and distal calf on the right leg. A duplex ultrasound showed no DVT and severe reflux in the common femoral veins. The rest of the deep system was normal. There was severe axial reflux in the great and small saphenous veins bilaterally. Right GSV= 13mm; Right SSV= 7mm; Left GSV = 8mm; Left SSV = 4mm. The patient was consented for bilateral GSV and SSV ablations. The right GSV was treated in the usual manner with two treatment cycles at the SFJ and a single cycle in the remainder of the thigh and upper calf. The treatment was complicated by difficulty compressing the vein despite manual sonographic pressure and liberal tumescent anesthetic. Duplex interrogation of the GSV following ablation showed it to be patent. Three-day post-op duplex ultrasound showed closure of the GSV just at the knee. The remainder of the vein was patent with no change in size or venous reflux. Ultrasound confirmed no evidence of arteriovenous malformation or AV fistula, and pulsatile flow was noted in the veins of both lower extremities. A repeat right GSV RFA was performed on the patient after two weeks. Subsequent ambulatory phlebectomy on the large varicosities had to be aborted after the first incision because of brisk bleeding. The patient was wrapped with a three-layer short stretch bandage.

record his surgeries. Soon, he told The New York Times, he hopes to stream live feeds of his operations to India to help train other orthopedic surgeons. “In India, foot and ankle surgery is about 40 years behind where we are in the U.S.,” he said in the Times article. “So to be able to use Glass to broadcast this and have orthopedic surgeons around the world watch and learn from expert surgeons in the U.S. would be tremendous.” Google Glass is being used to stream operations online, and doctors can float medical images in their field of view while performing surgery. They can even hold video conferences with colleagues during a surgical procedure. Software developers have

He returned two days later for follow up and reported that he was doing fine but needed to keep the bandages on all the time to control the bleeding. Duplex ultrasound showed the right GSV to now be patent with severe axial reflux and persistent pulsatility. The patient was then referred for cardiology consultation where he was diagnosed with severe tricuspid valve regurgitation, confirmed by echocardiogram. The severe tricuspid regurgitation was the cause of the central hypertension and the symmetric pulsatile venous flow in the lower extremities. After the full workup, the patient underwent tricuspid valve repair with post-op echo, demonstrating mild tricuspid valve regurgitation and normal CVP. Following surgical valve correction, the pulsatility in the patient’s superficial veins resolved completely and the distension of his varicosities also improved. Subsequent ablations and sclerotherapy were uneventful and resulted in complete closure of the refluxing segments. Our clinic recommends a cardiac workup and treatment of underlying abnormalities prior to endovenous ablation in patients with suspected tricuspid regurgitation, as this likely would have prevented early treatment failure in our patient. Tricuspid regurgitation (TR) has occasionally been known to lead to marked pulsation of the varicose veins. Pulsatile lower limb spectral Doppler waveform correlates well with rightsided heart failure, and right atrial pressures of more than 8mm Hg. In our patient, the right atrial pressure was 15mm Hg. We don’t recommend using venous duplex imaging of the lower extremities as a screening tool for right

begun to create new programs that project a patient’s vital signs, lab results, medical histories and surgical checklists onto the glasses. Not everyone is onboard. Dr. Matthew Katz, a radiation oncologist at Lowell General Hospital in Massachusetts, said recently on his blog: “Until the FDA or research confirms its safety, Google Glass is banned from my clinic as a privacy and medical practice hazard.” His primary worries about Glasswearing doctors are patient security and physician distraction. No doctor wants to get on the wrong side of HIPAA laws. The San Francisco Chronicle reported in January that employees of Google’s secretive X research group met with FDA staffers. At the time, the Chronicle

