Congress must act to protect vulnerable population from unnecessary limb loss
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Most Americans consider limb amputation to be the result of a traumatic and non-avoidable event. But for the 18 million citizens who develop Peripheral Artery Disease (PAD), the possibility of a preventable limb amputation is a stark reality.

During my years of practice, I have seen many patients present with PAD – the hardening of arteries that causes narrowing or blockage of vessels that carry blood from the heart to the legs caused by buildup of plaque in the arteries, or atherosclerosis. As a chronic, life-threatening circulatory condition, PAD puts patients at greater risk of the development of critical limb ischemia (CLI), resulting in extreme pain in the legs or feet and risking complications such as wounds and sores or the ultimate amputation of the affected limb.

The amputation of a patient’s limb is not a decision any health care provider takes lightly. Individuals with PAD who have undergone amputation face higher rates of mortality, specifically amongst older Americans. After a major amputation, 48 percent of patients over the age of 65 die within the first year and 71 percent die within three years. Further, once a major leg amputation occurs, the Medicare costs in caring for these patients escalate significantly.

These outcomes could be reduced, and in some cases entirely prevented, through the increase of revascularization services. Revascularization is the process of restoring blood flow to the limb through minimally invasive surgical intervention. When implemented correctly, and in a timely manner, revascularization can ultimately prevent disease progression, ultimately saving a limb. Despite this seemingly obvious solution is a life-altering problem, studies have shown that as many as one third of late-state PAD patients do not receive arterial testing to determine if they are a candidate for this procedure.

This is where Congress has the opportunity, and arguably the responsibility, to step in to prevent avoidable amputations for those eligible for this critical medical intervention by stopping proposed cuts for revascularization procedures under Medicare. These cuts are included in the 2019 Physician Fee Schedule (PFS) Proposed Rule, which cuts up to 30 percent in reimbursement for revascularization codes.

These proposed cuts, which will directly impact those over the age of 65 with PAD, stem from the Centers for Medicare & Medicaid Services (CMS) proposal that updates equipment and supply pricing data in the Medicare Physician Fee Schedule database. I have significant concerns with the reasoning behind these proposed reductions, as in some cases no pricing data at all exists in the CMS

database for these services.

Members of Congress must urge CMS to properly value revascularization services and the lifeline they provide for so many, in particular African Americans, Native Americans and Hispanic Americans over the age of 65. These ethnic groups are two to four times more likely to undergo a lower-limb amputation due to PAD, due to these groups having a higher level of risk factors such as high blood pressure and diabetes. In particular, African Americans have a higher prevalence of asymptomatic PAD – the disease without any symptoms – making revascularization treatments critically important.

While the highest cost of PAD is the loss of limbs for many patients, the annual monetary cost in the U.S. for patients with PAD is significant. Studies have found this number to exceed $21 billion, which is inclusive of nearly $10 billion alone for hospitalizations. At the same time, studies have found endovascular therapy to be the least costly option in the short-run for patients with PAD – which pays big dividends in the long run by reducing the heavy costs associated with amputation.

As we recognize Peripheral Artery Disease (PAD) Awareness Month this September, I hope that all members of Congress will swiftly urge CMS to properly value revascularization services, and ultimately not include the proposed cuts in the Final PFS Rule. My patients – the elderly and vulnerable communities that suffer from PAD – will thank you.

Jeffrey Carr, MD, FACC  is an Interventional Cardiologist and Endovascular Specialist. He is the Founding and Immediate Past President of the Outpatient Endovascular and Interventional Society and a member of the CardioVascular Coalition, a group dedicated to raising awareness for PAD and advocating for national healthcare policy and amputation prevention.