QUICK AND EASY Anthony Smeglin, MD, performs sclerotherapy at the Venus Vein Center in Cherry Hill, N.J.

With 40% of women and 25% of men suffering from varicose veins, spider veins or venous insufficiency, and new treatments that are less painful and invasive, now might be a good time to add venous disease treatments to your case mix. In addition to being in demand, these treatments are known for their high reimbursement, quick turnover and low risk of complications.

To treat achy varicose veins and their underlying causes, venous ablation — which uses a catheter to apply energy to a diseased vein and close it off — is a popular treatment. Anthony Smeglin, MD, an interventional cardiologist at the Venus Vein Center and assistant director of the vascular invasive service line at Our Lady of Lourdes Medical Center in Camden, N.J., says that patient comfort is essential for ablation. He prescribes patients 5 mg of diazepam to take before the procedure and tells them to apply a numbing EMLA cream. Dr. Smeglin also injects lidocaine as a local anesthetic before inserting tumescent anesthesia — a mix of saline, sodium bicarbonate and lidocaine — around the veins. He then inserts the catheter using ultrasound guidance, and uses heat from either radio waves or a laser to close the targeted vein. Patients are wrapped in elastic bandages following the ablation and can usually return to normal activities by the next day.

Reimbursement hoops
For venous ablation, insurers typically require pre-authorization that can involve a detailed and complex protocol. "If a patient has a medical venous disease, many insurers will require 3 months of graduated compression stockings before they'll authorize a vein procedure," says Dr. Smeglin. Laser ablation reimbursement is usually around $1,500, while radiofrequency ablation is paid at about $1,800, but typically has higher per-case costs. For sclerotherapy, where patients pay up front for the cosmetic treatment, the cost per session is usually around $400. These procedures take between 30 and 60 minutes, and often require several sessions for best results, says Dr. Smeglin.

PAINFUL PREDECESSOR Treating varicose veins no longer means invasive and painful procedures like vein stripping.

While laser and radiofrequency are the most common types of venous ablation, newer techniques use chemical or mechanical energy. One of the latest techniques uses a special catheter that scrapes the inside of the vein while dispersing a sclerosing agent to close the diseased vessel, says Steve Elias, MD, FACS, director of the Center for Vein Disease and the Wound Care Center at Englewood (N.J.) Hospital and Medical Center. Patients like that it's relatively painless, since tumescent anesthesia is not needed, but insurers have been slow to embrace it.

A laser or radiofrequency ablation system costs $30,000 to $40,000, although leasing is an option, experts say. You can also purchase customizable kits with the supplies needed for each case, like gowns, needles, ultrasound gel and tubing. Depending on the type of ablation, per-case supply costs can range from $200 to more than $600, says Dr. Smeglin. Find a quality tumescent infusion pump that features rapid administration of anesthesia, he adds, and shop for the best prices for tumescent infusion lines and compression stockings.

Another choice for office-based settings is sclerotherapy, which is usually performed for cosmetic reasons and not covered by insurance. Dr. Smeglin says the procedure involves using tuberculin needles to inject a sclerosing agent into the diseased vein, irritating it and causing it to close down and be absorbed by the body. Using tuberculin needles means the procedure is relatively painless and doesn't require local anesthesia. To further reduce discomfort, he uses polidocanol or sodium tetradecyl sulfate injections, which are more effective, "burn" less and have superior results over their cheaper alternative, hypertonic saline.

Whatever the treatment, a quality duplex ultrasound, which combines traditional ultrasound with Doppler ultrasound, is essential. Most machines cost $40,000 to $100,000. "Ultrasound is used for diagnosis, during the procedure and afterwards to make sure everything's okay," says Dr. Elias. "It's the last thing you want to skimp on." Dr. Smeglin prefers portable ultrasound machines, since they take up less space and are less expensive. A vascular ultrasound tech is as important as the system itself. "You want someone who's developed quality mapping skills," says Dr. Smeglin. "There's a nuance to it. It's helpful to you and the patient to pick up small varicose or branch veins that have disease."

Standing out in a growing field
Because these treatments attract patients for cosmetic and medical reasons, it's important to reach out to both groups, says Dr. Smeglin. Connect with physicians who can offer referrals — especially wound care centers or podiatrists who frequently see patients with venous disease — and turn to print advertising in local magazines and newspapers. "That's where you have the biggest bang for your buck," says Dr. Smeglin. Another great marketing tool, he says, is to offer monthly free vein screenings, where potential patients can meet with a clinician and get checked for venous disease. At his center, Dr. Smeglin says the vein screenings have brought out an "enormous turnout."