side heart failure because of its low sensitivity. Typical symptoms of tricuspid regurgitation: • Active pulsating JV • Pulsatile varicosity • Pulsatile deep and superficial venous system of the lower extremities • Lower extremities edema • Shortness of breath VTN Dr. Emma Stout recently became a Diplomate of the American College of Lymphatic and Venous Medicine. With this board certification, she joins an elite group of highly trained and specialized physicians focused on the diagnosis and treatment of vein disease (phlebology). She is the 5th double board certified physician at American AVVI, the only vein organization in the state of Colorado with all board certified physicians. Dr. Stout finished her phlebology fellowship under the direction of Dr. Gordon Gibbs, AVVI founder and chief medical executive. Dr. Stout is from Novara, Italy, and attended medical school at Sapienza University in Rome. Dr. Stout performed her residency at St. Mary Corwin Regional Medical Center in Pueblo.

reported that the FDA confirmed but did not comment on the visit, calling it a “meet and greet.” Bakul Patel, the senior policy adviser for the agency, told the Times the FDA would regulate only Glass software programs that function as medical devices just as it does for hand-held devices. Still, Dr. Oliver Muensterer, a pediatric surgeon and the first to publish a peer-review study on the use of Google Glass in clinical medicine, has no doubts about the product’s eventual widespread acceptance. “Not the current version,” he told the Times. “But a version in the future that is specially made for healthcare with all the privacy, hardware and software issues worked out.” VTN

AUGUST/SEPTEMBER 2014 ✜ VEIN THERAPY NEWS

SECONDLOOK ER nurse ﬁring reaﬃrms the hazards involving posting work ABC News has reported that the firing of a New York City nurse for her social media use has reaffirmed the hazards of healthcare workers bringing their work online. She was fired from her job as a nurse at New York Presbyterian Hospital after posting a photo to Instagram of an empty trauma room after the treatment of a man

hit by a subway train. She said she was fired for insensitivity, and that she had not violated the Health Insurance Portability and Accountability Act or HIPAA, she told ABC News. She says she did not take the picture, but rather reposted it from a doctor who also worked at the hospital. New York Presbyterian has not reprimanded or otherwise disciplined the doctor, according to the ABC News. Nurses serve on the frontline of healthcare, which means they must take special care in what they post, Nancy Spector, director of regulatory innovations for the National Council of State Boards of

VEIN THERAPY NEWS ✜ AUGUST/SEPTEMBER 2014

Nursing, told ABC News. “Most of the nurses who get into trouble have good intentions but they just don’t know how far reaching social media can be,” she said. “Remember, nothing can really be deleted.” FierceHealthcare earlier reported that at Chicago’s Northwestern Memorial Hospital, an emergency department physician posted photos of a model admitted for excessive drinking to his Instagram and Facebook accounts, and a doctor at St. John’s Mercy Medical Center in Missouri used social media not only to sound off on a pregnant patient’s frequent tardiness, but to disclose that the patient had suffered a stillbirth.

Nearly 60 percent of surveyed healthcare professionals told FierceHealthcare that their workplace access to social media is restricted, with their employers basing the limitations on wasted time and lowered productivity. Social media may have positive applications within healthcare, however. A January eHealth initiative report found blogs, message boards and social networking sites help break down communication barriers between patients and providers, and build meaningful, supportive relationships. VTN

