On the 28th Feb 2008 we received notification from AXA-PPP that they would not cover patients having any investigation or treatment at The Whiteley Clinic from 1st June 2008.
In addition, they would not approve any new patients to be seen or assessed at The Whiteley Clinic from 1st May 2008.
No explanation was given and no opportunity for discussion was invited.
In view of our widely presented and published innovation in the field of vein surgery and our widely recognized expertise in this field, we are at a loss to understand why AXA-PPP have decided to prevent people who have chosen to insure themselves with their company to have the benefit of our expertise.
We regularly perform price comparisons as well as patient satisfaction audits both of which show us in a very favourable light.
Our only recent discussions with AXA-PPP revolve around their refusing to pay for perforator vein treatment, despite clear evidence that such a position is not beneficial to their clients. As this might be a reason for their position, a full transcript of the argument as sent to AXA-PPP is attached below.
If anyone with varicose veins or venous problems who has chosen AXA-PPP for their private medical insurance, wishes to be seen by the experts at The Whiteley Clinic and the benefit of our innovative assessments and treatments, they will not be able to do so under their insurance policy.
As we have not been given any explanation, we suggest that anyone in such a position contact AXA-PPP directly to find out why, despite paying for private health cover, they are being prevented from access our expert services.
Text of letter sent to AXA-PPP in Jan 2008 regarding SEPS - "Sub fascial Endoscopic Perforating vein Surgery" - a specialist treatment for some sorts of varicose veins and vein conditions:
RE: SEPS
Thank you for your letter dated 27th of November 2007 which unfortunately did not arrive at our clinic. However I am in receipt of a faxed copy of this letter arrived on the 7th of January 2008.
I am grateful for your explanation of your position.
I would like to take this opportunity to explain our position in relation to treatment of incompetent perforators and what we offer our patients.
The medical indications for treating incompetent perforators in people with varicose veins and venous reflux disease are quite clear.
Peer reviewed papers have shown incompetent perforators are associated with primary varicose veins 1, increase in numbers as venous disease worsens before surgical treatment 2 and work from our own unit and others have shown that increased numbers of incompetent perforators are associated with recurrent varicose veins 3,4. Further research has shown incompetent perforators are one of the major causes of recurrent varicose veins - accounting for up to 50% of recurrences 5-7.
Although it was once thought that incompetent perforators became competent after treating the truncal reflux of the Great Saphenous vein 8,9, our own research has shown this to be flawed 10 . The reason for this misunderstanding was shown by our randomized study which followed patients up to one year - highlighting the errors by the previous studies which had short follow up periods. We have shown that the majority of the incompetent perforators remain incompetent at one year - once the immediate postoperative thrombophlebitis has settled down and these continue to reflux unless treated.
SEPS has been shown to be an effective way of treating incompetent perforating veins 10,11, but requires a general anaesthetic and is associated with some morbidity 12. We invented the technique of TRLOP to close perforators using a pinhole approach in 2001 13,14 and have now developed this technique to be to do this under local anaesthetic, saving considerable costs in terms of hospital stay and anaesthetic fees.
As I'm sure you're aware, we have already been down the path of knowing our cutting edge treatments are effective long before NICE gives approval. We went through the same arguments with VNUS Closure, after bringing this into the UK in 1999 and having years of success before NICE finally approving the technique.
To find out where NICE stand with regards the difference between what we as clinicians believe from our specialized knowledge and experience to be the correct way to treat our patients and what insurance companies agree to pay for, I have been in contact with NICE by telephone. I have been assured that as a professional, I should be treating patients to the best of my ability and understanding and NICE would expect such treatments to be funded. I was assured that NICE approval should not be used as a criterion for funding or not.
Therefore as to the way forwards, I quite understand if your company decides not to fund this treatment. I assume that is covered in your contract with the people whom you insure. However I cannot ethically, morally nor legally offer my patients what I consider to be sub-standard treatment, nor advise them to have a treatment plan that is incomplete which I have good evidence (presented above) to suppose that they will have a higher chance of recurrence of their problem .