SECONDLOOK

Elevator buttons colonize, harbor more bacteria than do toilets It’s no secret that clinics and hospitals can be germ factories, but the extent of it has just been explored in a new Canadian study that found elevators, of all places, harbor the most bacteria that can lead to infections. Researchers at the University of Toronto found that elevator buttons often have the highest level of bacteria – more so than toilets – but that the bacteria was not “clinically relevant” most of the time. Researchers include Christopher E. Kandel, Andrew E. Simor and Donald A. Redelmeier A total of 120 elevator buttons and 96 toilet surfaces were swabbed over multiple intervals at three tertiaPhoto credit: Chris Campbell via Flickr ry hospitals in Toronto, according to a study published this year in Vol. 8, No. 3 of Open Medicine. “Hospital-acquired infections are a substantial cause of morbidity and mortality,” the report states, noting that the “prevalence of nosocomial infection among hospital inpatients is estimated to be as high as 10 percent.” “Furthermore, even brief exposure to a hospital emergency department can increase the risk of such an infection. A variety of inanimate objects, including white coats, computer keyboards, cellular telephones, stethoscopes, adhesive tape, ultrasound transducers, and radiographic equipment, harbor bacteria,” the authors report. It underscores a growing target among several startups and biotech companies that are seeking to reduce or eliminate hospital-acquired infections (HAIs), a persistent issue that all hospitals would like to contain to maintain the best possible outcomes. Companies cited in the report include: • Aerobiotix, a company that is building devices that use UV light to attack moving pathogens, bacteria and spores prevalent in hospital air. • VenatoRx Pharmaceuticals, which was formed by the former executive team at Protez, a company that developed antibiotics to combat HAIs and other infections. • LifeAire Systems, which makes an in-duct air purification system designed to improve air quality in critical areas for hospitals, last year raised $2 million. The elevator buttons theory is new, the authors suggest, and perhaps offers a more complete picture on HAIs and how to combat them. “Previous studies have most commonly identified colonization by skin bacteria,” the report states. “Surface contamination has also been implicated in the propagation of drug-resistant bacteria. Moreover, bacteria can persist on inanimate objects for days.” Authors of the study therefore hypothesized that hospital elevator buttons “may be an additional under-recognized site

Good doctoring is not rocket science — it is also not digital EDITOR’S NOTE: Dr. Mandrola is not writing about phlebology. But he gave Vein Therapy News permission to reprint his blog post on good doctoring, which has serious application in every discipline.

By John Mandrola, MD Sometimes I worry about where technology is leading the healthcare profession. It is not just the distraction of white screens and electronic health records. These are bad, terrible, in fact. The concern I have runs deeper than just monopolistic EHRs. We, and I mean we as in the caregivers, are losing touch with the basics. I see it everyday, especially, but not exclusively, in the younger generation of nurse and doctor. The collective loss of fundamentals is happening so slowly and steadily that no one seems to notice. Indolent is what we say in medical-speak. Here is what I mean. What makes the practice of medicine work well is not at all complicated. It starts with a story. What is a person’s story? A BNP level, a set of shadows on an ultrasound, a white count, a rhythm strip with squiggles, these are not stories. I begin almost every new patient visit with words like this: “What is bothering you most... I want to know what you say, not your doctors.” When I do this, it is as if magic occurs. I met with a clinician a month ago at the Heart Rhythm Society meeting in San Francisco. He told me something that I’ll never forget about the patient encounter: “I can almost always tell within a few minutes of meeting an (AF) patient what the correct treatment will be. It’s as if God himself speaks, and tells me the right course for that patient.” I know that sounds like hyperbole, and maybe it is, a little. But what it highlights is the power of observing people, their faces, their clothes, their families, their reading material. You simply cannot know the correct course for a person from a chart, an x-ray or an ultrasound. As a consultant, I see people for abnormal heart rhythms. But often, the heart rhythm is not what is bothering them. Often it is that their body hurts, or they can’t sleep, or they are unsteady, or they can’t remember things. You see the trouble? A doctor is tasked with treating the person in front of them, not his ECG, or low ejection fraction. This is what is getting lost. As the healthcare machine increasingly embraces mobile sensors, digital records, and binary quality metrics, what

of microbial contamination.” “At a single university in a community setting, for example, about one-third of elevator buttons were colonized by bacteria,” the authors note. They found that there was a 61 percent prevalence of colonization of bacteria on elevator buttons, irrespective of where said buttons were located.

used to be the care of people has tragically become the treatment of aberrations of 1s and 0s. There is more. It is not just loss of the human narrative; it is also the loss of the human touch, the act of the physical exam. I was recently made fun of on Twitter for suggesting that the treatment of congestive heart failure aided by an invasive monitor stuck into a pulmonary artery would prove no better than a doctor’s observation. The believers in allthings-tech laughed me off the social platform. But that’s BS. And such a defeatist approach to fundamentals is what I am talking about. Consider the case of CHF. When fluid builds up in the body, patients, especially educated ones, will tell a story of increased breathlessness, swelling or a fullness in the abdomen. They know; and they will tell you if prompted and listened to. The physical findings (observations) of CHF are also quite reproducible. These are not complex findings mind you, rather, they are simple things such as a scale reading a higher weight, distension of neck veins, crackling of breath sounds, a palpably full abdomen, and swelling of the legs. There is also the appearance of the person from the door. We call this the “general appearance.” And it is everything, except quantifiable. Good doctoring is not rocket science. But it is also not digital. It is not on a white screen. It is not numbers from a pulmonary artery. And it does not come quickly. It requires seeing patients alongside mentors over years. What worries me is that we are taking our eyes and ears off people. We are distracted, perhaps intoxicated, by the 1s and 0s. This is not to say that technology and computers can’t help us. Of course they can. But no machine, not even an Apple product, can replace looking and listening to the person we are trying to help. Machines and sensors don’t tell stories. Perhaps the next generation of smart people will figure out a way to keep the fundamentals of medical practice and let technology aid us rather than distract and intoxicate us. My tiny nudge is to remember the first rule of getting out of a hole: stop digging. VTN Dr. John Mandrola is a cardiologist who specializes in heart rhythm disorders. He writes about doctoring and cycling on his website and blog at www.drjohnm.org and he is a regular columnist at theHeart.org.

The prevalence did not vary based on day of the week or within the elevators. By comparison, toilets only had a 43 percent prevalence of bacteria colonization. VTN

READ MORE: www.openmedicine.ca/ article/view/634/554

AUGUST/SEPTEMBER 2014 ✜ VEIN THERAPY NEWS

CUSTOM MEDICAL SPECIALTIES, INC. Custom is our Standard™ – Custom Tubing Configurations Are Our Speciality

Low Pressure | Ribbed Tubing | Sterile | Disposable | Non-Latex

High Pressure | Sterile | Disposable | Non-Latex

CMS-914 (12'L x .25" I.D. x .395" O.D.)

CMS-1217 (9'L x .375" I.D.)

CMS-1215 (12'L x .185" I.D. x .285" O.D.)

CMS-1218 (12'L x .375" I.D.)

12' long, highly flexible aspiration tubing with flexible grip ends to securely fit onto the machine and handle.

High flow, aspiration tubing in two convenient lengths that will withstand the demands of power-assisted lipoplasty.

Packed 20/cs.

High Flow | High Pressure | Sterile | Disposable | Non-Latex CMS-1228 Sm. End: approx. .180" I.D. x .311" O.D. Lg. End: approx. .396" I.D. x .596" O.D. High flow, aspiration tubing in two convenient lengths that will withstand the demands of power-assisted lipoplasty. Packed 20/cs.

We assemble a wide variety of disposable trays in our new, 40,000 square foot FDA registered facility. Our four Class 10,000 clean rooms provide the capability to handle all of your standard and custom tray needs, and our experienced Quality Control staff assures you of the highest quality and service in the industry.

We also offer:

Sterile | Disposable | Non-Latex

CMS-1211

CMS-1212

Tumescent Pump Tubing with Single Spike and Drip Chamber, Two Slide Clamps.

15’ long infiltration tubing with a clear drip chamber and a silicon pressure tube insert for use with peristaltic infiltration pumps.

15’ long infiltration tubing with a spike and a silicon pressure tube insert for use with peristaltic infiltration pumps..

Packed 25/cs.

Custom Medical Specialties

Vein/Lipo tumescent tubing sets, tumescent pump tubing, MicroAire® compatible liposuction tubing, vein trays, probe covers, and absorbent pads. Surgery drainbags, collection containers, equipment covers and accessories.