As such, we will continue to recommend treatment of incompetent perforators to our patients in those people with incompetent perforating veins contributing to their problem. We will explain to the patients our rationale for doing so and quote the research to ensure that they understand our reasoning
If they do decide, either for financial or other reasons, to go ahead with treatment without the incompetent perforator treatments, we will be happy to perform all of the other techniques but will, with their consent, not perform SEPS or the equivalent. However the patients will be warned that we take no responsibility should they develop recurrences due to this inadequate approach.
I hope this position is acceptable to you as it satisfies your position (as in your letter) and our own professional position with regards offering our patients a specialist opinion.
References:
1 - Lapropoulos N, Mansour MA, Kang SS, Gloviczki P, Baker WH. New insights into perforator vein incompetence. Eur J Vasc Endovasc Surg 1999; 18: 228-234
2 - Labropoulos N, Tassiopoulos AK, Bhatti AF, Leon L. Development of reflux in the perforator veins in limbs with primary venous disease. J Vasc Surg 2006; 43: 558-562
3 - Jiang P, van Rij AM, Christie R, Hill G, Solomon C, Thomson I. Recurrent varicose veins; pattern of reflux and clinical severity. Cardiovasc Surg 1999; 7: 332-339.
4 - Rutherford EE, Kianifard B, Cook SJ, Holdstock JM, Whiteley MS. Incompetent perforating veins are associated with recurrent varicose veins. Eur J Vasc Endovasc Surg 2001; 21: 458-460
5 - Jutley RS, Cadle I, Cross KS. Preoperative assessment of primary varicose veins: a duplex study of venous incompetence. Eur J Vasc Endovasc Surg 2001; 21: 370-373
6 - Seidel AC, Miranda F Jr, Juliano Y, Novo NF, dos Santos JH, de Souza DF. Prevalence of varicose veins and venous anatomy in patients without truncal saphenous reflux. Eur J Vasc Endovasc Surg 2004; 28: 387-390
7 - Sandri JL, Barros FS, Pontes S, Jacques C, Salles-Cunha SX. Diameter-reflux relationship in perforating veins of patients with varicose veins. J Vasc Surg 1999; 30: 867-874
8 - Campbell WB, West A. Duplex ultrasound audit of operative treatment of primary varicose veins. Phlebology 1995; 1(Suppl 1): 407-409
9 - Stuart WP, Adam DJ, Allan PL, Ruckley CV, Bradbury AW. Saphenous surgery does not correct perforator incompetence in the presence of deep venous reflux J Vasc Surg 1998; 28: 834-8.
10 - Kianifard B, Holdstock J, Allen C, Smith C, Price B, Whiteley MS. Randomised clinical trial of the effect of adding subfascial endoscopic perforator surgery to standard great saphenous vein stripping Br J Surg 2007; 94: 1075-1080
11 - Roka F, Binder M, Bohler-Sommeregger K. Mid-term recurrence rate of incompetent perforating veins after combined superficial vein surgery and subfascial endoscopic perforating vein surgery. J Vasc Surg 2006; 44: 359-363.
12 - Kianifard B, Price S, Whiteley MS. Clipping perforators without dividing them could reduce postoperative pain and swelling following subfascial endoscopic perforator surgery. Ann R Coll Surg Engl. 2002 May;84(3):210-1.
13 - Kianifard B, Browning L, Holdstock J M, Whiteley MS. Surgical technique and preliminary results of perforator vein closure - TRLOPS (Transluminal Occlusion of perforators(Abstract)Br J Surg. 2002; 89: 507-526. 14 - Percutaneous radiofrequency ablations of Varicose Veins (VNUS Closure) Mark S Whiteley, Judy Holdstock In: Roger M Greenhalgh ed, Vascular and Endovascular Challenges . London; BibaPublishing 2004. p 361- 381 |