Radiology CT/MRI injection lines, mammography products, IV administration sets and flush waste sets Procedure Trays Custom arthrogram, biopsy, interventional, mammography trays, and more.

• Sets are assembled in the USA in our Pine Level, NC Facility. • No minimum order on product. • Excellent Sales team that can help you find product that fits your facility’s needs. • Product available Direct or through Distribution • International business welcome.

Custom is our Standard™ 330 East Main Street | Pine Level, NC 27568 CustomMedicalSpecialties.com

Call 800-495-0299 for your custom solution today!

SECONDLOOK AGENTS OF CHANGE continued from page 1

earthquake that killed tens of thousands, as well as additional destruction from Hurricanes Sandy and Isaac, is still visible throughout the country.

NO ULTRASOUNDS

The key to Dr. Bush’s special treatment is that it does not require the use of an ultrasound. He said ultrasounds are rarely available in Third World countries. “Physical examination alone can determine the origin of varicosities and all significantly refluxing GSVs are easily palpated in the standing position. “Using the techniques that we have developed, patients can get quality care with excellent results at minimal costs.” “The procedure has sound physiologic basis and, in fact, can be easily implemented in the

ambulatory phlebectomy clinics in the United States. Those patients with no insurance and limited means to pay will benefit greatly from this procedure.” This is an ongoing study and the results will be published after a one- to two-year follow-up of patients “The goal is to obtain results comparable to that obtained with conventional treatment at a much higher cost in the United States.”

JACMEL SURGERY

During the trip, they treated patients in rural clinics, mission clinics, homes and the Complexe Medico-Chiruirgal Rose-Marie Paul in Jacmel, Haiti. It was on the third day of their trip that Dr. Bush assisted Dr. Joseph Leon Paul, a Haitian orthopedic surgeon with a specialty in hand surgery, during general surgery at the hospital

in Jacmel. He also demonstrated his special procedure to treat venous disease without an ultrasound for Dr. Paul and other doctors. The demonstration patient had saphenous insufficiency and multiple varicosities in the left leg that were visible while standing. Dr. Bush used tumescent for high ligation. The vein in the man’s left leg was exposed inches below the groin where the vein goes over the adductor muscle and mobilized for about 2cm, then divided and ligated. Using a small metal cannula with side ports that he had originally developed for administering tumescent in the fascial sheath, Dr. Bush inserted the cannula down the distal vein to the level of the knee. Then he injected foam as the catheter was withdrawn, giving uniform distribution. The vein was then ligated.

“Exit phlebectomies are performed (the branch feeding the distal varices), and if subsequent varices need to be treated, they can be treated with foam injection only.” Mild compression is used with ABD pads, kerlix and ACE wrap. “This procedure allows immediate ambulation.” Dr. Bush credited Soffer Health and Water’s Edge Dermatology for donating supplies to the mission trip, and Terason for the use of the uSmart 3200T tablet.”

OTHER AGENTS OF CHANGE

The Bushes work with several permanent organizations that are trying to meet the immediate and future needs of the people in Haiti. LIFE’S PATH (www.lifespathhaiti.org): Life’s Path was founded in June, 2010, by Executive Director Becky Reeser, RN, who traveled to

AUGUST/SEPTEMBER 2014 < VEIN THERAPY NEWS

SECONDLOOK Haiti immediately after the earthquake, spending three weeks in Jacmel providing medical care to earthquake victims; and by Louis Jacques, vice president of Haitian relations. After returning to the United States, she returned to Haiti within a short time, and has been at Life’s Path ever since. “Changing lives in Haiti has become my passion,” Nurse Reeser said. “The Life’s Path mission is to hand up, not continually hand out; and we offer hope for a brighter future to end the cycle of extreme poverty. These children’s future requires not only an education, but also the survival tactics.” Peggy Bush said anyone wanting to make a difference in this ongoing tragedy should consider donating to Life’s Path. “You can send a child to school for only $25 a month, and 100 percent of the money goes to the child.” FOTCOH (http://fotcoh.org): Friends of the Children of Haiti provides medical services,

clean water and economic opportunit y to the tens of thousands in the country, that is, according to the World Bank, now the poorest place you can go on the planet. That designation came after the earthquake of 2010, but before Hur- They flew into Port-au-Prince, Haiti, and drove over the mountains to Cyvadier. ricanes Sandy and Isaac inflicted even more death, destruction, flooding and homelessness. Co-founder Barb Hammond also pleads for $25 a month child sponsorship donations, which provides food, education and healthcare. UMC GLOBAL MISSIONS (w w w.umcmission.org/Giveto-Mission/Search-for-Projects/ Projects/418325): This churchbased mission provides a number of ministries in Haiti that focus on integrated, sustainable community development solutions that will support the Haitian people into the future. VTN

Transportation is still primitive throughout the country.

SEE US AT

The ACP 2014 (Phoenix).Booth 617

Peggy Bush with Haitian children.

BEAUTY STARTS WITH A CLEAN CANVAS Ron Bush with a Haitian girl

VEIN THERAPY NEWS ✜ AUGUST/SEPTEMBER 2014

PRODUCTNEWS

WHY MONKEY AROUND?!?! ® VenaPulse Contact us about a

✓ Hands-Free

*Rapidly inflates & Deflates tourniquet cuff with a foot switch! ✓ Decreases Exam time by 30 min. ✓ Ideal for testing 43cm diameter & larger ✓ Consistent evaluations Indications For Use:

• Distal augmentations • Proximal augmentations • Vein mapping • Locating suitable distal vessel for

bypass • Quantification of venous flow • Reflux measurements of specific venous valves

PH:

(304) 758-2370 WAGNERMEDICAL@HOTMAIL.COM FAX: (304) 758-0055

Serving You for 25 years with the Best Vein and Sclerotherapy Products. Please Contact Us For More Information!

Covidien launches enhanced Trellis The commercial launch of Covidien’s next generation Trellis peripheral infusion system, a pharmacomechanical thrombolysis device that enables focused treatment of blood clots that lead to Post-thrombotic Syndrome (PTS), has been announced. The newest enhancements of the Trellis system is that it has been optimized to enhance drug delivery and the removal of the dissolved clot. PTS is a long-term effect of deep vein thrombosis (DVT), a condition where a clot develops in one of the body’s deep veins above the knee. PTS develops when a DVT interferes with the blood flow returning from the leg back to the heart. It can cause lower leg pain and swelling, and can damage the valves in the veins that normally stop blood from flowing backwards down the leg. PTS occurs in almost half of patients within two years after DVT, and up to 33 percent of patients with PTS develop ulcers and skin deterioration. The Trellis system provides a way for physicians to dissolve acute thrombus and intervene on DVT before it advances to PTS. The system is comprised of an over-the-wire catheter with two occlusive balloons to close off the treatment area and block drug release to other areas of the body; an infusion zone to deliver the lytic drug; and an oscillation drive unit that disperses the drug to dissolve the clot. The updated Trellis system features enhanced drug delivery and increased amplitude of the dispersion wire to better distribute the drug throughout the clot. Additionally, the new system features a larger aspiration window than the previous version, which allows for better removal of the drug and the dissolved clot, according to Mark A. Turco, MD and CMO at Covidien’s Vascular Therapies. “Covidien is committed to providing clinicians and patients with advanced technology that is clinically relevant and demonstrates economic value, Dr. Turco said. “Our clinical data has demonstrated that the Trellis system’s targeted lytic delivery may reduce the risk of bleeding complications normally associated with systemic thrombolytic infusion. “Furthermore, intervening in patients with DVT may help improve long-term outcomes in a population that can suffer significant complications if left untreated.” The Trellis peripheral infusion system is currently available in the U.S., Europe and Canada. VTN